Thomas L. Mehlhoff

Ilizarov treatment of infected nonunions of the distal humerus after failure of internal fixation: an outcomes study.

Objective: To report the functional outcomes of Ilizarov treatment of infected nonunion of the distal humerus. Design: Prospective case series. Setting: Tertiary referral center. Patients: Between July 1998 and August 2003, 6 consecutive patients (age 33 to 73 years) were referred to us with an infected nonunion of the distal humerus following failure of open reduction and internal fixation. The average time from initial injury to presentation with the nonunion was 27 months (range, 6 to 99 months). The average number of prior surgeries was 2.8 (range, 1 to 4). Intervention: Hardware removal, ulnar nerve neurolysis, 1 stage debridement, autogenous bone grafting, and application of an Ilizarov external fixator with acute compression in the operating room followed by slow gradual compression (0.25-0.50 mm per day) for several weeks postoperatively. Measurements: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; SF-12 Physical Component Scale (PCS); Brief Pain Inventory; quality-adjusted life years. Results: All patients attained bony union. One patient refractured 3 weeks after removal of the external fixator following a fall and ultimately underwent total elbow arthroplasty. At an average follow-up of 4.1 years (range, 2 to 7 years), none of the remaining 5 patients had undergone any additional surgery on their arm and all were free of infection. For these 5 patients, significant improvements were seen in standardized DASH scores (42% initially to 78% at follow-up, P = 0.017), worst pain intensity ratings (5.4 initially to 0.8 at follow-up, P = 0.007), and SF-12 PCS scores (37 initially to 44 at follow-up, P = 0.041). On average, the pretreatment to posttreatment improvement was equivalent to 3.8 quality-adjusted life years. Conclusions: Ilizarov treatment of infected distal humeral nonunions that have failed internal fixation restores function, decreases pain, and improves quality of life. The Ilizarov method should be considered a primary treatment option for this disabling and difficult clinical problem.

Elbow lateral collateral ligament injuries

The lateral collateral ligament (LCL) of the elbow is a complex capsuloligamentous structure critical in stabilizing the ulnohumeral and radiocapitellar articulations. LCL injury can result in elbow instability, allowing the proximal radius and ulna to externally rotate away from the humerus as a supination stress is applied to the forearm. Elbow dislocation is the most common cause of LCL injury, followed by iatrogenic injury. LCL pathology resulting in late recurrent instability is rare but disabling. The diagnosis requires a high index of suspicion, detailed history, and focused physical examination maneuvers. Stress radiographs are often the most useful imaging modality. Despite controversy over the anatomy of the LCL complex and the relative importance of its component structures, treatment of late instability is focused on lateral ligament reconstruction from the humerus to the ulna using tendon grafts with reasonably good outcomes.

Bilateral ruptures of the distal biceps brachii tendon

BACKGROUND The purpose of this study was to identify characteristics associated with bilateral ruptures of the distal biceps tendons. METHODS We present a retrospective case series of 25 patients who sustained non-simultaneous bilateral distal biceps brachii tendon ruptures that were repaired surgically, with follow-up available on 10 patients. The average age of the patients was 50 years (range 28-76). All patients were male. The mean time from the first tendon rupture to the contralateral tendon rupture was 2.7 years (range 0.5 - 6.3). Follow-up averaged 45 months (range 24-85). RESULTS Patients with bilateral ruptures tended to be middle-aged men, who commonly participated in weight lifting, manual labor, or sports, and who had higher rates of nicotine (50%) and anabolic steroid use (20%) than the general population. After surgical repair of 9 of 10 patients, patients with bilateral distal biceps tendon ruptures had good to excellent outcomes. With the numbers available, outcomes were not statistically associated with manual labor, past medical history, prescription medications, prior tendon injury, body mass index, current activity in sports, use of nutritional supplements, or anabolic steroid use, although workers compensation claims approached statistical significance (p = 0.059). CONCLUSIONS Patients who sustained bilateral distal biceps tendon ruptures tended to be middle-aged men with higher rates of nicotine and anabolic steroid use than the general population.

Total Elbow Arthroplasty: Surgical Technique

Implant arthroplasty about the elbow using custom metal components for the distal humerus and proximal ulna was developed in the 1960s. Before this time, the only salvage procedures available for destructive joint disease about the elbow were resection arthroplasty, fascial interposition arthroplasty, or elbow arthrodesis. Today, many total elbow arthroplasty designs are available and used throughout the world. The Coonrad-Morrey total elbow prosthesis (Zimmer, Warsaw, IN) is the most widely used implant for elbow arthroplasty in the United States and has been chosen for discussion in this surgical technique article.

Distal humeral fractures: fixation versus arthroplasty.

The management of the distal humeral fracture in the adult elbow continues to be problematic. The bony anatomy of the distal humerus challenges fixation of the fracture, especially when compromised by comminution and osteoporotic bone. There is little controversy that a wellperformed open reduction and internal fixation will yield a superior outcome to the historical ‘‘bag of bones’’ treatment. New techniques for exposure and precontoured plates with locking technology have enhanced the potential for fixation of these fractures. Still, internal fixation using plates is not without complications and sometimes unsatisfying results. Osteoporosis in the elderly often leads to severe comminution, which may render open reductioneinternal fixation (ORIF) impossible. Total elbow arthroplasty (TEA) in the elderly has been shown to be a viable option, but it has its own complications and mandates permanent lifting restrictions. Distal humeral hemiarthroplasty eliminates polyethylenewear, but not loosening, and itsmediumto long-term results, need for restrictions, and potential complications are yet unknown. This review will present the challenges for management of the highly comminuted type C distal humeral fracture. The treatment principles to better achieve ORIF in these complex cases will be discussed, followed by suggestions regarding when to consider arthroplasty. Finally, we present an algorithm for the treatment of distal humeral fractures to assist decision making for the orthopaedic surgeon.

Triceps Tendon Repair

Complete triceps tendon rupture is relatively rare, but more commonly seen in the athletic population. Loss of extension strength is the functional deficit for the elbow after rupture of the triceps tendon. Although partial tears may be treated conservatively, complete tears of the triceps tendon must be repaired to provide active extension at the elbow. Our preferred surgical technique for repair of the acute triceps tendon rupture is presented, as well as strategies for reconstruction of the triceps tendon with an Achilles tendon allograft.