Raúl Barco

Long-Term Results of Radial Head Resection Following Isolated Radial Head Fractures in Patients Younger Than Forty Years Old

BACKGROUND In the past, radial head resection was the surgical treatment of choice for radial head fractures that could not be internally fixed. More recently, radial head implant arthroplasty has gained popularity for the treatment of isolated radial head fractures. The purpose of the present study was to review the long-term results of radial head resection after radial head fractures not associated with elbow instability in patients younger than forty years of age. METHODS Twenty-six patients younger than forty years of age who had sustained an isolated fracture of the radial head (including six patients who had sustained a Mason type-II fracture and twenty who had sustained a Mason type-III fracture) that had been treated with primary radial head resection were reviewed retrospectively at a minimum of fifteen years (mean, twenty-five years). Outcomes were evaluated according to the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand score. Radiographic assessment of osteoarthritic changes and the carrying angle was also performed. RESULTS Twenty-one patients (81%) had no elbow pain, three had mild pain, and two had moderate pain. The mean arc of motion was from 9 degrees to 139 degrees of flexion. All but one patient had a functional arc of motion. The mean pronation was 84 degrees, and the mean supination was 85 degrees. Nineteen elbows had normal strength in comparison with the unaffected side. The mean Mayo Elbow Performance Score was 95 points; the score was classified as good or excellent for twenty-four elbows (92%) and as fair for two. The mean Disabilities of the Arm, Shoulder and Hand score was 6 points. Three patients complained of wrist pain, which was mild in two patients and moderate in one. In four patients, some degree of elbow instability could be detected on physical examination. The mean carrying angle of the involved elbow was significantly greater than that of the uninjured elbow (21 degrees compared with 10 degrees). Radiographic changes of arthritis were considered mild in seventeen elbows and moderate in nine. We could not detect significant differences in functional outcome on the basis of the degree of radiographic change. CONCLUSIONS Radial head resection in young patients with isolated fractures without instability yields long-term satisfactory results in >90% of cases. Osteoarthritic changes are uniformly present but typically are not associated with functional impairment.

Natural History of Unreduced Gartland Type-ii Supracondylar Fractures of the Humerus in Children: A Two to Thirteen-year Follow-up Study

BACKGROUND The preferred treatment of type-II supracondylar humeral fractures remains controversial. The purpose of this study was to evaluate the long-term clinical and radiographic outcome of type-II supracondylar humeral fractures in children treated with immobilization in a splint without reduction. METHODS The medical records of forty-six consecutive patients who sustained a supracondylar Gartland type-II fracture of the humerus treated with immobilization in a splint were reviewed. Age at the time of fracture, sex, side involved, dominant extremity, duration of immobilization, and complications were recorded. Radiographic assessment included the Baumann angle, carrying angle, and lateral humerocapitellar angle. Patients returned for clinical evaluation, and the Mayo Elbow Performance Score and the criteria of Flynn et al. were recorded. Patients completed the QuickDASH, an abbreviated form of the Disabilities of the Arm, Shoulder and Hand questionnaire, to measure disability. RESULTS The average age (and standard deviation) at the time of fracture was 5.5 ± 2.6 years. The average duration of follow-up was 6.6 ± 2.8 years. The initial lateral humerocapitellar angle was a mean of 12.8° ± 9.8°, the mean Baumann angle was 12° ± 5.7°, and the mean radiographic carrying angle was 9° ± 11.3°. There were significant differences between injured and uninjured elbows at the time of follow-up with regard to flexion (mean, 137.9° ± 9.1° for injured and 144.8° ± 7.1° for uninjured elbows; p < 0.001), extension (mean, 13.2° ± 5.9° for injured and 7.4° ± 5.1° for uninjured elbows; p < 0.001), clinical carrying angle (mean, 9° ± 8.1° for injured and 12.1° ± 4.9° for uninjured elbows; p = 0.003), radiographic carrying angle (mean, 8.9° ± 8.1° for injured and 14.2° ± 5.5° for uninjured elbows; p < 0.001), and lateral humerocapitellar angle (mean, 30.5° ± 11° for injured and 41.9° ± 9.9° for uninjured elbows; p < 0.001). The mean score was 10 ± 15.3 points for the QuickDASH questionnaire, 4.7 ± 12.2 points for the QuickDASH-sports questionnaire, and 95.6 ± 10.5 for the Mayo Elbow Performance Score. According to the Flynn criteria, results were satisfactory in 80.4% of the patients. CONCLUSIONS Patients with a type-II supracondylar fracture of the humerus treated conservatively had a mild cubitus varus deformity and a mild increase in elbow extension, although functional results were excellent in the majority of patients.

