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PubMed1999

[Joint preserving operations and endoprosthetic joint substitutions in hemophiliacs. Indications and long term results].

Hemophilic arthropathy is the result of recurrent joint bleedings in patients with severe haemophilia A or B and von Willebrand Syndrome. Conservative orthopaedic treatment is preferred in every stage of the arthropathy. Synovectomy is indicated only after failure of the conservative regimen after 3 to 6 months in order to control synovitis and recurrent bleeding. This paper presents the indications, methods, and results of different joint preserving operations. Especially synovectomy of the elbow joint with or without radial head resection shows very good long term results. Radiosynoviorthesis is an alternative in certain cases. The end stages of hemophilic arthropathy are characterised by pronounced joint contractures. We achieved very good long term results by implanting total hip joints (n = 13) and total knee joints (n = 20) with a median follow up of 102 respectively 53 months. No perioperative complications like bleeding or infection were registrated. Only one aseptic loosening of a cemented cup occurred 14 years postoperatively as well as one septic loosening 14 months postoperatively in an HIV positive haemophilic. Another HIV positive patient developed a hematogenic abscess on both operated on hips without loosening of the endoprosthesis. Bicondylar prosthesis (n = 14) showed 6 very good, 6 good and 2 fair results in the HSS-score. Only one subsidence of an uncemented tibia plateau without definitive loosening occurred 55 months later. The functional results of constrained knee endoprostheses (n = 6) were not as good (2 good, 2 fair, 2 poor). However, these patients suffered preoperatively from severe contractures and malalignments. Aseptic loosening or late infections did not occur even in case of HIV infections.

Adolescent↗
PubMed2004

Load-sharing at the wrist following radial head replacement with a metal implant. A cadaveric study.

BACKGROUND: Surgical excision of the radial head is frequently required after a comminuted fracture of the radial head. The outcome of this procedure is often unpredictable, with some patients experiencing ulna-sided pain in the wrist secondary to proximal migration of the radius. Insertion of a radial head prosthesis could prevent proximal radial migration and restore normal load-sharing at the wrist. The thickness of the radial head implant is an important variable in restoring anatomical radial length; however, the effects of varying the length of implants that were used to reconstruct the radius on load-sharing at the wrist have not been studied biomechanically, to our knowledge. METHODS: A miniature load cell was attached to fifteen fresh-frozen cadaveric forearms to record force in the distal part of the ulna as the wrist was axially loaded to 134 N of compression force. Proximal displacement of the radius relative to the capitellum was also recorded. Loading tests on intact forearms were performed with the elbow in valgus and varus alignment and with three positions of wrist rotation (neutral, 45 degrees of pronation, and 45 degrees of supination). Loading tests were then repeated, with the same positions of varus and valgus elbow alignment and wrist rotation as had been used in the tests of the intact forearm, after radial head excision and subsequent insertion of metal radial head implants that restored anatomical length, implants that produced a radial length that was longer than the anatomical length, and implants that produced a radial length that was shorter than the anatomical length. Testing of these different implant thicknesses was repeated after sectioning of the interosseous membrane. RESULTS: The mean distal ulnar forces and mean proximal radial displacements following insertion of an implant that restored anatomical length were not significantly different from the corresponding values for the intact forearm. At neutral wrist rotation, replacing that implant with an implant that increased the radial length by 4 mm (after sectioning of the interosseous membrane) decreased the mean distal ulnar force from 13.4% to 3.3% of the applied wrist force with the elbow in valgus alignment and from 29.1% to 8.6% with the elbow in varus alignment. Replacing the implant that restored anatomical length with one that decreased the length by 4 mm (after sectioning of the interosseous membrane) significantly increased the mean distal ulnar force from 13.4% of the applied wrist load to 33.3% with the elbow in valgus alignment and from 29.1% to 51.6% with it in varus alignment. The mean distal ulnar forces were not significantly affected by the position of wrist rotation when the elbow was in valgus alignment. However, when the elbow was in varus alignment, the mean distal ulnar forces associated with all reconstructed radial lengths were significantly higher when the wrist was placed in 45 degrees of supination. CONCLUSIONS: In this cadaveric model, insertion of a metal implant maintained distal ulnar forces at normal levels, at all three positions of wrist rotation, when the radius had been restored to its original anatomical length. Distal ulnar forces and proximal radial displacements were significantly affected by the reconstructed length of the radius. CLINICAL RELEVANCE: Radial head implants are utilized to prevent proximal migration of the radius as the wrist is loaded; this is especially important when the interosseous membrane has been ruptured and thus cannot help to limit radial displacement. At the time of surgery, comminution and displacement of a radial head fracture may make estimation of the original radial length difficult. Our results demonstrate that, in terms of distal ulnar loading, it is preferable to insert an implant that is too thick rather than too thin.

