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PubMed1991

Cellular events in the mechanisms of prosthesis loosening.

The functional restoration of a joint damaged by trauma or disease is obtained by prosthetic surgery. In particular the implantation of hip prostheses is regarded as routine in orthopedic surgery and thorough research has been developed in this field. The prosthetic replacement of the knee and even more so the ankle and elbow occurs less frequently in clinical practice and has been studied less intensively. The results of artifical hip replacement are generally good, both in terms of pain relief and the restoration of satisfactory joint function. Nevertheless, as time passes, a high rate of failures have been recorded due to prosthesis infections, fracture and wearing of the prosthetic components and prosthesis loosening by various causes. The use of ultra-filtered air and laminar flow in operating theatres and antibiotic prophylaxis have dramatically reduced the incidence of infections in total hip arthroplasty. Thanks to the setting up of new stem configurations and the use of superalloys that are highly resistant to fatigue failure, the fracture of the femoral component has been virtually eliminated as a complication of total hip arthroplasty replacements. Loosening is thus the most frequent complication in total hip replacement.

Bone Cements↗
PubMed2006

Design and implementation of an instrumented ulnar head prosthesis to measure loads in vitro.

The development of a novel instrumented implant for ulnar head replacement is presented in this study. This implant was instrumented with strain gauges to quantify bending moments about the anatomic axes of the distal ulna, and subsequently the distal radioulnar joint (DRUJ) reaction force magnitude. The implant was surgically inserted in seven cadaveric upper extremities, which were subsequently mounted in a custom joint simulator. Simulated active unresisted pronation and supination motion trials were conducted using computer-controlled pneumatic actuators to simulate forearm musculature. Passive (unloaded) trials were also conducted. The reaction force across the DRUJ ranged from 2 to 10 N in magnitude during this unresisted motion. Increased bending moment magnitudes were measured when the forearm was positioned in supination compared to pronation. The magnitude of joint bending moments showed a consistent pattern with forearm position, regardless of simulated active or passive rotation, or supination and pronation motion trials. This result illustrates that the primary influence on joint load is likely the position and contact with the radial articulation. This study of DRUJ loading should be useful for biomechanical modeling, implant design considerations and improved knowledge of articular mechanics.

Aged↗
PubMedDate not supplied

The Kudo total elbow arthroplasty in patients with rheumatoid arthritis.

A Kudo total elbow arthroplasty (TEA) was performed in 36 elbows in 35 patients with rheumatoid arthritis. Of those 35, 4 died, 6 prostheses were revised, and 2 were lost to follow-up. Twenty-four elbows with a mean follow-up of 58 months were radiologically and clinically reviewed. Sixteen were scored as excellent by use of the Mayo score and Hospital for Special Surgery 2 score. The mean increase in active motion was 25 degrees. Two humeral and four ulnar radiologic loosenings were noted. Two early dislocations were successfully treated with closed reduction and cast immobilization, two patients used an elbow brace after the closed reduction, and one patient underwent a resection arthroplasty for instability and deep wound infection. Four aseptic loosenings, of which three had an intraoperative fracture at the index operation and one had instability, were revised. Despite initially excellent results, longer follow-up of TEA in rheumatoid patients demonstrated deterioration of the outcome and increased loosening.

Adult↗
PubMed2005

The kinematic importance of radial neck length in radial head replacement.

Comminuted radial head fractures can be treated with a radial head implant. The effects of lengthening (2.5 mm, 5 mm) and shortening (2.5 mm, 5 mm) of the radial neck, were compared to the nominal length in six human upper extremity cadavers. Total varus-valgus laxity and ulnar rotation were recorded. We hypothesized that restoring the exact length of the radius is important to maintain normal kinematics in the elbow joint. Lengthening or shortening of more than 2.5 mm significantly changed elbow kinematics. Lengthening caused a significant decrease (p < 0.001) in varus-valgus laxity, with the ulna tracking in varus and external rotation. Shortening caused a significant increase in varus-valgus laxity (p < 0.001) and ulnar rotation (p < 0.001), with the ulna tracking in valgus and internal rotation. Our study suggests that a restoration of radial length is important and that axial understuffing or overstuffing the radiohumeral joint by 2.5 mm or more, will alter elbow kinematics.

Aged↗
PubMed1996

Isolation and quantitation of debris particles around failed silicone orthopedic implants.

Silicone elastomer implants have a relatively low rate of complications, but inflammatory reactions to debris have been reported. To characterize the size and number of debris particles, we isolated and quantified the debris particles present in the periarticular tissues of 10 patients with failed silicone wrist, elbow, or finger implants. Five rheumatoid synovia without implants were used for negative controls. The number of particles ranged from 0.99 to 24.8 x 10(9) per gram (dry weight) of tissue, and nearly all particles were silicone, as determined by x-ray spectroscopy. The implantation duration ranged from 3.2 to 10.6 years, and for the five wrist implants, the number of particles correlated with duration in vivo. The particles were small (mode particle diameter was 0.59 +/- 0.057 micron). These results suggest that billions of particles, most of which are smaller than 1 micron, are present adjacent to failed silicone implants, and may be associated with inflammation and bone resorption.