Application of adipose tissue-derived stem cells in a rat rotator cuff repair model

INTRODUCTION Healing tissue of the rotator cuff does not regenerate the native enthesis; fibrovascular scar tissue is formed instead and this has less favourable biomechanical properties. The purpose of this study was to determine if the application of adipose tissue-derived stem cells (ASCs) could improve biomechanical and histological properties of the repair. MATERIAL AND METHODS Fifty Sprague-Dawley rats underwent detachment and repair of the supraspinatus tendon, 32 for the biomechanical study and 18 for the histological examination. Animals were randomised in two groups to receive either a collagen carrier alone (untreated group) or the carrier plus 2×10(6) ASCs (ASCs group). A control group (suture only) was also included for the histological examination. The animals were sacrificed at 2 and 4 weeks for the biomechanical study and at 24 hours, and 1 and 4 weeks for the histological study. Maximum load failure energy, elastic energy, mechanical deformation, stiffness and absorbed energy were measured. Immunofluorescence testing was conducted to show the presence of ASCs in the repair area. RESULTS There were no differences between the untreated group and the ASCs group in any of the biomechanical variables at the 2- and 4-week time points. The mechanical deformation before failure was higher for the ASCs group compared with the untreated group at 2 weeks and 4 weeks (p=0.09), as was the absorbed energy (p=0.06). Differences in maximum load to failure between 2 and 4 weeks were significant for the untreated group (p=0.04) but not for the ASCs group (p=0.17). Histological examination showed less acute inflammation with diminished presence of oedema and neutrophils in the ASCs group. There were no differences in the orientation of collagen fibres between groups at either time point. In the ASCs group, collagen was present only at the last time point. CONCLUSION The application of ASCs in a rat rotator cuff repair model did not improve the biomechanical properties of the tendon-to-bone healing. However, the ASCs group showed less inflammation, which may lead to a more elastic repair and less scarred healing.

Complications in reverse shoulder arthroplasty

The reported rate of complications of reverse shoulder arthroplasty (RSA) seems to be higher than the complication rate of anatomical total shoulder arthroplasty. The reported overall complication rate of primary RSA is approximately 15%; when RSA is used in the revision setting, the complication rate may approach 40%. The most common complications of RSA include instability, infection, notching, loosening, nerve injury, acromial and scapular spine fractures, intra-operative fractures and component disengagement. Careful attention to implant design and surgical technique, including implantation of components in the correct version and height, selection of the best glenosphere-humeral bearing match, avoidance of impingement, and adequate management of the soft tissues will hopefully translate in a decreasing number of complications in the future. Cite this article: Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev 2016;1:72-80. DOI: 10.1302/2058-5241.1.160003.

Lateral epicondylitis of the elbow

Lateral epicondylitis, also known as ‘tennis elbow’, is a very common condition affecting mainly middle-aged patients. The pathogenesis remains unknown but there appears to be a combination of local tendon pathology, alteration in pain perception and motor impairment. The diagnosis is usually clinical but some patients may benefit from additional imaging for a specific differential diagnosis. The disease has a self-limiting course of between 12 and 18 months, but in some patients, symptoms can be persistent and refractory to treatment. Most patients are well-managed with non-operative treatment and activity modification. Many surgical techniques have been proposed for patients with refractory symptoms. New non-operative treatment alternatives with promising results have been developed in recent years. Cite this article: Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391-397. DOI: 10.1302/2058-5241.1.000049.

