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For those with levels of loss above the elbow, the normal prescription choice is now considered to be the use of an electric elbow combined with a myoelectric hand using a single site three state control. The lightweight VASI unit controlled by a harness mounted switch is mounted in a prosthesis the socket of which is total contact, and allows improved power transfer.
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As a result of better patient selection, implant design, and surgical technique, the long-term results of total elbow arthroplasty in patients with rheumatoid arthritis has improved significantly over the past 10 years. The semiconstrained hinge implant is used in the presence of severe bone and ligament destruction. The non-constrained surface replacement requires intact bone and ligamentous supports. Best results are obtained if surgery is undertaken before severe soft tissue contractures, muscle atrophy, and neurologic disability of the involved extremity develop.
We report on a case of arthroscopic treatment of septic arthritis of the elbow joint in a 65-year-old man with an elbow endoprosthesis. Two months after arthroplasty of the elbow joint, the patient developed acute septic arthritis of the right elbow. Methicillin-sensitive Staphylococcus aureus was identified as the causative organism. Six days after the onset of symptoms, the patient was treated with a single arthroscopic procedure of the infected periprosthetic joint, including irrigation with 5 L of Ringer's lactate solution, debridement, and partial synovectomy with a 4.5-mm curved shaver. Intravenous antibiotic therapy was also used for 3 months including rifampicine and fucidic acid according to the intraoperative cultures. The acutely infected total elbow arthroplasty could be cured without removal of the endoprosthesis of the elbow. Ten months postoperatively, the patient remains free of symptoms and his blood rates are within normal limits.
Radial head fractures are a particularly common yet challenging problem facing orthopedic surgeons today. Over the years multiple treatment modalities have been used including conservative management, open reduction and internal fixation, head excision, and radial head arthroplasty. The clinical outcome studies of metallic radial head arthroplasty systems indicate that head replacement is a reasonable option to offer patients with comminuted radial head fractures and complex elbow trauma. Overall the results for this procedure are quite encouraging and appear durable given the severity of the elbow injuries treated with radial head arthroplasty. This article discusses the history, classification, and treatments of radial head fractures. A description of the stabilizing structures of the elbow as they relate to radial head fractures also is included. Surgical considerations that relate to radial head arthroplasty are detailed and encompass arthroplasty indications, surgical technique, postoperative rehabilitation, and complications. Finally the arthroplasty outcomes literature and a review of current implant options also are discussed.
Twenty 1-stage ipsilateral shoulder and elbow joint replacements were performed in 17 patients from 1988 to 1998 in the Nottingham Shoulder and Elbow Unit, Nottingham, England. There were 12 women and 5 men with a mean age at operation of 57 years. All 17 patients had rheumatoid arthritis. The indication for performing the 2 joint replacements in 1 stage was severe symptomatic involvement of both joints. The shoulder was replaced first, with the patient being repositioned and redraped for the elbow replacement. The follow-up averaged 5 years 2 months (range, 23 months to 13 years 8 months). All patients had significant pain relief and improvement in function, and 12 of the 15 patients reviewed would have been prepared to have the same procedure on the other side, if it became necessary (in 3, this had been done). The procedure offers major advantages because the number of anesthetics is reduced, it is more cost-effective, and it facilitates functional rehabilitation.
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When the traumatic amputation level or the degree of damage to the arm or forearm does not justify reimplantation of the severed part there may be sufficient undamaged skin to be used as a free flap to resurface the arm or the stump. Stump length or the elbow joint may thus be preserved and more durable skin cover for the fitting of a prosthesis may be obtained. A "spare-parts" forearm free flap may be raised on the radial or ulnar vessels or both. Three cases are reported.
We reviewed six capitellocondylar metal-to-plastic total elbow replacement prostheses with radial head components, implanted in patients with rheumatoid arthritis. At an average of 4.7 +/- 1.5 years, relief of pain, improvement of function, and a functional range of motion were preserved. Five of the six elbows (83%) were clinically rated good or excellent. Radiolucent lines were seen at the bone-cement interface in 50% of the humeral component stems and in all ulnar component boats within 2 years after surgery; none had progressed at subsequent examination. Most were less than or equal to 1 mm wide, and none were associated with clinical deterioration. Only one of the humeral components was radiographically loose. No radiolucent lines were seen along the stems of the ulnar or radial components. There were no postoperative dislocations when the radial component was used, presumably because the prosthetic radial head provided increased constraint. None of these elbows have required revision. Radial head replacement in capitellocondylar arthroplasty had been discontinued because radiolucent lines were observed at early review. However, the absence of clinical failure, dislocation, or progression of radiolucency at long-term follow-up examination favor radial head replacement in primary unconstrained total elbow arthroplasty.
