Stuart D. Patterson

Arthroplasty with a Metal Radial Head for Unreconstructible Fractures of the Radial Head

Background: Treatment of unreconstructible comminuted fractures of the radial head remains controversial. There is limited information on the outcome of management of these injuries with arthroplasty with a metal radial head implant. Methods: The functional outcomes of arthroplasties with a metal radial head implant for the treatment of twenty‐five displaced, unreconstructible fractures of the radial head in twenty‐four consecutive patients (mean age, fifty-four years) were evaluated at a mean of thirty‐nine months (minimum, two years). There were ten Mason type-III and fifteen Mason‐Johnston type-IV injuries. Two of these injuries were isolated, and twenty‐three were associated with other elbow fractures and/or ligamentous injuries. Results: At the time of follow-up, Short Form-36 (SF‐36) summary scores suggested that overall health-related quality of life was within the normal range (physical component = 47 ± 10, and mental component = 49 ± 13). Other outcome scales indicated mild disability of the upper extremity (Disabilities of the Arm, Shoulder and Hand score = 17 ± 19), wrist (Patient‐Rated Wrist Evaluation score = 17 ± 21 and Wrist Outcome Score = 60 ± 10), and elbow (Mayo Elbow Performance Index = 80 ± 16). According to the Mayo Elbow Performance Index, three results were graded as poor; five, as fair; and seventeen, as good or excellent. The poor and fair outcomes were associated with concomitant injury in two patients, a history of a psychiatric disorder in three, comorbidity in two, a Workers’ Compensation claim in two, and litigation in one. Subjective patient satisfaction averaged 9.2 on a scale of 1 to 10. Elbow flexion of the injured extremity averaged 140° ± 9°; extension, -8° ± 7°; pronation, 78° ± 9°; and supination, 68° ± 10°. A significant loss of elbow flexion and extension and of forearm supination occurred in the affected extremity, which also had significantly less strength of isometric forearm pronation (17%) and supination (18%) as well as significantly less grip strength (p < 0.05). Asymptomatic bone lucencies surrounded the stem of the implant in seventeen of the twenty-five elbows. Valgus stability was restored, and proximal radial migration did not occur. Complications, all of which resolved, included one complex regional pain syndrome, one ulnar neuropathy, one posterior interosseous nerve palsy, one episode of elbow stiffness, and one wound infection. Conclusions: Patients treated with a metal radial head implant for a severely comminuted radial head fracture will have mild-to-moderate impairment of the physical capability of the elbow and wrist. At the time of short-term follow-up, arthroplasty with a metal radial head implant was found to have been a safe and effective treatment option for patients with an unreconstructible radial head fracture; however, long‐term follow‐up is still needed.

Functional outcome of semiconstrained total elbow arthroplasty.