Minimally invasive poly-axial screw plating for three-part fractures of the proximal humerus

The purpose of this study was to evaluate the poly-axial locked plating system inserted through a minimally invasive approach for the treatment of three-part fractures of the proximal humerus. Twenty-three patients with a three-part fracture of the proximal humerus treated with a poly-axial locking plate through a percutaneous approach were available for clinical and radiological analysis at a minimum of 2 years follow up (average 36 months; range, 24-54 months). To assess objective and subjective outcomes the Constant Score (CS) and the Disabilities of the Arm, Shoulder, and Hand (DASH) score were obtained. All complications were recorded. There were 17 women and 6 men, with a mean age of 62 years (range, 18-86). All fractures healed. At final follow up, the mean forward flexion, external rotation and internal rotation were 126°, 44° and L1, respectively; the mean CS was 64 and the mean DASH score was 23. Twelve patients (52%) had a postoperative complication, which included screw cut-out, stiffness and infection. The poly-axial locked plating system through a minimally-invasive approach may be an appropriate treatment for three-part fractures of the proximal humerus and may reduce the biological aggression of conventional plate fixation.

Applied Anatomy and Surgical Approaches to the Elbow

Knowledge of the anatomy and surgical approaches is crucial to develop a surgical strategy while minimizing complications. The most widely used approaches of the elbow will be reviewed with an emphasis on how to extend the approaches if so needed and according to which exposures are best used for the most common elbow pathologies. Key aspects of neurovascular relationships are discussed to protect them during elbow surgery.

Uso de células troncales derivadas de lipoaspirado en un modelo experimental animal de rotura de manguito rotador

AIM Rotator cuff repairs have shown a high level of re-ruptures. We hypothesized that the use of adipose-derived stem cells (ASC) could improve the biomechanical and histological properties of the repair. MATERIAL AND METHODS Controlled experimental study conducted on 44 BDIX rats with section and repair of the supraspinatus tendon and randomization to one of three groups: group A, no intervention (control); group B, local applications of a fibrin sealant; and group C, application of the fibrin sealant with 2 x 10(6) ASC. At 4 and 8 weeks a biomechanical and histological analysis was performed. RESULTS There were no differences in load-to-failure at 4 and 8 weeks between groups. The load-to-failure did increase between week 4 and week 8. Histologically the tendon-to bone union showed a disorganized fibrovascular tissue. Group C showed a different inflammatory pattern, with less presence of neutrophils and more presence of plasma cells. CONCLUSION The use of ASC does not improve the biomechanical or histological properties of the repair site. More studies are needed to improve techniques that enhance the healing site of the repair.

Management of Elbow Trauma: Anatomy and Exposures

The elbow is a complex joint from the anatomic and biomechanical point of view. A thorough understanding of elbow anatomy greatly aids the surgeon in dealing with elbow trauma. The close vicinity of neurovascular structures should always be kept in mind when selecting a surgical approach. Any approach to the elbow needs to be safe and versatile. Knowledge of the attachment and orientation of elbow ligaments reduces the risk of inadvertent intraoperative injury and/or postoperative instability. Surgeons dealing with elbow trauma should have a good working understanding of elbow anatomy and the available approaches to effectively and efficiently conduct the surgical procedure to maximize outcomes and minimize complications.

Elbow instability secondary to lateral epicondylar nounion in an adult

Symptomatic nonunion of the lateral epicondyle of the elbow is a rare injury. We present the case of a 36-year-old woman who complained of elbow pain and instability several months after a conservatively treated lateral epicondyle fracture that evolved into nonunion. In order to reestablish elbow stability, the patient underwent removal of the nonunited epicondylar fragment and ligament repair, with excellent clinical outcome.