Elbow Joint↗
PubMed2004

Modeling and finite element analysis of a new revision implant for the elbow.

Failed total elbow arthroplasties often are associated with significant bone loss, especially at the level of both humeral condyles. Regular implants might not be ideal for those revision cases and either custom-made implants or complex bone reconstruction procedures with grafts are needed. The goal of the current study was to develop a new revision implant, based on an existing total elbow system (GSB III). The new revision humeral component, with an anterior flange instead of condylar flanges, was designed in a computer-aided design program and virtually implanted in a modeled humerus from a cadaver and subsequently was tested in a finite element model under different loading conditions. The overall distribution of the von Mises stress, as a generalized stress intensity factor, did not differ significantly between the GSB III and the new revision component. There was a tendency that the anterior flange, compared with the condylar flanges, protected the implant-cement-bone interface in the critical region of the distal stem. The finite element analysis suggests that the revision concept for failed total elbow arthroplasties, to rely on existing anterior humerus cortex instead of reconstruction of the condylar bone, seems to have no disadvantage in terms of stress distribution on the implant.

Arthroplasty, Replacement↗
PubMed2003

Arthroplasty of the elbow in haemophilia.

Total elbow replacement can be a valuable option for the treatment of the elbow in haemophilia where there are associated arthropathic changes. We describe the outcome of seven elbow replacements in five consecutive patients with severe haemophilia A (native factor levels < 1%) at a mean of 42 months (25 to 65) after operation. All the patients had excellent relief of pain and improvement in function. One failure was due to infection in an immunocompromised patient with both HIV and Hepatitis C antibodies who was on anti-retroviral chemotherapy. The implant was revised at 30 months in a one-stage procedure and showed no evidence of loosening or infection 35 months later.

Adult↗
PubMed1989

Cast immobilization after total elbow arthroplasty. A safe cost-effective method of initial postoperative care.

Seventeen nonconstrained total elbow replacements were inserted in 12 patients. One patient died prior to the one-year follow-up examination, and two others required revision in the immediate postoperative period. The remaining 14 primary total elbow arthroplasties in 11 patients were included in this study. There were eight women and three men with an average age of 58.1 years. The diagnosis was rheumatoid arthritis in 12 patients and posttraumatic arthritis and juvenile rheumatoid arthritis each in one patient. Postoperatively, patients were immobilized in a long arm cast. The mean hospital stay was 4.3 days. At four weeks, the patients were seen for cast removal. Instructions were given for range of motion (ROM) exercises and patients were encouraged to resume normal daily activities as tolerated. No formal physical therapy was prescribed. The average follow-up period was 32 months. Preoperatively, the mean elbow motions were flexion 124 degrees, extension 34 degrees, pronation 65 degrees, and supination 44 degrees. At the last follow-up examination, ROM had improved significantly in all directions except extension (flexion 141 degrees, extension 36 degrees, pronation 77 degrees, and supination 61 degrees). There was one ulnar nerve palsy that only partially resolved. Another patient's elbow had initially subluxed due to excessive shortening of the humerus; however, he had an excellent ROM and was asymptomatic at 31 months. There were no dislocations or wound healing problems. Cast immobilization provides an effective means of promoting soft-tissue healing, permitting early discharge from the hospital and simplifying the postoperative rehabilitation while achieving satisfactory ROM without formal physical therapy.

Adult↗
PubMed1986

Surgical treatment of arthritis in the elderly.

Arthritis in the elderly can be very effectively treated by a combination of careful orthopaedic and rheumatological assessment. The overall functional assessment, and definition of the aims and likely results of surgical treatment by the team approach, involving occupational therapists, physiotherapists and social workers, are important for success. There are many worthwhile surgical procedures available to relieve pain, and restore mobility and independence to those affected by osteoarthritis and rheumatoid arthritis.

Aged↗
PubMed1996

Articulated radial head replacement and elbow release for post head-injury heterotopic ossification.

This is a case report of the release of an elbow ankylosed by post-head-injury heterotopic ossification. An extensive bony resection and soft-tissue release was required. At surgery a pathological, osteoporotic fracture of the radial head was found that could not be preserved and thus was removed. In its place an articulated "floating radial head prosthesis" was used that allowed immediate rehabilitation and avoided the need for temporary joint distraction or stabilization. The initial excellent function achieved has been maintained, at a > 3-year follow-up and without the complications experienced with silicone radial head prostheses.

Adult↗
PubMed1987

Prosthetic replacement of the proximal humerus.

Eighteen patients had prosthetic proximal humeral replacement with either a metal or ceramic prosthesis. Three replacements were performed for fracture nonunions, five for benign neoplasms, six for low-grade malignancies, and four for high-grade malignancies. Retention of elbow and hand function was good. In five of the 11 ceramic prostheses, failure occurred at the humeral-prosthetic junction even though it was designed for biologic fixation. Ten of 18 prostheses subluxated or dislocated. Twelve of 18 patients have had revision operations. While the revision rate in this initial series was high, valuable experience was gained for further investigations of shoulder arthroplasty.

