Samuel A. Antuña

Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications.

Background: Primary degenerative arthritis of the elbow is an uncommon disorder that recently has been more clearly recognized. The purpose of this study was to analyze the long-term results and complications of ulnohumeral arthroplasty as treatment of primary osteoarthritis of the elbow and to document any tendency for recurrence of the arthritis after the procedure.Methods: The results of ulnohumeral arthroplasties performed at our institution, between 1986 and 1996, in forty-six elbows (forty-five patients) with primary osteoarthritis were reviewed at an average of eighty months (range, twenty-four to 164 months) after the operation. There were forty-four men and one woman with a mean age of forty-eight years. All patients complained of pain with terminal elbow extension. The pain was associated with locking in fourteen elbows and with ulnar nerve symptoms in twelve. The surgical procedure involved fenestration of the olecranon fossa and excision of olecranon and coronoid osteophytes in all patients, with removal of loose bodies in thirty-six elbows. A capsular release was performed in nineteen elbows, and an ulnar nerve transposition or neurolysis was done in eight. Preoperative and follow-up assessment included evaluation of elbow pain and range of motion with the Mayo Elbow Performance Score.Results: The mean arc of flexion-extension improved from 79° (range, 10° to 135°) preoperatively to 101° (range, 45° to 135°) at the time of follow-up (p < 0.05). At the last follow-up examination, thirty-five elbows (76%) were not painful or were only mildly painful and eleven were moderately or severely painful. According to the Mayo Elbow Performance Score, the result was excellent for twenty-six elbows, good for eight, fair for four, and poor for eight. Thirteen of the forty-five patients reported some degree of ulnar nerve symptoms postoperatively, and six of them required another operation to decompress or translocate the nerve. Two other patients underwent additional surgery because of persistent symptoms.Conclusions: The data from this study show that ulnohumeral arthroplasty can yield satisfactory long-term pain relief and an increase in the range of motion. Patients with severe preoperative limitation of elbow extension of >60° and flexion of <100° and those who undergo manipulation under anesthesia in the early postoperative period to increase motion are at risk for the development of ulnar nerve dysfunction postoperatively. One should consider prophylactic ulnar nerve decompression or mobilization under these circumstances.

Shoulder Arthroplasty for Arthritis After Instability Surgery

Background: We are not aware of any large published studies regarding the intermediate to long-term results of shoulder arthroplasty performed for the treatment of osteoarthritis after instability surgery. Therefore, we reviewed the results of this procedure, the risk factors for an unsatisfactory outcome, and the rates of failure in our patients. Methods: Between January 1, 1978, and December 31, 1997, thirty-three patients (thirty-three shoulders) with glenohumeral arthritis after instability surgery were treated with a shoulder arthroplasty at our institution. Two patients were excluded from the study: one died less than two years postoperatively, and one had not been managed by the senior surgeon. The remaining thirty-one patients, including twenty-one patients who had had a total shoulder arthroplasty and ten who had had a hemiarthroplasty, were followed for a minimum of two years (mean, seven years) or until the time of revision surgery. The mean age at the time of the shoulder arthroplasty was forty-six years. Results: Shoulder arthroplasty was associated with significant pain relief (p < 0.001) as well as significant improvement in external rotation (from 4° to 43°; p < 0.001) and active abduction (from 94° to 141°; p < 0.001). There was not a significant difference between the hemiarthroplasty group and the total shoulder arthroplasty group with regard to postoperative external rotation, active abduction, or pain. According to a modification of the rating system of Neer et al., there were four excellent, two satisfactory, and four unsatisfactory results in the hemiarthroplasty group and three excellent, five satisfactory, and thirteen unsatisfactory results in the total shoulder arthroplasty group. Three patients in the hemiarthroplasty group and eight patients in the total shoulder arthroplasty group underwent revision surgery. The estimated survival of the components (and 95% confidence interval) was 97% (91% to 100%) at two years, 86% (74% to 99%) at five years, and 61% (42% to 86%) at ten years. Conclusions: The data from the present study suggest that shoulder arthroplasty for the treatment of osteoarthritis of the glenohumeral joint following instability surgery in this relatively young group of patients provides pain relief and improved motion but is associated with high rates of revision surgery and unsatisfactory results due to component failure, instability, and pain due to glenoid arthritis.

Complex Fractures of the Proximal Humerus

Fractures of the proximal humerus may be really challenging both in young patients and in the elderly population. Complex articular fractures should be mainly fixed in the young patient with good bone quality. Plate fixation is more commonly used, but nailing is gaining popularity in order to avoid osteonecrosis. Complex fractures in the elderly are mainly treated nonoperatively or with a reverse shoulder replacement. The use of hemiarthroplasty has been reduced to cases with good tuberosities.

