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PubMed1986

Silicone rubber replacement of the severely fractured radial head.

Ten patients, at an average of 3.4 years after Swanson silicone rubber radial head replacement following acute trauma, were evaluated for pain, motion, and grip strength. Three had excellent results, one had a fair result, and two had poor results. Three patients had arthritis at the distal radioulnar joint. The arthritis was correlated with a positive ulnar variance in the uninjured wrist. Degenerative arthritis at the elbow was present in 56% (five out of nine). Ulnar variance was increased significantly in the wrists on the injured side, compared with the opposite wrist and to a control group. A 20-kg grip stress radiograph analysis showed the silicone rubber prostheses to deform and wrist subluxation to occur. A biomechanical study of six human cadaver upper extremities indicated that the flexible implants transferred minimal forces across the radiocapitellar joint. A radial head replacement with a modulus of elasticity similar to bone showed a more physiologic loading at the elbow. Both the clinical and biomechanical studies indicated that the silicone rubber prostheses is unable to transmit physiologic forces from the proximal radius to the capitellum. A less flexible radial head prosthesis should provide more normal physiologic stresses and may lead to improved clinical results.

Biomechanical Phenomena↗
PubMed2003

[GUEPAR I total elbow arthroplasty in rheumatoid arthritis: 19 implants followed an average of 67 months].

INTRODUCTION: The GUEPAR I total elbow arthroplasty is a nonconstrained implant used since 1985. Only one multicenter study has reported the mid-term results of this implant in rheumatoid arthritis. We presented a monocentric retrospective study evaluating the results of 19 GUEPAR I total elbow arthroplasty in rheumatoid arthritis with a mean follow-up of 67 months. MATERIALS AND METHODS: Between 1988 and 1996, 19 GUEPAR I total elbow arthroplasties have been performed on 16 patients (3 bilateral). There were 15 women and one man, averaged age 58 years. Radiographically, the elbow was classified as stage IIIA in 8 cases, and stage IIIB in 11 cases, according to the Mayo Clinic classification. A triceps splitting approach with tendon reflection was performed in all cases. A postoperative immobilization at 45 degrees extension was used for all patients during 21 days averaged, and active mobilization was then started. RESULTS: At 67 months averaged follow-up (range, 2 to 12 years) the Mayo Elbow score improved from 36 to 75 points. The overall results were considered as excellent for 8, good for 5, fair for 2, and poor for 4. Nine elbows were totally painfree and six had minimum pain. Postoperative arc of motion reached 36 to 126 degrees in extension-flexion and 147 degrees in rotation. Eleven out of 19 elbows had a normal functional score. Two elbows dislocated and two others had a valgus instability lower than 10 degrees. There were thirteen complications affecting 11 of the 19 elbows (68%), and six of these eleven elbows had a revision procedure (31%): 3 peroperative medial column fractures, one postoperative medial column fracture which has been fixed, two elbow dislocated with one ulnar component revision, and 3 loosed implants which has been revised. There were persistent ulnar paresthesiae in two cases with a secondary neurolysis performed in one. Finally two infections developed 6 years after the initial procedure, one superficial, and one deep, which lead to removal of the total elbow arthroplasty. DISCUSSION-CONCLUSION: The GUEPAR I total elbow arthroplasty is a nonconstrained implant indicated essentially in rheumatoid arthritis. Without intrinsic stability this implant must be contraindicated in front of bone stock deficiency, or chronic instability of the elbow. In selected cases the GUEPAR I total elbow arthroplasty offers a painfree elbow with a functional range of motion.

Adolescent↗
PubMed1994

Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases.

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis.

Adult↗
PubMed1998

Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study.

The functional outcomes of amputated arms that were either replanted or had a prosthesis were compared. In addition, factors that influenced the functional outcome of replants were evaluated. The Carroll test was used to evaluate functional capacity of 22 successful upper extremity replantations at or proximal to the wrist as well as 22 amputees (at similar levels) fitted with a variety of prosthetic devices. The outcome was excellent or good in 8 (36%) replanted limbs. This proportion was statistically higher than those grades in the prosthetic group. When the groups were more closely matched (adults with below elbow injuries), the replantation group had 6 (50%) good or excellent outcomes and the prosthetic group had none. An analysis of covariance of the replantations demonstrated a statistical association between a better outcome in younger patients with more distal injuries. This study indicates that replantation produces superior functional results compared with amputation and a prosthesis.

Adolescent↗
PubMed2000

Lengthening of congenital below-elbow amputation stumps by the Ilizarov technique.

Patients with short congenital amputations below the elbow often function as if they have had a disarticulation of the elbow. We have reviewed the results in six patients who had lengthening of such stumps by the Ilizarov technique to improve the fitting of prostheses. The mean lengthening was 5.6 cm (3.4 to 8.4), and in two patients flexion contractures of the elbows were corrected simultaneously. Additional lateral distraction was used in one patient to provide a better surface on the stump. There were no major complications. All six patients were able to use their prosthesis at the latest follow-up after 39 to 78 months.