Aged↗
PubMed2006

The anatomy of the bicipital tuberosity and distal biceps tendon.

The anatomy of the distal biceps tendon and bicipital tuberosity (BT) is important in the pathophysiology of tendon rupture, as well as surgical repair. Understanding the dimensions of the BT and its angular relationship to the radial head and radial styloid will facilitate surgical procedures such as reconstruction of the distal biceps tendon, radial head prosthesis implantation, and reconstruction of proximal radius trauma. We examined 178 dried cadaveric radii, and the following measurements were collected: radial length, length and width of the BT, diameter of the radius just distal to the BT, distance from the radial head to the BT, radial head diameter, width of the radius at the BT, radial neck-shaft angle, and styloid angle. Furthermore, the morphology of the BT ridge was defined as smooth (absent), small, medium, large, or bifid. Of the specimens, 48 were further analyzed with a computed tomography scanner at the level of the BT to determine the distance to traverse both the anterior and posterior cortex and the anterior cortex alone. Eighteen fresh-frozen cadaveric elbows were dissected, and the insertion footprint of the distal biceps tendon was defined. The BT has a mean length of 22 +/- 3 mm and a mean width of 15 +/- 2 mm. The tendon insertion footprint is a ribbon-shaped configuration on the most ulnar aspect of the BT, and it occupies 63% of the length and 13% of the width of the BT. The BT ridge is absent in 6% of specimens and bifid in 6%, and the remaining 88% of specimens have a single ridge that may be classified as small, medium, or large. The mean diameter of the radial head is 22 +/- 3 mm. The mean radial neck-shaft angle is 7 degrees +/- 3 degrees , and the mean BT-radial styloid angle is 123 degrees +/- 10 degrees . None of the measurements correlated with patient age, sex, or race. We concluded that the morphology of the BT ridge is variable. The insertion footprint of the distal biceps tendon is on the ulnar aspect of the BT ridge. The dimensions of the radius and BT are applicable to several surgical procedures about the elbow.

Cadaver↗
PubMed1996

Reversal of blood flow direction for the salvage of forearm straight and looped ePTFE-shunts.

Long venous anastomotic stenosis of a forearm haemodialysis graft necessitates extension of the venous limb. If the extension graft crosses the antecubital region, it will be subject to kinking, and re-occlusion may be the consequence. We report our experiences with a procedure proposed by Schulak combining reversal of blood flow of forearm looped grafts and extension of the venous limbs along the ulnar aspect of the elbow. Detailed information is given on how to modify the original method in order to treat patients with straight grafts, or with looped grafts and a "misplaced" venous extension. Ten patients were successfully treated with Schulak's procedure or its modification. No intra- or post-operative complications occurred. During follow-up (from 3 to 12 months), all grafts have remained patent.

Anastomosis, Surgical↗
PubMedDate not supplied

[Improvement of prostheses and orthotic aids for the handicapped using electric stimulation and the registration of bioelectric signals].

Electro-mechanical devices can help a variety of patients with motor disabilities. Surface EMG from remaining muscles in an amputated arm can be used to control powered electronic hands, wrists and elbows. Sensory signals such as knee angle and ankle torque can be used to control the visco-elastic properties of a knee joint for above-knee amputees. Finally, percutaneous electrodes can be used to stimulate paralyzed muscles to replace hand function in quadriplegics and leg function in paraplegics. This article summarizes recent progress in each of these areas.

Artificial Limbs↗
PubMedDate not supplied

Pediatric unilateral below-elbow amputees: retrospective analysis of 34 patients given multiple prosthetic options.

Thirty-four unilateral below-elbow amputees from the Shriners Hospitals for Children/Twin Cities were retrospectively analyzed in long-term follow-up. All of these patients were provided with a variety of prosthetic options, including a "passive" cosmetic upper extremity device. Most of the patients were also fitted with conventional prostheses using a body-powered voluntary closing terminal device (97%) as well as myoelectric prostheses (82%). These patients were considered consistent prosthetic users by the clinic team. The average follow-up was 14 years, with many of the patients being followed up throughout their entire childhood. All patients were sent questionnaires, and the authors carried out patient interviews and chart review. Final analysis indicated that 15 patients (44%) selected a simple cosmetic "passive hand" as their prosthesis of choice. In long-term follow-up 14 patients (41%) continued as multiple users. Fourteen patients (41%) selected the conventional prosthesis using a voluntary closing terminal device as the prosthesis of choice. Only five patients (15%) selected the myoelectric device as their primary prosthesis. The authors conclude that successful unilateral pediatric amputees may choose multiple prostheses on the basis of function and that frequently the most functional prosthesis selected in the long term is the simplest in design. The authors believe strongly that unilateral pediatric amputees should be offered a variety of prosthetic options to help with normal activities of daily living.

