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PubMed1978

[Experiences with primary osteosynthesis in radial head fractures].

Displaced fractures of the radial head are indications for early surgery. The resection is unsatisfactorily leading often to an instable elbow in valgus deformity and to painful troubles in the distal radio ulnar joint. Prosthesis implantation has its own problems. Reconstructive surgery is obviously the best solution. 21 internal fixations in 20 patients were performed using small screws (and 2 plates) between 1968 and 1976. The functional and radiological results are excellent in 15 out of 19 controlled patients. 3 patients have a moderate reduction of the mobility, 1 patient a non-union. -We were impressed by 4 operative observations: The fractures and the displacements use to be unexpectedly important. There is usually a periostal bridge between the head fragments and the neck. That is why complete devitalization of the articular fragments is rare. In about half of our cases we found an important avulsion of the humeral articular cartilage. In 8 of 10 cases these avulsions were interposed in the fragments of the radius. Their removal is necessary for the reduction. -These observations should influence the indication for reconstructive surgery in fractures of the radial head.

Adolescent↗
PubMed1995

Replacement of "other" joints.

Replacement of larger joints other than the hip and knee has been relatively disappointing and remains in a developmental stage. In the small joints, initial enthusiasm for silicone rubber arthroplasty has diminished in all sites except the MCPs because of the recognition of the high frequency of silicone synovitis. Further research and development is ongoing. This article was intended to facilitate understanding of the choices of operative procedures, the types of available components, and particularly, the specifics of radiographic assessment of the success or failure of these "other" prostheses. We hope this information will be helpful in assessing postoperative radiographs, as "We only see what we look for and we only look for what we know."

Ankle Joint↗
PubMed1996

[Quality control of prosthetic replacements of knee, ankle, toe, shoulder, elbow and finger joints in Norway 1994. A report after the first year of registration of joint prostheses in the national registry].

Total hip replacements have been recorded in the Norwegian Arthroplasty Register since 1987, and recording of the other joint arthroplasties was started in January 1994. After 12 months 1,589 primary arthroplasties had been registered; these referred to 962 knees, 11 ankles, 76 toes, 113 shoulders, 69 elbows, 12 wrists, 335 fingers and 11 carpometacarpal 1 joints. Median age of the patients was 70 years. 80% were women. Rheumatoid arthritis was the predominant reason for joint replacement, except in the case of the knees where the dominant cause was osteoarthrosis (71%) and of shoulders, 28% of which were replaced because of fractures. Cement was used in 83% of the primary arthroplasties in knee, ankle, shoulder, and elbow joints. 74% of the cement types used contained antibiotics. 9% were uncemented and 8% hybrids. 97% were given systemic antibiotic prophylaxis, most commonly first generation cephalosporins. 114 reoperations were reported. The reason was aseptic loosening in 56%, and infection in 15%. The cooperation with Norwegian orthopaedic surgeons is good. The Register thus provides a reliable picture of implants of Norway, and a good basis for future follow-up studies.

Adult↗
PubMed2004

Detrimental effects of overstuffing or understuffing with a radial head replacement in the medial collateral-ligament deficient elbow.

BACKGROUND: Comminuted radial head fractures associated with an injury of the medial collateral ligament can be treated with a radial head implant. We hypothesized that lengthening and shortening of the radial neck would alter the kinematics and the pressure through the radiocapitellar joint in the medial collateral ligament-deficient elbow. METHODS: The effects of lengthening (2.5 and 5 mm) and shortening (2.5 and 5 mm) of the radial neck were assessed in six human cadaveric upper extremities in which the medial collateral ligament had been surgically released. The three-dimensional spatial orientation of the ulna was recorded during simulated active motion from extension to flexion. Total varus-valgus laxity and ulnar rotation were measured. Radiocapitellar joint pressure was assessed with use of pressure-sensitive film. RESULTS: Radial neck lengthening or shortening of >/=2.5 mm significantly changed the kinematics in the medial collateral ligament-deficient elbow. Lengthening caused a significant decrease (p < 0.05) in varus-valgus laxity and ulnar rotation (p < 0.05), with the ulna tracking in varus and external rotation. Shortening caused a significant increase in varus-valgus laxity (p < 0.05) and ulnar rotation (p < 0.05), with the ulna tracking in valgus and internal rotation. The pressure on the radiocapitellar joint was significantly increased after 2.5 mm of lengthening. CONCLUSIONS: This study suggests that accurate restoration of radial length is important and that axial understuffing or overstuffing of the radiohumeral joint by >/=2.5 mm alters both elbow kinematics and radiocapitellar pressure. CLINICAL RELEVANCE: This in vitro cadaver study indicates that a radial head replacement should be performed with the same level of concern for accuracy and reproducibility of component position and orientation as is appropriate with any other prosthesis.