Adolescent↗
PubMed2006

Treatment of glenohumeral arthritis with a hemiarthroplasty: a minimum five-year follow-up outcome study.

BACKGROUND: Glenohumeral hemiarthroplasty is well established as a method to treat glenohumeral arthritis. This study was designed to report longer-term results and to provide a decision model to assist surgeons in achieving successful outcomes. Our selection strategy for hemiarthroplasty included shoulders with (1) a concentric glenoid with eburnated bone, (2) a nonconcentric glenoid that could be converted to a smooth concentric surface, and (3) a humeral head centered within the glenoid after soft-tissue balancing. METHODS: Fifty-seven consecutive patients (sixty-four shoulders) who had osteoarthritis of the glenohumeral joint, without advanced disease in the glenoid, were treated with hemiarthroplasty. In each instance, a modular prosthesis was implanted. Clinical assessment was performed preoperatively and at one-year intervals postoperatively for at least five years with use of patient self-assessment instruments, including the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and a visual analog pain scale. A detailed radiographic analysis was performed to determine the presence of glenohumeral subluxation, periprosthetic radiolucency, and glenoid bone loss. RESULTS: Forty-three patients (fifty shoulders) were followed for a minimum of five years (mean, 7.5 years). Of the remaining fourteen patients (fourteen shoulders), ten were lost to follow-up, three had died, and one was excluded. For the Simple Shoulder Test, and for every visual analog scale measure, the results at the final follow-up evaluation were significantly better than the preoperative results (p < 0.0001 for each). The mean Simple Shoulder Test score at the time of the final follow-up was 9.4 positive responses compared with 9.7 positive responses at the two-year evaluation (p = 0.32), and the mean visual analog scale score for pain was 18.6 points compared with 14.9 points at two years (p = 0.45). Radiographic analysis showed the majority of stems had either no lucency or lucencies only near the tip of the stem. Glenoid bone loss and subluxation improved postoperatively, and the results were maintained at the final follow-up evaluation. CONCLUSIONS: Shoulder hemiarthroplasty provides sustained good-to-excellent pain relief and functional improvement at five to ten years postoperatively in carefully selected patients with osteoarthritis.

Adult↗
PubMed2001

[Microbiological and immunological monitoring in polyarticular rheumatoid arthritis after total joint replacement].

HISTORY AND ADMISSION FINDINGS: A 51-year-old man with polyarticular rheumatoid arthritis since the age of 10 years, which had required three total joint replacements, presented in a generally good condition for replacement of the left elbow joint, which was swollen and had reduced movement. TREATMENT AND COURSE: The postoperative condition was without complication until the 7th day when arthritic signs set in, interpreted as part of the underlying disease, and cortisone was administered. After microbiological tests had been done and the patient's general state had deteriorated, antibiotic treatment with flucloxacillin and gentamycin as well as local irrigation and suction-drainage of all involved joints was started. Granulocyte and monocyte functions were analysed. Staphylococcal isolates from the patient induced reduced "respiratory burst" activity of the neutrophil granulocytes, apparently the cause of the septic dissemination. He was discharged on the 32. postoperative day, to be followed-up as an out-patient. CONCLUSION: Both adequate antibiotic administration and, especially, thorough local reduction of pathogens are needed for efficacious treatment. Rapid restoration of granulocyte function and of the "immunocompetence" of monocytes within normal limits are part of the reason for a good therapeutic response. This indicates the need for up-to-date preoperative immunological diagnosis in patients with suppressed immunity to assess the risk of infection and thus plan elective intervention.

Anti-Bacterial Agents↗
PubMed2005

Coonrad-Morrey total elbow arthroplasty for tumours of the distal humerus and elbow.

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern.

Aged↗
PubMed1992

Postoperative complications of distal humeral fractures. 27/96 adults followed up for 6 (2-10) years.

Of 96 adult patients with a distal intercondylar, intraarticular fracture of the humerus treated operatively during a 10-year period, 27 patients suffered a local complication, while the total number of individual complications were 34. There were six postoperative infections, 12 neural injuries, and 16 fixation failures. Because of the complication, a reoperation was performed in 12 of the 27 patients. The final outcome was assessed at a reexamination after a mean follow-up period of 6 (2-10) years. Three patients had a permanent dysfunction of the ulnar nerve. In another 3 patients, failure of the fixation had resulted in an established nonunion of the distal humerus. It appeared that the possibilities of internal fixation in several cases had been overestimated.

Adolescent↗
PubMedDate not supplied

Bicipital groove orientation: considerations for the retroversion of a prosthesis in fractures of the proximal humerus.