Complex Distal Humerus Fractures

Complex distal humerus fractures include supracondylar humerus fractures and distal articular fractures. These fractures may have an increased degree of complexity due to soft-tissue compromise or bony comminution. The initial goal of treatment in these injuries is to perform an anatomic reduction and internal fixation with early rehabilitation, but a selected group of patients may benefit from elbow arthroplasty. Distal humerus fractures are difficult fractures to treat and have a high rate of complications. These fractures should probably be treated in specialized centers. Internal fixation is the gold standard for the majority of these injuries. It is usually necessary to perform additional surgical gestures during surgery, including soft-tissue procedures, bone augmentation or grafting, bone remodeling, and nerve release, which increases the complexity of these injuries. The use of an elbow arthroplasty may be beneficial in the elderly or in patients with previous joint disease. Patients should be counseled that appropriate treatment may render a functional painless elbow but may need additional procedures and extensive rehabilitation

37 – Radial Head Fracture: General Considerations, Conservative Treatment, and Radial Head Resection

1 Phylogeny, 2 Alex A. Malone and Susan G. Larson 2 Anatomy of the Elbow Joint, 9 Bernard F. Morrey, Manuel Llusá-Pérez, and José R. Ballesteros-Betancourt 3 Biomechanics of the Elbow, 33 Kai-Nan An and Bernard F. Morrey 4 History and Physical Examination of the Elbow, 47 Mark E. Morrey and Bernard F. Morrey 5 Functional Evaluation of the Elbow, 66 Bernard F. Morrey 6 Radiography of the Elbow, 75 Nicholas G. Rhodes and Daniel E. Wessell 7 Computed Tomography of the Elbow, 87 Hillary W. Garner 8 Magnetic Resonance Imaging of the Elbow, 93 Joseph M. Bestic 9 Ultrasound Imaging of the Elbow, 101 Michael R. Moynagh 10 Extensile Surgical Exposures: Humerus, 110 Mark E. Morrey, Manuel Llusá-Pérez, and José R. Ballesteros-Betancourt 11 Surgical Exposures of the Elbow, 126 Bernard F. Morrey 12 Surgical Exposures of the Forearm, 151 José R. Ballesteros-Betancourt, Manuel Llusá-Pérez, and Joaquin Sanchez-Sotelo 13 General and Regional Anesthesia and Postoperative Pain Control, 157 Sandra L. Kopp, Terese T. Horlocker, and Robert L. Lennon 14 Principles of Elbow Rehabilitation, 164 Adam M. Pourcho and Jay Smith 15 Continuous Passive Motion, 171 Bernard F. Morrey 16 Splints and Bracing of the Elbow, 173 Bernard F. Morrey 17 Examination Under Anesthesia, 178 Bernard F. Morrey

Morphometry of the radiocapitellar joint: is humeral condyle diameter a reliable predictor of the size of the radial head prosthesis?

BACKGROUND AND HYPOTHESISnRadial head arthroplasty (RHA) is a reliable procedure to manage complex injuries of the elbow, but complications due to inadequate sizing have been observed. Radiocapitellar morphometry has been studied widely, but RHA preoperative planning is not yet well defined. We hypothesized that specific morphologic parameters of the radiocapitellar joint measured with simple clinical software for radiographic analysis could be useful tools for clinical practice to predict RHA size preoperatively.nnnMETHODSnRadiologic radiocapitellar joint dimensions (humeral condyle diameter [HCDi], radial head diameter [RHDi], and radial head height) were analyzed on true anteroposterior and lateral radiographs, using commercial picture archiving and communication system software, in 43 patients with non-osseous pathology of the elbow and 24 patients with RHA. Interobserver concordance was studied, and a regression model to relate different parameters was developed.nnnRESULTSnInterobserver concordance was greater than 0.8 for HCDi and RHDi on the lateral view and RHDi on the anteroposterior view for the general population. The parameter with the best correlation with the radial head arthroplasty diameter (RHADi) size was HCDi on the lateral view. A regression model was calculated and defined as follows: RHADiu2009=u20096.99u2009+u20090.733 × HCDi on lateral view. This model allows prediction of RHADi in 67% of cases.nnnCONCLUSIONnRadiologic radiocapitellar parameters show good interobserver reliability. RHADi can be calculated preoperatively from HCDi on the lateral view in 67% of cases.

Fracture-Dislocations of the Elbow

Fractures-dislocations of the elbow are complex and severe injuries with a high potential for complications and suboptimal or poor results. Careful physical exams and adequate imaging studies are essential to understand all injuries and provide satisfactory management. In the “terrible triad,” there is an elbow dislocation along with fractures of both radial head and coronoid process, leading to posterolateral rotatory instability. In these injuries, it is essential to treat the LCL tear and the radial head fracture. Coronoid fractures should be fixed in those cases with type II and III fractures which render the elbow unstable after radial head reconstruction. Varus posteromedial rotatory instability typically has both LCL tear and fracture of the anteromedial facet of the coronoid process, where the MCL attaches. The important aspect of the treatment is to repair the LCL and to fix the coronoid fragment. In transolecranon fractures-dislocations and complex Monteggia injuries, the principal damage lies on bony stabilizers. The standard of care is through precontoured plates and screws with careful assessment of any ligament tear, which will require adequate repair to prevent early failure of the implant or severe complications. An external fixator should be used in all cases with residual instability after appropriate treatment of these injuries. The principles of treatment are to provide a stable fixation of bone fragments and strong repair of ligaments to allow early range of motion to decrease the likelihood of elbow stiffness.