Aged↗
PubMed2004

Total elbow arthroplasty: current indications, factors affecting outcomes, and follow-up results.

Indications for total elbow arthroplasty (TEA) are expanding in light of newly published follow-up studies. The unique characteristics of the pathologic condition, appropriate patient selection, suitable choice of prosthesis, and proper surgical technique are critical factors that have a large impact on the ultimate results of TEA for any indication. This article addresses these factors as they relate to various indications and presents a review of the recently published results of the 10-year follow-up studies for TEA.

Arthritis↗
PubMed1986

[Elbow joint].

The elbow joint is a key joint for positioning of the hand. Four operations have to be considered for the rheumatoid elbow: removal of rheumatoid nodules and bursectomy, resection of the radial head, synovectomy, and arthroplasty. Synovectomy and arthroplasty are carefully analyzed, both from the point of view of recent international literature as well as personal experience. Synovectomy of the elbow is highly effective even when performed relatively late (stage 3 according to Larsen-Dahle-Eek) insofar as pain relief and swelling are concerned. In long-term disease, deterioration as assessed by radiology can usually not be prevented, but clinical improvement may be the reason for the relatively rare indication for arthroplasty. According to recent literature, the results of elbow arthroplasty vary greatly. Fully constrained hinges should no longer be used, and no decision has been made so far on whether semiconstrained or nonconstrained surface replacement is preferred. We use the semiconstrained GSB Mark II prosthesis, which has provided results in nearly 50 cases that rank among the best reported from the point of view of pain relief, improvement of ROM, and low complication rate. Use of our so-called transtricipital approach to the elbow has proved particularly valuable, especially with regard to lack of extension and muscle strength.

Arthritis, Rheumatoid↗
PubMed1994

[Microsurgical coverage of proximal amputation of the forearm. Functional value of preservation of the elbow joint].

The authors reported three traumatic cases of below-elbow amputation. The proximal squeleton of the forearm was bare-exposed and the replantation was not done due to the mechanism of the injury. To preserve the function of the elbow joint which the main components were safe, the soft tissue coverage was realized by a musculocutaneous latissimus dorsi free flap in each case. A body-powered forearm prosthesis was adapted for the three patients who were able to return to an adapted job in an average time of 8 months. The importance of the preservation of the elbow joint to improve the function in upper limb amputees is discussed.

Adult↗
PubMed2004

The effect of the orientation of the noncircular radial head on elbow kinematics.

OBJECTIVE: The objective of this study was to identify the effect of radial head shape and orientation on elbow kinematics in the otherwise intact elbow. DESIGN: Biomechanical study, analyzing simulated active motion of cadaveric arms. BACKGROUND: A discrepancy exists between the noncircular anatomy of the radial head and radial head prostheses. The effect of radial head shape is unknown. METHODS: Kinematic effects of radial head shape were tested in six fresh-frozen upper extremities. A custom-made native radial head prosthesis was used to simulate altered shape conditions, by rotating the radial head 90 degrees. Three-dimensional spatial orientation of the ulna was recorded, during simulated active motion. A three factor ANOVA was used to compare (a) nominal and 90 degrees oriented conditions, (b) throughout the flexion arc (c) in three forearm positions (P < 0.05). Post-hoc Tukey tests were done to assess significance. RESULTS: No significant effect of altering radial head shape was found on total ulnohumeral laxity and angulation during gravity valgus stress. We did find a significant effect on total ulnar axial rotation and rotation during gravity valgus stress. CONCLUSION: The outer shape of the radial head seems to change rotation of the ulna during flexion-extension in an otherwise intact elbow. RELEVANCE: The shape of the radial head effects intact elbow kinematics. Clinical importance of this finding is clear. If a sub-optimally placed radial head prosthesis were to be used in an otherwise intact elbow, the elbow could be at risk for early ulnohumeral arthritis.

Biomechanical Phenomena↗
PubMed1992

[Radio-carpal amputation and prosthesis].

Radio-carpal amputation was rejected for a long time because of the difficulties of fitting both myoelectrical and mechanical prostheses, only allowing a purely aesthetic prosthesis. As a result of miniaturization of control systems and the progress in computers, we believe that this now constitutes the best site for amputation whenever it is possible. Preservation of the antero-posterior bony contours of the radius allows the use of short sockets attached by a system of clips. In this way, flexion-extension of the elbow is left free and the movements of pronation and supination can be used. Liberation of the proximal joints facilitates integration of the prosthetic hand.

Amputation, Surgical↗
PubMed1994

[Treatment of displaced and comminuted multifragment fractures of the head of the radius: is resection a therapeutic option?].