The bicipital groove anatomy is well documented, and this groove is used as a landmark to guide retroversion during implantation of a shoulder prosthesis. Whereas the proximal part of the groove is used in osteoarthritis, the distal part is used in fractures. If used in 4-part fracture cases, we must assume that the bicipital groove orientation is constant from proximal to distal. We measured the groove orientation in 40 cadaveric humeri using 3 superimposed computed tomography sections. The reference axis was the transepicondylar axis at the elbow level. The measured angle of the bicipital groove was 55.8 degrees +/- 4.5 degrees at the anatomic neck and 65.1 degrees +/- 3.5 degrees at the surgical neck. This difference (mean of 9.3 degrees, with extremes of -3 degrees and 22.5 degrees) was statistically significant. We confirmed a wide range of variation from 22 degrees to 89 degrees in the orientation of the groove. Because the values listed in the literature for lateral fin placement of a prosthesis have not been measured at the surgical neck level and because of the great variation in groove orientation, we caution surgeons about the use of the bicipital groove as a reliable landmark in shoulder replacement for fractures. Considering the risk of over- or under-retroversion of the prosthesis, we recommend the use of a fracture jig with retroversion set to 20 degrees.

Arthroplasty, Replacement↗
PubMed2006

Prosthetic management of children with unilateral congenital below-elbow deficiency.

BACKGROUND: There is substantial controversy concerning the prosthetic management of children with unilateral congenital below-elbow deficiency. The optimal age at the time of the initial fitting, the value of intensive prosthetic training, and the preferred prosthetic design for these children have not been established. METHODS: The outcomes of prosthetic management for 260 children with unilateral congenital below-elbow deficiency, treated between 1954 and 2004, were analyzed with respect to ongoing clinic attendance and self-reported prosthetic use. A successful prosthetic outcome was defined as a child and parents who continued to attend the limb-deficiency clinic and claimed at the time of the most recent follow-up that the prosthesis had been worn for any period of time. An unsuccessful prosthetic outcome was defined as a child and parents who were lost to follow-up or who claimed at the time of the most recent follow-up that the child never wore the prosthesis. Survival analysis was performed. RESULTS: An unsuccessful prosthetic outcome was noted for 127 children (49%). Initial fitting prior to the age of three years was associated with improved prosthetic outcome (p < 0.001). With the numbers studied, there was no additional benefit noted for fitting before one year of age (p = 0.60). Improved prosthetic outcomes were noted in children who had received intensive training at the time of fitting with an active terminal device (p = 0.005). Provision of a variety of prosthetic designs over the growing years was also associated with improved prosthetic outcome (p < 0.001). CONCLUSIONS: This study supports the initial prosthetic fitting for a child with unilateral congenital below-elbow deficiency prior to the age of three years, the provision of intensive training under the direction of an occupational therapist when an active terminal device is applied, and utilization of a variety of prosthetic designs over the child's years of growth. Further analysis of outcomes for the prosthetic management of these children will require more precise definitions of outcome in multiple domains and the development and validation of specific outcome instruments.

Age Factors↗
PubMed1979

Fitting below-elbow prostheses which convey a sense of touch.

A myoelectrically controlled electric hand has been modified so that the gripping force between thumb and index finger may be measured. The measurement is used to control a sensory feedback device applied to the surface of the skin within the socket of the prosthesis informing the wearer of the strength of grip exerted. Two people have been fitted with this prosthesis and they report that the sensory feedback gives them reassurance when using the arm. To date there has not been any noticeable adverse tissue reponse from the applied sensory stimulus.

Adult↗
PubMed1983

Surgical treatment of Still's disease (juvenile chronic arthritis).

We have carried out 433 operations on 268 patients suffering from Still's disease during the period 1959-1979, the average age of the patients being 21 years. A synovectomy of the knee was performed on 76 knees with a good result in 68%, while a similar operation on the elbows of 16 patients was more successful and 90% did well. Stapling of the knee in young children with genu valgum was carried out on 33 knees with a good correction in the great majority. Soft tissue operations were carried out with encouraging results on 24 hips and 9 knees, the patients having severe deformities of these joints. Reconstructive surgery was necessary in some patients with severe damage to their hips and knees, and we obtained good results in the great majority. Two hundred and forty eight total hip replacements have been carried out on 132 patients during the last 14 years and 84% have had a good result, but owing to the skeletal stunting frequently present a special small sized hip prosthesis had to be used. Knee replacement has been less satisfactory but was carried out on 40 knees in 28 patients and 55% had a good result. The main complications seen with these joint replacements have been due to infection or loosening. Multiple joint replacement has been carried out on 42 patients, 13 of which had both hips and knees replaced with 54% good results. Difficulties were experienced in anaesthetizing some patients owing to a stiff neck and jaw, but this was overcome by the use of Ketamine anaesthesia.

Adolescent↗