Amputation, Surgical↗
PubMedDate not supplied

Treatment of locked posterior fracture-dislocations of the shoulder by total shoulder arthroplasty.

Total shoulder arthroplasty is indicated in the treatment of locked posterior fracture-dislocations of the shoulder where there is extensive damage to the articular surfaces of the humerus and glenoid. This report reviews the surgical technique, postoperative rehabilitation program, and functional results of seven shoulders in five patients who had locked posterior dislocations of the shoulder. Activities involving overhead positioning of the arm and heavy lifting continued to be challenging for this group of patients. The American Shoulder and Elbow Surgeons' Shoulder Score improved from 20.1 before surgery to 55.6 after surgery (p = 0.018). The extrication of the posteriorly dislocated humeral head may be difficult from an anterior deltopectoral approach. The authors describe the use of a secondary posterior incision facilitating the extrication of the humeral head. In this series total shoulder arthroplasty reliably decreased the patients' level of pain, improved their range of motion, and significantly improved their level of function.

Adult↗
PubMedDate not supplied

Outcomes of hemiarthroplasty for fractures of the proximal humerus.

We reviewed 80 shoulders (72 shoulders in 71 patients) treated with hemiarthroplasty. At follow-up, 66 patients (93%) were pain-free and satisfied with their results; the mean American Shoulder and Elbow Surgeons score was 76.6, the mean Simple Shoulder Test score was 7.5, the average forward flexion was 128 degrees, external rotation was 43 degrees, and internal rotation was to L2. Radiographic analyses revealed nearly anatomic tuberosity reconstruction in 58 shoulders, heterotopic ossification in 18, pseudosubluxation in 10, and superior migration in 15. Patients with superior migration had statistically lower mean American Shoulder and Elbow Surgeons scores, mean Simple Shoulder Test scores, and decreased forward flexion. Tuberosity complications occurred in 16 shoulders. Malunion of the greater tuberosity was the most common complication. Healing of the greater tuberosity more than 2 cm below the humeral head correlated with a worse functional result. Hemiarthroplasty for indicated fractures of the proximal humerus results in shoulder-level function and reproducible pain relief.

Adult↗
PubMed1993

Generalized representation of handwriting: evidence of effector independence.

Previous analyses of writing data have provided qualitative evidence of temporal and spatial similarities across muscle effectors. In order to further explore the notion of effector independence in handwriting a single case study approach was adopted that employed quantitative analyses. A left-handed individual who lost his left hand and forearm in an automobile accident and wore a myoelectric arm was tested. After his accident he learned to write with the right hand developing this skill for 8 years. Once he was fitted with the myoelectric arm he began again to write with the left hand. Thus, the acquired writing patterns of both hands reflect two well-learned skills which utilize different muscle effectors. Wright's NAME-EQUATION paradigm (1990) was utilized which required the subject to write his name and the equation X + Y = Z with the dominant, non-dominant hand and the elbow of the dominant arm. A control subject was also tested. For the subject wearing a myoelectric arm (primary subject), kinematic and handwriting analysis revealed astonishing similarities between the different effectors tested. For the control subject, the obtained results showed that as the effectors changed so did the handwriting kinematics. The collective findings support the hypothesis that motor programs, the directives that guide skilled movement, can be generalized across different effectors, but only after considerable practice.

Adult↗
PubMedDate not supplied

Athletic activity after joint replacement.