The treatment of displaced comminuted fractures of the radial head type III of the Mason classification is still controversial. The restoration of anatomy including additional lesions with a stable fixation is a prerequisite of early mobilisation. Removal of the radial head, in case of severe comminution, and complete separation of the fragments from the radial neck remain the exception. Insertion of a prosthesis as a spacer is only recommended if there is a remaining instability of the elbow after resection of the radial head. With this treatment modality we have 22/29 good to very good results evaluated by the Morrey score after a follow-up period of 8 years (4-11 years).

Adult↗
PubMed1996

[Guépar's total radio-carpal prosthesis in the surgery of the rheumatoid wrist. Apropos of 72 cases reviewed].

PURPOSE OF THE STUDY: Total wrist arthroplasty is an alternative to arthrodesis in the treatment of the rheumatoid wrist. MATERIAL AND METHODS: Seventy-two GUEPAR total wrist arthroplasties in sixty-four patients with rheumatoid arthritis were reviewed 1 to 10 years after the operation (average follow-up of 4 years). GUEPAR total wrist arthroplasty is a bicondylar prosthesis. The radial component made of polyethylene is cemented in the radius. The carpal component made of metal is fixed by two screws in the second and the third metacarpal. This component is constitued by two pieces: a perforated lower part permitting the passage of the screws and its metacarpal fixation and a biconvex cover fixed on the lower part by a micro-screw. RESULTS: In preoperative evaluation, all patients had severe pain and loss of function. Post-operatively, 89 per cent had no pain or mild pain and 96 per cent had better function. The average arc of flexion-extension was 47 degrees preoperatively and 39 degrees postoperatively. There were no deep infections or dislocations. Seventy percent of the patients were satisfied but eleven wrists (15 per cent) required revision: 5 cases for prosthesis revision and 6 cases for implant removal and arthrodesis. Prosthesis revisions were justified by the unscrewing of the carpal component micro-screw: they gived good results. Arthrodesis was required for 4 radial component loosening and for 2 important bone resorptions under the carpal component. Radial component loosening was associated in 3 cases with unscrewing of the micro-screw. Radiographical analysis showed in nearly all cases of this serie a bone resorption under the carpal component. This resorption was 2 mm wide at an average of to 2 years and 4 mm wide at 4 years. DISCUSSION: Clinical results of this study are good but eleven wrists required revision. Nine of these revisions were due to anomalies of first prosthesis: the unscrewing of the carpal component micro-screw was accountable to abnormal use of polyethylene with reaction of the wear products and loosening of the radial component. This problem is now resolved. More disquieting is the bone resorption under the carpal component. In fact, this resorption was constant and evolutive. It was very likely due to micro-movements between the metacarpal screws and the carpal lower part. Also, the conception of the metacarpal-fixation of this prosthesis must be revised. CONCLUSION: In rheumatoid arthritis, wrist arthrodesis gives good results if nothings affects the fingers, elbow or shoulder. If they are affected, total wrist arthroplasty is an alternative. Long term loosening of total wrist arthroplasty is a significant problem so its indication must be reserved for old patients.

Adult↗
PubMed1981

Total elbow arthroplasty. A five-year experience at the Mayo Clinic.

During the five years from 1973 through 1977, eighty Mayo and Coonrad total elbow arthroplasties were performed in seventy-two patients at the Mayo Clinic. Follow-up after at least two years (average, four years) revealed that the results were good in 60 per cent, fair in 16 per cent, and poor in 24 per cent. Pain was a major symptom in 80 per cent of the elbows preoperatively but in only 3 per cent postoperatively. At follow-up, motion had increased: extension-flexion by 10 degrees (average range, 29 to 131 degrees of flexion) and forearm rotation by 26 degrees (average range, 61 degrees of pronation to 59 degrees of supination). Excluding eleven prostheses with loosening for which revision was necessary, there were forty-four complications (55 per cent) after eighty procedures. Of these forty-four complications, eleven were ulnar neuropathies (two permanent and nine transient); four were wound-healing problems; ten, significant triceps weakness; eleven, intraoperative fractures of the medial or lateral supracondylar bone column; seven, deep infections; and one was an ulnar fracture. Although the complication rate was very high, most of the complications occurred during the early years of the study. Follow-up revealed twenty-nine elbows with radiolucency around the components: in twenty-five about the humeral and in four about the ulnar component. Revisions were performed in nineteen (24 per cent) of the eighty elbows: in eleven because of loosening, in seven because of deep infection, and in one because of ankylosis. Intraoperative supracondylar fracture and defective cementing of the prosthesis were important factors contributing to prosthetic loosening. When the arthroplasty was successful, the relief of pain was dramatic, stability was excellent, and the range of motion was superior to that provided by any other procedure currently available.

Arthritis↗
PubMed1985

Multiple replacements of major joints in rheumatoid arthritis.