Background: The objective of the present study was to review the results of primary total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. Two hypotheses were tested: (1) the results in patients with inflammatory arthritis would be superior to those in patients with a traumatic or posttraumatic condition, and (2) the isometric extensor torque after total elbow arthroplasty would be significantly less than that of the contralateral elbow. Methods: Forty-seven consecutive patients (fifty-one elbows) had the operation performed by one of three surgeons between November 1, 1989, and June 30, 1996. Thirty-six surviving patients (thirty-nine elbows) were available for follow-up. The mean duration (and standard deviation) of follow-up was 50 ± 11 months (range, twenty-four to ninety-seven months). The mean age at the time of the operation was 64 ± 11 years (range, twenty-seven to eighty-seven years). Eighteen patients (twenty-one elbows) had inflammatory arthritis. Eighteen patients (eighteen elbows) had an acute fracture or posttraumatic condition (posttraumatic osteoarthritis in eight, an acute fracture of the humerus in seven, nonunion of the distal aspect of the humerus in two, and primary osteoarthritis in one). The patients were evaluated with use of questionnaires (the Mayo elbow performance index, the Short Form-36 [SF-36], and the Disabilities of the Arm, Shoulder and Hand [DASH] Questionnaire); clinical examination by an orthopaedic surgeon who was not involved with the preoperative, operative, postoperative, or follow-up care; radiographs; and elbow strength-testing with an isokinetic dynamometer. Results: The mean score (and standard deviation) on the Mayo elbow performance index for the group that had inflammatory arthritis (90 ± 11 points) was significantly higher than that for the group with a traumatic or posttraumatic condition (78 ± 18 points) at the time of the latest follow-up (p < 0.05). In both groups, the mean extensor torque of the involved elbow was significantly less than that of the contralateral elbow (p < 0.05). No significant difference between the groups was found with respect to the flexion-extension arc of motion. Ten elbows (26 percent) had ulnar nerve dysfunction (a transient deficit in six and a permanent deficit in four); nine (23 percent), an intraoperative fracture (of the humeral diaphysis in four, of the ulnar diaphysis in four, and of the olecranon in one); three (8 percent), a periprosthetic infection; three, a triceps disruption; and one (3 percent), a revision because of a fracture of the ulnar component. There were no other revisions. Of the thirty-four elbows with complete radiographic follow-up, twenty-three had no change in the bone-cement interface. Progressive radiolucency was noted around the ulnar prosthesis in eight elbows, around the humeral prosthesis in one elbow, and around both components in two elbows. Conclusions: Patients who had a total elbow arthroplasty with use of a semiconstrained Coonrad-Morrey prosthesis were generally satisfied; the mean level of patient satisfaction was 9.2 of a possible 10 points for those who had inflammatory arthritis and 8.6 points for those who had a fracture or posttraumatic condition. The rates of complications involving the ulnar nerve, intraoperative fracture, triceps disruption, deep infection, and periprosthetic radiolucency are of concern.

Ligamentous Stabilizers Against Posterolateral Rotatory Instability of the Elbow

Background: The lateral ulnar collateral ligament, the entire lateral collateral ligament complex, and the overlying extensor muscles have all been suggested as key stabilizers against posterolateral rotatory instability of the elbow. The purpose of this investigation was to determine whether either an intact radial collateral ligament alone or an intact lateral ulnar collateral ligament alone is sufficient to prevent posterolateral rotatory instability when the annular ligament is intact. Methods: Sequential sectioning of the radial collateral and lateral ulnar collateral ligaments was performed in twelve fresh-frozen cadaveric upper extremities. At each stage of the sectioning protocol, a pivot shift test was performed with the arm in a vertical position. Passive elbow flexion was performed with the forearm maintained in either pronation or supination and the arm in the varus and valgus gravity-loaded orientations. An electromagnetic tracking device was used to quantify the internal-external rotation and varus-valgus angulation of the ulna with respect to the humerus. Results: Compared with the intact elbow, no differences in the magnitude of internal-external rotation or maximum varus-valgus laxity of the ulna were detected with only the radial collateral or lateral ulnar collateral ligament intact (p > 0.05). However, once the entire lateral collateral ligament was transected, significant increases in internal-external rotation (p = 0.0007) and maximum varus-valgus laxity (p < 0.0001) were measured. None of the pivot shift tests had a clinically positive result until the entire lateral collateral ligament was sectioned. Conclusions: This study suggests that, when the annular ligament is intact, either the radial collateral ligament or the lateral ulnar collateral ligament can be transected without inducing posterolateral rotatory instability of the elbow. Clinical Relevance: Surgical approaches to the lateral side of the elbow that violate only the anterior or posterior half of the lateral collateral ligament should not result in posterolateral rotatory instability of the elbow. This is important information for surgeons planning various procedures on the lateral aspect of the elbow, such as reconstruction of a fractured radial head, radial head replacement, or total elbow arthroplasty.

Metallic radial head arthroplasty improves valgus stability of the elbow.