The first decade of the 21st century has been declared the "Bone and Joint Decade" by 35 nations and 44 states in the United States as of March 2001. It is not surprising that Americans are interested in musculoskeletal disease and the treatment of bone and joint disorders because our population is aging, the prevalence of arthritic joints is increasing, and senior Americans are demonstrating a strong desire to stay active in activities of daily living and athletics. One of the most successful treatments for painful arthritic joints, which limit activity, is total joint replacement, which predictably relieves pain and improves function. Much has been written about the technical aspects of total joint arthroplasty. Less has been written about safe and appropriate activities for patients who have had joint replacement operations. This article evaluates athletic activity after joint replacement by reviewing the orthopaedic literature and surveying members of The Hip Society, The Knee Society, and The American Shoulder and Elbow Surgeons Society. The authors have developed consensus recommendations for appropriate athletic activity for patients who have had joint replacement operations. This article is intended to serve as a guide for orthopaedic surgeons and primary care physicians who give patients recommendations for athletic activity after joint replacement. This article is also intended to stimulate further research in the area of athletic activity after total joint arthroplasty.

Arthroplasty, Replacement↗
PubMed1983

A long-term review of children with congenital and acquired upper limb deficiency.

A long-term review of 131 children fitted with upper limb prostheses at the Ontario Crippled Children's Centre between 1965 and 1975 is reported. There were 116 children with congenital deficiencies and 15 who had had amputations. Follow-up ranged from 7 to 17 years. A total of 42 children had abandoned their prostheses, 37 of whom had congenital deformities and five were amputees. The level of deficiency was of fundamental importance in determining whether the prosthesis would be accepted; in the forearm, the longer the stump, the more likely it was that the child would discard the prosthesis. Overall, 50 per cent of children fitted over the age of two years abandoned their prostheses compared with only 22 per cent of patients who had been fitted before the age of two years. The highest drop-out rate was at the age of 13 years when the children became more conscious of their cosmetic appearance. Suggestions for reducing the high drop-out rate in the early teens are put forward.

Adolescent↗
PubMed2004

Functional outcome of patients with proximal upper limb deficiency--acquired and congenital.

OBJECTIVE: To investigate the functional outcome of patients with proximal upper limb deficiency--acquired and congenital (elbow disarticulation, transhumeral, shoulder disarticulation and forequarter level). DESIGN: Cohort observational study. SUBJECTS: All proximal upper limb amputees and patients with congenital upper limb absence currently registered with the Sheffield Mobility and Specialised Rehabilitation Centre. METHODS: A self-administered postal questionnaire and medical records were used to collect data. The questionnaire obtained information about demographic details, dominancy of the amputated arm and independence and participation in activities of daily living (ADL), domestic and recreational activities. The prevalence of pain in the phantom limb and stump, and information regarding the remaining arm was also obtained. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the psychological state of the subjects. RESULTS: Trauma was the commonest cause of proximal upper limb loss (71.25%). Transhumeral amputation was the predominant level (78.75%). Although 73.2% returned to work following amputation, 66.6% had to change job. Overall rejection rate of prosthesis was 33.75%. Twenty-five per cent of patients found the prosthesis beneficial for driving and a small proportion used the prosthesis for employment and recreational activities, but the vast majority used the prosthesis primarily for cosmesis. Pain in the phantom limb was reported in 60% of our patients but there was no significant correlation between this and depression. Symptoms of overuse injury in the nonamputated limb were higher than expected in the normal population. CONCLUSION: As many as 33.75% of patients with proximal upper limb deficiency rejected their prostheses and many who continue to wear them do not find them useful in ADL and employment, etc. It is vital that rehabilitation programmes should focus on both prosthetic and nonprosthetic training to achieve maximal independence.

Activities of Daily Living↗
PubMed1997

The role of cultured Schwann cell grafts in the repair of gaps within the peripheral nervous system of primates.

With recent advances in cell culture techniques it is possible to isolate human SCs from adult peripheral nerves, expand and purify their number in cell culture, and construct a cellular prosthesis from the cultured cells. The current study was designed to ascertain whether these techniques could be used to repair nonhuman primate nerve injuries. In 12 adult female cynomologous monkeys, the musculocutaneous (msk) nerve was divided and prevented from regenerating and the brachioradialis nerve (brach) was exposed bilaterally (n = 24 nerves) and injured so that a 15-mm gap existed within the nerve. The brach nerves were either repaired with sural nerve autografts (n = 6), guidance channels which contained monkey SCs (120 x 10(6) cells/ml; n = 6), or guidance channels without SCs (n = 6). The remaining brach nerves (n = 6) had either no injury or an injury to the nerve without a repair. Autologous expanded primate SCs were increased in number at least 10-fold over a 2-week period at which time the SC purity exceeded 99.9%. Monkeys in each group, including the control group, regained some degree of elbow flexion after 3 months despite sectioning both the mask nerve and the brach nerve; therefore, we were unable to determine simply on clinical grounds which repair was the most effective in promoting functional recovery. Brach nerves repaired with sural nerve grafts were superior to both the channels which contained SCs and empty channels in regards to the number of myelinated axons proximal, within, and distal to the repair site (P < 0.05). Electrophysiologic results closely paralleled the histologic data with evidence of reinnervation of the brachioradialis muscle based on the compound muscle action potential in both sural nerve graft and monkey SC channel repair groups.