Adolescent↗
PubMed1981

Training program for a myo-electrically controlled prosthesis with sensory feedback system.

A myo-electrically controlled prosthesis that incorporates a sensory feedback mechanism to provide the wearer with a sense of touch or gripping force in the prosthetic hand was developed for patients with below-elbow amputations. A training protocol was established in which patients were taught to produce myo-electric control signals and to interpret the sensory feedback. The protocol includes functional training in daily living skills. The experiences of four patients trained with these limbs are described.

Activities of Daily Living↗
PubMed2005

Function after resection of humeral metastases: analysis of 59 consecutive patients.

UNLABELLED: Metastatic bone disease of the humerus may require surgery for treatment of an impending or existing pathologic fracture or for alleviating disabling pain. Prompt restoration of function is a main goal of surgery, although published results do not reveal if that goal is being met. We retrospectively reviewed range of motion and function of 59 patients operated on from 1986-2003 for those indications. After resection, tumors around the humeral head and condyles (n = 20) were reconstructed with a prosthesis, and tumors at the humeral diaphysis (n = 39) were reconstructed with cemented nailing. Each patient's range of motion was recorded, and functional outcome was evaluated according to the American Musculoskeletal Tumor Society system. Patients who had cemented nailing had better shoulder motion, hand positioning, lifting ability, and emotional acceptance than patients who had endoprosthetic reconstruction. Pain alleviation and dexterity were comparable in both groups. All patients had a stable extremity, and the overall function of 56 patients (95%) was greater than 68% of normal upper extremity function. An aggressive surgical approach in patients with humeral metastases who met the criteria for surgical intervention was associated with good function. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Arthralgia↗
PubMedDate not supplied

The metal prosthesis in radial head fracture: indications and preliminary results.

Radial head displaced irreparable fracture is an indication for prosthesis; it becomes elective also when there are associated injuries of the skeletal and ligamentous stabilization systems. A retrospective study was conducted to evaluate the functional and radiographic results in 10 patients (mean age 39.6 yrs; minimum 20, maximum 80) submitted to radial head replacement. There were 4 Mason-Johnston type IV Rochwerger subtype "b" fractures, 7 type III fractures (1 associated with an Essex-Lopresti injury and 1 with fracture of the ulnar proximal metaepiphysis). Mean follow-up was 24.6 months (minimum 18, maximum 32). Postoperative functional evaluation of the elbow and ipsilateral wrist was carried out using the ESSSE/SECEC form (mean score 80.7/100; minimum 63, maximum 96) and the PRWE (mean score 11.1; minimum 0, maximum 36) respectively. Radiographically there were postoperative calcifications in 30% of cases and periprosthetic lucency in 40%. The results of this study encourage the use of a metal prosthesis, but a longer follow-up is needed for a better evaluation.

Adult↗
PubMed2005

Primary total elbow replacement for fractures of the distal humerus.

OBJECTIVE: Achieving stability and pain-free function for osteoporotic intraarticular multifragmentary fractures of the distal humerus in elderly patients by primary total elbow replacement (TER). INDICATIONS: Non-soft-tissue-attached fragments, poor-quality bone, where stable osteosynthesis is not attainable. Severely comminuted intraarticular closed type C fractures according to the AO classification with multiple small bone/cartilage fragments. In case of degenerative joint diseases and/or previous surgery in rheumatoid patients also type A and B fractures. High compliance, low demand, and old patient > 65 years. CONTRAINDICATIONS: Type II or III Gustilo-Anderson open fractures (primary irrigation and debridement). Preexisting infection, open wounds. Younger, high-demand or noncompliant patient. Paralysis of the biceps muscle. SURGICAL TECHNIQUE: Supine positioning of patient. Triceps-sparing dorsal approach. Elevation of medial aspect of the triceps from posterior aspect of the humerus and capsula, reflecting the triceps in continuity with the ulnar periosteum and the forearm fascia. If removal of distal part of the humerus, the triceps insertion can be left intact. Preparation of humerus: no reconstruction of multifractured condyles; excavate bone from medial and lateral supracondylar ridges with burr. Preparation of ulna: remove tip of olecranon. Cemented humeral and ulnar components. Bone graft interposition behind anterior flange of humeral component. Resection of radial head and coronoid process, if impingement after trial reduction. Triceps reattachment transosseous through olecranon. POSTOPERATIVE MANAGEMENT: No formal physical-therapy sessions. Avoid single-event weight lifting of > 5 kg and repetitive lifting of > 1 kg. Discourage playing racquets sports. RESULTS: 49 acute distal humeral fractures in 48 patients (average age: 67 years) were treated with TER. 43 fractures were followed at an average of 7 years. According to the AO classification, five fractures were type A, five type B, and 33 type C. The average flexion arc at follow-up was 24-131 degrees, the Mayo Elbow Performance Score averaged 93. Data of complications were obtained from records in all 49 patients. 32 of the 49 elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Ten additional operative procedures, including five revision arthroplasties, were required. The retrospective review supports recommendation for TER for the treatment of an acute distal humeral fracture, when strict inclusion criteria are observed.

Aged↗