The stabilizing influence of radial head arthroplasty was studied in eight medial collateral ligament deficient anatomic specimen elbows. An elbow testing apparatus, which used computer controlled pneumatic actuators to apply tendon loading, was used to simulate active elbow flexion. The motion pathways of the elbow were measured using an electromagnetic tracking device, with the forearm in supination and pronation. As a measure of stability, the maximum varus to valgus laxity over the range of elbow flexion was determined from the difference between varus and valgus gravity loaded motion pathways. After transection of the medial collateral ligament, the radial head was excised and replaced with either a silicone or one of three metallic radial head prostheses. Medial collateral ligament transection caused a significant increase in the maximum varus to valgus laxity to 18.0 degrees +/- 3.2 degrees. After radial head excision, this laxity increased to 35.6 degrees +/- 10.3 degrees. The silicone implant conferred no increase in elbow stability, with a maximum varus to valgus laxity of 32.5 degrees +/- 15.5 degrees. All three metallic implants improved the valgus stability of the medial collateral ligament deficient elbow, providing stability similar to the intact radial head. The use of silicone arthroplasty to replace the radial head in the medial collateral ligament deficient elbow must be questioned. Metallic radial head arthroplasty provides improved valgus stability, approaching that of an intact radial head.

Outcome after open reduction and internal fixation of capitellar and trochlear fractures

BACKGROUND Capitellar and trochlear fractures are uncommon fractures of the distal aspect of the humerus. There is limited information about the functional outcome of patients managed with open reduction and internal fixation. METHODS The functional outcome of twenty-eight patients, with a mean age (and standard deviation) of 43 +/- 13 years, who were treated with open reduction and internal fixation for capitellar and trochlear fractures was evaluated at a mean duration of follow-up of 56 +/- 33 months. Patient outcomes were assessed with physical and radiographic examination, range-of-motion measurements, strength testing, and self-reported questionnaires (Short Form-36, Mayo Elbow Performance Index, American Shoulder and Elbow Surgeons Elbow Assessment Form, and Patient-Rated Elbow Evaluation scales). RESULTS Eleven fractures involved the capitellum with or without fracture of the lateral ridge of the trochlea, four involved the capitellum and trochlea as one piece, and thirteen involved the capitellum and trochlea as separate fragments. These fractures were further characterized by the presence or absence of posterior comminution. Fourteen patients had isolated fractures, and fourteen had other elbow, forearm, or wrist injuries. Patients with more complex fractures required more extensive surgery, had more complications resulting in secondary procedures, and had poorer outcomes compared with those with simple fractures. The average score on the Mayo Elbow Performance Index (91 +/- 11), the average quality-of-life scores (46 on the physical component and 50 on the mental component of the Short Form-36), and the average range of motion (19 degrees to 138 degrees ) suggest favorable patient outcomes overall. Two comminuted fractures did not unite and required conversion to a total elbow arthroplasty. CONCLUSIONS Patients with isolated noncomminuted capitellar and/or trochlear fractures have better results than those with more complex fractures. A classification system based on the radiographic patterns of these fractures is recommended.

ACUTE ELBOW DISLOCATIONS: Simple and Complex

The elbow is the second most common joint dislocated in adults. Up to 20% of dislocations are associated with fractures. Treatment principles are reduction of the joint, stabilization of associated fractures, and early motion. Ligament repairs or reconstruction and hinged external fixators are necessary in some cases to restore stability for early motion. In general, simple dislocations have a better prognosis than complex dislocations (fracture-dislocations).

Outcome of plate fixation of olecranon fractures.