Great progress has been made in surgery of the elbow during the past decade. Better definition of ligamentous anatomy, recognition of previously undescribed instability patterns, and development of ligament reconstruction techniques have helped improve surgery designed to restore stability of the elbow. Surgical release of elbow contractures helps patients with stiffness gain very satisfactory range of motion. New techniques and advances in prostheses have broadened the indications for total elbow arthroplasty, and cases that were previously considered inoperable can now be treated surgically with excellent outcomes. Elbow surgery enters the new millennium having accomplished much, but problems and challenges remain.
Comminuted osteoporotic intercondylar fractures of the distal humerus are a treatment dilemma. We report the case of an elderly patient with a type C3 T-condylar fracture initially treated with continuous passive motion. This treatment resulted in a loss of medial stability. Pain relief and adequate function were achieved with a custom distal humeral replacement and repair of the medial collateral ligament.
This paper describes the use of computer modelling and simulation during the design and development of a motorized upper limb orthotic system to be used to aid the dysfunctional human arm. The orthosis consisted of a three-degree-of-freedom shoulder module and a lower arm module providing movements at the elbow and wrist. Simulation software has been used to model the mechanism created by the connection of the orthosis and the arm. With this model it has been possible to analyse the kinematics and kinetics of both the arm and orthosis during a variety of dynamic loading conditions. In particular, the power requirements of the orthotic joints during the execution of specific tasks have been determined and these data have been used to specify the motors of a working prototype. The effect of misalignment between real and orthotic shoulder joints has also been investigated and a potentially hazardous situation has been highlighted prior to testing of the prototype by a volunteer in the laboratory.
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The function of the hand and arm was studied after total elbow arthroplasty in a consecutive series of 18 rheumatoid patients with a total of 20 primary arthroplasties and one revision. Extensive clinical evaluation with locomotion score and Sollerman's hand function test was undertaken preoperatively and at 6 months postoperatively. The mean flexion range increased 25 degrees and extension lag decreased 5 degrees. Pain relief was achieved in all the cases, and 16 of 20 primary operated on elbows became fully painfree. Hand function score (max. 80) improved from 52 to 64, upper extremity score (max. 100) from 57 to 68 and subjective score (max. 100) from 46 to 58. Complications were 2 cases of ulnar nerve paresthesia and 1 epicondylar fissure.
Fifty-four patients in whom a total of fifty-eight semiconstrained modified Coonrad elbow implants had been inserted for rheumatoid arthritis were followed for a mean of 3.8 years (range, two to eight years). At the latest follow-up, there was little or no pain in fifty-three elbows (91 per cent). The arc of motion was from an average point in flexion of 20 degrees to an average point in flexion of 129 degrees, representing an average increase of 12 degrees of extension and 11 degrees of flexion. The average arc of pronation was 78 degrees, an increase of 14 degrees, and the average arc of supination was 77 degrees, an increase of 18 degrees. An additional ten patients who had had insertion of ten modified Coonrad implants during the same period were followed for less than two years but were included in the assessment of complications. Fifteen (22 per cent) of the sixty-eight elbows had a complication: four, infection; eight, acute or delayed condylar or ulnar fracture; and one each, ulnar neuritis, avulsion of the triceps, and fracture of the implant. Radiographic evaluation was performed for fifty-four of the fifty-eight elbows; the other four were excluded from this evaluation because of infection. A satisfactory radiographic appearance of the cement--its extent and the absence of skip areas--was noted for all of the ulnar components and for fifty-one (94 per cent) of the humeral components. No patient had radiographic evidence of a loose implant. A reoperation was performed in six elbows (10 per cent of the fifty-eight; 9 per cent of the sixty-eight): four were done for infection; one, for insufficiency of the triceps; and one, for a fractured ulnar component. Of the fifty-eight elbows, forty (69 per cent) had an excellent result; thirteen (22 per cent), a good result; four (7 per cent), a fair result; and one, a poor result.
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