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In a patient with a severely damaged elbow, the complication of gas gangrene could be controlled without amputating the arm. However, massive bony defects resulted in a flail elbow joint and an attempt to fit a specially designed endoprosthesis replacement failed. Four years post-injury, the flail joint was fused by three bone grafts on three separate occasions. These experiences are reported and discussed.
Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a period of 30 years. There were eight primary and two secondary tumours in four men and six women with a mean age of 47.5 years (15 to 76). The mean follow-up was eight years (9 months to 31 years). Four patients required further surgery, three having revision for aseptic loosening; two of these and one other later needing a rebushing. There were no cases of postoperative nerve palsy, infection, local recurrence or mechanical failure of the implant. Four patients died from their disease, all with the prosthesis functioning satisfactorily. At follow-up the mean flexion deformity of the elbow was 15 degrees (0 to 35) and the mean range of lexion was 115 degrees (110 to 135). The functional results showed a mean Toronto extremity salvage score of 73% of normal. Endoprosthetic replacement of the distal humerus and elbow is a satisfactory method of treating these rare tumours.
In 34 primary and 18 revision total elbow arthroplasties (TEAs), rheumatoid arthritis (RA) was the most common indication, with traumatic arthritis next most common. The indications were primarily pain and decreased range of motion. Follow-up time averaged 7.6 years for index arthroplasties. Complication rates of primary arthroplasties were high, with 40% neural problems, 9.3% aseptic loosening, and 13.3% early postoperative infection. Overall function was satisfactory in 68% of patients with RA. In agreement, the rates of revision were high. Overall satisfaction was good, and function was fair in patients with TEA.
From 1993 to 1996, we implanted 20 primary GSB IlI prostheses in 17 patients with rheumatoid arthritis. The Mayo Clinic performance index for the elbow was used for the evaluation. The average follow-up was 3 (2-5) years. At the follow-up examination, 12 elbows had an excellent result and 8 a good result. The median performance index increased from 30 (15-53) points to 95 (80-100) points. The subjective assessment was excellent for 11 elbows, good for 8 and poor for 1.2 elbows had radiographic loosening with a progressive radiolucent line and a change in the orientation of the prosthesis.
The authors report 6 patients (7 joints) in whom inflammation, dermal necrosis, dermatitis or fistula formation was attributed to the materials commonly used for joint endoprostheses. Histological appearances and chemical analyses of the involved tissues are presented, together with a discussion of the possible mechanism and methods of diagnosis and treatment.
INTRODUCTION: Rehabilitation of traumatic upper limb amputees depends on a multitude of factors. This study attempts to evaluate the success of prosthetic rehabilitation in this group of patients, determine the reasons for non-compliance and find ways to increase prosthetic acceptance. MATERIALS AND METHODS: The prosthetic rehabilitation status of 71 traumatic upper-limb amputees was assessed by a questionnaire and clinical review. A Prosthetic Rehabilitation Scoring (PRS) system, based on patient satisfaction, prosthetic usage and activity level, was devised to quantify the success of rehabilitation. RESULTS: The rehabilitation was found to be equally good in above-elbow and below-elbow amputees. The delay in fitting of the prosthesis had no correlation with successful rehabilitation. Chances of successful rehabilitation decreased when the prosthesis fitting was done in older patients. The main reasons for inadequate use of the prosthesis were repeated mechanical failure and the high cost of repair and replacement. CONCLUSION: In order to achieve an optimum benefit for the patient in a developing country, the prosthesis should be durable, inexpensive and have a low cost of maintenance.
Elucidation of the contact areas between joint surfaces is important to both prosthetic design and the understanding of degeneration of articular cartilage. Numerous experimental methods are available to study joint contact, including cartilage staining, joint space casting, and pressure sensitive film techniques. This study attempts to compare the ability of each experimental technique to determine elbow joint contact. The silicone casting technique appears to be the best method to study joint contact area. The effects of magnitude and orientation of applied forces on the elbow joint contact patterns are studied.
This study examined the kinematic characteristics of the Pritchard ERS elbow-resurfacing system, with special attention paid to the effects of the radial head component. The kinematics between the ulna and humerus were assessed in 6 human cadaveric specimens by an electromagnetic tracking system throughout a full flexion/extension range of motion. The elbows were studied under 2 loading conditions, in 3 orientations (neutral, varus, and valgus), and under 4 surgical conditions. The varus/valgus and internal/external rotation laxities were used to assess the condition differences. Specifically, the maximum laxities throughout the extension motion were compared, as were the laxities at 40 degrees, 75 degrees, and 110 degrees of flexion. Both the varus/valgus and internal/external rotation laxities of the ulnohumeral joint increased after total elbow arthroplasty (TEA) implantation, with and without a radial head. This increase was most evident in the extension portion of the arc of motion. At 40 degrees of flexion, the varus/valgus laxity of the intact elbow was 4 degrees +/- 2 degrees versus 11 degrees +/- 8 degrees for a TEA with a radial head and 22 degrees +/- 11 degrees for a TEA without a radial head while the elbow was being subjected to compressive loads via the biceps, brachialis, and triceps. The kinematic data demonstrate a consistent increase in laxity with the Pritchard ERS TEA. They also indicate that a radial head component is necessary for optimal tracking and stability of the ERS arthroplasty.