Objectives To evaluate the functional outcome of plate fixation for displaced olecranon fractures, both simple and comminuted. Design Retrospective patient, chart, and radiographic review. Setting Academic teaching hospital. Patients Twenty-five patients who underwent plate fixation of displaced olecranon fractures by two surgeons were independently reviewed at an average follow-up of thirty-four months (range, 15–69 months). Main Outcome Measurements Physical capability was assessed by measuring range of motion and isometric elbow strength. Patient-rated outcomes were evaluated using the SF-36, DASH, Mayo Elbow Performance Index (MEPI), and visual analogue scales for patient satisfaction and pain. Radiographs were evaluated preoperatively, postoperatively, and at the time of final review. Results The average patient age was fifty-four years (range, 14–81 years). The Mayo classification of fractures was fourteen Type II and eleven Type III. An adequate reduction was maintained in all elbows until union. Physical capability measures indicated nonsignificant side-to-side differences in motion or strength, except for supination motion, which was reduced in the injured arm (p = 0.003). The MEPI-rated outcome was twenty-two excellent or good. Patient satisfaction was high (9.7/10), with a low pain rating (1/10). The mean DASH score was consistent with almost normal upper extremity function. The SF-36 showed no difference in physical health as compared with the average American population. Twenty percent of patients required plate removal because of prominence of the internal fixation. The outcome was not influenced by fracture pattern. Conclusion Plate fixation is an effective treatment option for displaced olecranon fractures with a good functional outcome and a low incidence of complications.

Distal Biceps Brachii Tendon Repair An In Vitro Biomechanical Study Of Tendon Reattachment

Clinical reports suggest that suture anchors can simplify repair of distal biceps tendon avulsions. In this study, fixation strengths of Mitek and Statak suture anchors were compared with strength of reattachment using transosseous suture tunnels in eight cadaveric radii. Cyclic loading and load-to-failure testing were performed: No specimen failed during testing to 50 N for 3600 cycles; however, four of the Mitek anchors and one of the Statak anchors protruded out of the medullary canal. The mean load to failure of the Mitek suture anchor complexes was 220 54 N, that of the Statak suture anchor complexes was 187 64 N, and that of the transosseous sutures was 307 142 N. There was no significant difference in the failure load or mechanism of failure between the Statak and Mitek anchors. Transosseous sutures failed at significantly greater loads on static testing than the suture anchors. Cyclic loading results suggest that the bony fixation achieved using these three techniques should be sufficient to allow immediate passive mobilization of the elbow after surgery. Protrusion of the suture anchors out of the tuberosity during cyclic loading is a concern because of potential development of a gap at the repair site and interference with forearm rotation.

Muscle forces and pronation stabilize the lateral ligament deficient elbow.

The influence of muscle activity and forearm position on the stability of the lateral collateral ligament deficient elbow was investigated in vitro, using a custom testing apparatus to simulate active and passive elbow flexion. Rotation of the ulna relative to the humerus was measured before and after sectioning of the joint capsule, and the radial and lateral ulnar collateral ligaments from the lateral epicondyle. Gross instability was present after lateral collateral ligament transection during passive elbow flexion with the arm in the varus orientation. In the vertical orientation during passive elbow flexion, stability of the lateral collateral ligament deficient elbow was similar to the intact elbow with the forearm held in pronation, but not similar to the intact elbow when maintained in supination. This instability with the forearm supinated was reduced significantly when simulated active flexion was done. The stabilizing effect of muscle activity suggests physical therapy of the lateral collateral ligament deficient elbow should focus on active rather than passive mobilization, while avoiding shoulder abduction to minimize varus elbow stress. Passive mobilization should be done with the forearm maintained in pronation.

The midline posterior elbow incision. An anatomical appraisal

The formation of a painful neuroma after operations on the medial or lateral sides of the elbow is a common problem. Our aim was to determine the relationship of the cutaneous nerves to the three usual skin incisions around the elbow. In 18 freshly frozen cadaver arms we made three standard 16 cm incisions in the skin medially, laterally, and posteriorly and explored them using loupe magnification. The number of nerves crossing each incision was determined by gross observation and their diameter measured by electronic microcallipers. In ten arms, biopsies of the nerves in each incision were sent for histological examination. We found significantly more cutaneous nerves crossing the medial and lateral incisions than the posterior. The diameter of the nerves crossing the posterior incision was significantly smaller than those crossing the lateral incision. Cutaneous nerves are at considerable risk of injury when medial or lateral incisions are used to approach the elbow, but the posterior approach carries less hazard. The routine use of the posterior incision may reduce the incidence of symptomatic paraesthesia and the formation of a painful neuroma after operation.