Multiple total joint replacements were performed in 51 handicapped rheumatoid patients. Three joints were replaced in 23 patients, four joints in 25 patients, five joints in one patient, and six joints in two patients, for a total of 186 replacements of elbow, hip, knee and ankle joints. By the time of followup, seven of the patients had died due to unrelated causes. Evaluation of the walking ability in the remaining 43 patients revealed that 20 out of 22 nonambulatory patients had become able to walk indoors and outdoors, and 21 patients who had been able to walk only indoors became able to walk outdoors as well. Major complications occurred in 11 patients: femoral neck fracture in three, supracondylar fracture of the femur in three, cervical myelopathy in two, and loosening of the femoral prosthesis in two patients. The factors responsible for poor results in two patients were cervical problems and loss of motivation.

Adult↗
PubMed1998

The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study.

Sixty-nine patients (seventy-eight elbows) who had rheumatoid arthritis were managed with a Coonrad-Morrey total elbow arthroplasty between 1981 and 1986. At the time of the present review, forty-one patients (forty-six elbows) were alive and had been followed for at least ten years after the procedure (Group 1). The remaining twenty-eight patients (thirty-two elbows) had died or had had a revision less than ten years after the procedure or had been followed for less than ten years (Group 2). The patients in Group 1 had a younger mean age at the time of the procedure, but all other preoperative parameters were similar for both groups. At the latest follow-up evaluation, 97 per cent of the elbows (forty-five of the forty-six in Group 1 and thirty-one of the thirty-two in Group 2) were not painful or were only mildly painful. The mean arc of flexion-extension was 28 to 131 degrees; this represents an increase of 13 degrees (15 degrees in Group 1 and 7 degrees in Group 2) compared with the preoperative value. The mean arc of pronation was 68 degrees, and the mean arc of supination was 62 degrees; this represents an increase of 21 degrees. The results for seventy-four of the seventy-eight elbows (all forty-six in Group 1 and twenty-eight of the thirty-two in Group 2) were considered satisfactory by the patients. One patient thought that the status of the elbow was unchanged compared with preoperatively, and three thought that it was worse. Seventy-six of the seventy-eight elbows had long-term radiographic evaluation; the two remaining elbows were excluded because a resection arthroplasty had been performed. There were two loose ulnar components; one was associated with an infection, and the other had been causing no symptoms at the time of the patient's death. In addition, both components were radiographically loose in an elbow that had had a revision without cement after a previous total elbow arthroplasty. Five bushings (7 per cent) were completely worn, and six (8 per cent) were partially worn. Complications occurred in eleven elbows (14 per cent) and were serious, necessitating reoperation, in ten (13 per cent). Delayed complications included three avulsions of the triceps, two deep infections, two ulnar fractures, and one fracture of an ulnar component. In addition, two elbows were revised because of aseptic loosening. No patient had persistent ulnar neuritis or serious skin complications. At the latest clinical follow-up evaluation, according to the Mayo elbow performance score, forty-three of the seventy-eight elbows had an excellent result; twenty-six, a good result; seven, a fair result; and two (both in Group 2), a poor result. The rate of survival of the prosthesis was 92.4 per cent, with 86 per cent good or excellent and 14 per cent fair or poor results.

Activities of Daily Living↗
PubMed2006

Improved myoelectric prosthesis control accomplished using multiple nerve transfers.

BACKGROUND: The control of shoulder-level disarticulation prostheses is significantly more difficult than that of prostheses for more distal amputations. Amputees have significant difficulties coordinating the separate functions of prosthetic shoulder, elbow, wrist, and hand/hook components. The user must lock one joint at a particular position in space before subsequently moving a different joint. METHODS: A patient with bilateral humeral disarticulations after an electrical injury underwent a novel nerve transfer procedure designed to improve the control of a myoelectric prosthesis. The median, radial, ulnar, and musculocutaneous nerves were transferred to the nerves of segments of the pectoralis major and minor muscles. Those muscles then act as bioamplifiers of peripheral nerve signals when the normal upper extremity nerves are activated by the patient's brain. Therefore, when the patient thinks "flex elbow," the transferred musculocutaneous nerve fires, and a segment of the pectoralis major contracts. An electromyographic signal is then detected transcutaneously and causes the prosthetic elbow to flex. RESULTS: Three of the four nerve transfers were successful. One of the nerve transfers unexpectedly yielded two separate controllable muscle segments. Standardized testing using a "box-and-blocks" apparatus was performed with the patient's previous myoelectric device and the current device after nerve transfers. The patient's performance improved by 246 percent. CONCLUSIONS: Nerve transfers to small muscle segments are capable of creating a novel neural interface for improved control of a myoelectric prosthesis. This is done using standard techniques of nerve and flap surgery, and without any implantable devices.

Arm↗