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In rheumatoid arthritis, the elbow is involved in 20 to 50% of the cases. Surgical treatment for rheumatoid arthritis is proposed to patients in whom an appropriate and adequate attempt at medical management has failed. Improvements in surgical technique and prosthetic design have led to more predictable results in the surgical treatment of the rheumatoid elbow. Surgical treatment of the patient with rheumatoid arthritis continues to evolve. Synovectomy continues to be an effective palliative procedure, preferred in the early stages of disease (I, II, IIIA) with or without radial head resection. Further investigation into the use of arthroscopic techniques may result in decreased morbidity and a quicker recovery. In more advanced stages (IIIA, IIIB, IV), total elbow replacements by experienced surgeons employing contemporary designs, unconstrained or semiconstrained, and surgical techniques are associated with a high degree of success with long-term follow-up, approaching that fortotal hip and knee replacement. Finally, interposition arthroplasty can be proposed for young adults with stage II or IIIA rheumatoid arthritis in whom the elbow is mainly stiff and painful.
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Previously published work has revealed an 87% survivorship after 12 years for the standard Souter-Strathclyde total elbow arthroplasty in patients with rheumatoid arthritis. Of the 13% that were revised, 75% were due to loosening of the humeral component. The aim of this research was to identify the specific epidemiologic and intraoperative factors that predisposed to this humeral loosening. Specifically, factors such as age, sex, radiologic staging of the disease, position of the implant in bone, and size of the implant inserted were evaluated. After analysis of 186 cases, we concluded that the position of the humeral component within the humerus is crucial for long-term survivorship. Specifically in the lateral plane, the stem should be aligned in the plane of the humerus and the implant inserted to the correct depth. The articular surface of the implant should lie at the level of the normal trochlea. At the anteroposterior plane, the implant should sit centrally and not be lateralized. We conclude that good surgical technique is crucial to the long-term effectiveness of this implant.
Three special cases of tabic arthropathy are reported. The disease is displayed in detail. One case showed an aneurysma of the arteria ulnaris. After resection of the aneurysma conservative treatment was performed. In a second case with active not yet diagnosed tabic hip a cemented total hip was implanted, which failed only 9 weeks later. The third case was an inactive tabic hip joint. The implantation of a cementless Autophor hip proved well. Total joint replacement has not to be performed in an active state of the disease, but can be done after consolidation. The significance of the VDRL-test for justing the activity of the disease is displayed.
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Total elbow arthroplasty remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow. Complication rates have historically been quite high, and early revision was not uncommon. A greater understanding of elbow anatomy and kinematics has led to advances in prosthetic design and surgical technique. The success of modern elbow arthroplasty for low-demand patients with rheumatoid arthritis has approached that of hip and knee arthroplasty. Mechanical failures have been noted to increase as a complication of both longevity and the use of elbow arthroplasty in a younger, higher-demand patient population. As the indications for total elbow arthroplasty widen to include more complex situations, it becomes more important to precisely recreate the flexion-extension axis of the elbow to optimally balance muscle forces and ligaments in an effort to improve implant durability. Advances in implant modularity and instrumentation can make determination and recreation of the flexion-extension axis more reliable and reproducible. An anatomic convertible implant allows the surgeon great versatility in choosing to perform hemiarthroplasty or unlinked or linked total elbow arthroplasty with assurance that later revision can be performed without the compulsory removal of well-fixed components. Conversion from an unlinked to a linked constraint, and visa versa, can be performed at any time. If late conversion is required, it can be performed in a minimally invasive fashion.
I suggest that for too long the problem of the rheumatoid elbow, particularly the need for surgical intervention, has been underestimated. Where the latter has been advocated the philosophy has been adopted that synovectomy and debridement with excision of the head of the radius is probably all that is required, or that in the late case excision arthroplasty may yield an adequate result. I suggest that these approaches are no longer tenable. Synovectomy and debridement with or without excision of the head of the radius does indeed retain an extremely valuable place in the management of stage 1, 2, and early stage 3 disease. In the later stages of the disease, however, serious consideration must now be given to total joint replacement, the results of which can be remarkably successful and durable, and the complications from which can now be contained within acceptable limits provided that the operating team is fully experienced. It must also be stressed how necessary it is in the medical or combined clinic to pursue careful clinical and radiological monitoring of the rheumatoid elbow so that signs of dangerous deterioration can be recognised early, and surgery applied at a time when optimal conditions for the particular surgical weapons to be used still exist.
UNLABELLED: We present a case of a prolonged anaphylactic reaction that occurred in temporal relationship to the administration of cefazolin. Subsequent allergy testing was positive for latex and negative for cefazolin-both unexpected results. Our case illustrates that medications administered before the onset of anaphylaxis should not be assumed to be the causative allergen and that a latex allergy should be considered in the differential diagnosis. Because the etiology of an anaphylactic reaction cannot be immediately determined, patients experiencing intraoperative cardiovascular collapse should be treated in a latex-free environment. IMPLICATIONS: We describe a patient who experienced latex-induced intraoperative anaphylaxis. The event coincided with antibiotic administration, which prompted us to erroneously assume that the causative allergen was medication related. Allergy to latex must always be considered as a potential culprit of perioperative cardiovascular collapse.
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