Animals↗
PubMed1987

PTFE grafts for hemodialysis access. Techniques for insertion and management of complications.

In a series of 602 procedures, over 90% of primary forearm insertions of PTFE grafts between the radial artery and a cubital vein were possible. Thrombosis of the graft, which was invariably due to venous outflow obstruction, was the most common complication encountered. Revision of the venous anastomosis was not necessary in about one-third of the thrombosed grafts if a size 3 coronary dilator could be passed and the augmentation test was satisfactory. For revisions, creation of a new venous anastomosis using a jump graft was preferred over patch angioplasty or venous endarterectomy. Crossing the elbow for this purpose did not adversely affect graft patency. The incidence of aneurysm formation and infection was 16% and 35%, respectively. Infections involving the graft were managed by drainage, antibiotics, and bypass of the infected portion. Immediate bypass and delayed bypass were equally effective. About one-half of the infected grafts were salvaged by these techniques. The most common organism was Staphylococcus aureus. With a combination of the techniques outlined above, the service life of individual PTFE grafts can be extended. Two-year access patency in this series was 77%.

Aneurysm↗
PubMed1997

[Effect of the rotator cuff condition on the results of shoulder arthroplasty].

PURPOSE OF THE STUDY: The purpose of this report was to study the repercussions of rotator cuff condition on unconstrained shoulder arthroplasty results. METHODS: Between 1986 and 1993, 40 unconstrained shoulder prostheses were performed (24 total and 16 hemiarthroplasties). At the time of the operation, rotator cuff condition was reported to be normal in 15 shoulders, atrophic in 10, scarred in 3, torn in 12. Clinical and radiographical results were analyzed and supplemented with a rotator cuff echography. Postoperative follow-up averaged 42.25 months (12 to 97 months). RESULTS: When the rotator cuff was intact at the time of operation, clinical results were the best at the time of review. Constant score, overall mobility, forward elevation, external rotation with the elbow along the side were better for intact than for atrophic, scarred or torn rotator cuffs (p < 0.01). Ruptures repaired by local tissue transfer or trapezo deltoidal flap substitution (3 cases) gave satisfactory results, whereas two dacron cuff prostheses failed. In the non repaired ruptures (7 cases), arthroplasty resulted in 3/4 fair or poor results. At the time of review, the total incidence of postoperative rotator cuff tears was high (12 cases), functional repercussions were variable. Among the 15 rotator cuff tears observed at the time of the review, the long head of the biceps was present and in place in 9 cases and ruptured in 6 cases. In these latter cases, Constant score (p < 0.01), the forward elevation (p < 0.01), external rotation with elbow along side (p < 0.05) and overall mobility (p < 0.05) were worse; moreover, humeral head superior migration was greater (p < 0.01). DISCUSSION: Our study confirms the superiority of clinical results when the cuff was intact at the time of the operation. The repair of rotator cuff tears seems to be justified. When the rupture has not been repaired, clinical results were fair or poor in 5 cases out of 7, the initial rupture spread to the other tendons in 3 cases out of 7. Secondary ruptures were frequent (12 cases). No predictive factor was identified, but an overlapping of the greater tuberosity appears to be detrimental. Among rotator cuff tears present at the time of review, long head of the biceps rupture jeopardized clinical results and was associated with a proximal migration of the humeral head which was significantly more severe than with an intact non displaced long head of the biceps. CONCLUSION: During unconstrained shoulder prosthesis implantation, it is therefore recommend to systematically repair any associated rotator cuff rupture, in order to avoid any greater tuberosity overlap relative to the prosthetic head and to preserve the long head of the biceps tendon which limits upward migration of the humeral head and improves prosthetic kinetics.

Adult↗
PubMed1986

Is flap cover of exposed metalwork worthwhile? A review of 28 cases.

The long term results of flap cover in 28 cases of exposed metalwork are presented. The patients fall into two groups; those with exposure of plates after internal fixation of fractures (14), and those with exposed knee or elbow prosthetic joints (14). The average duration of metal exposure at the time of referral was 6.4 weeks. In the majority of cases, cover was achieved by local muscle or fasciocutaneous flaps. The average duration of follow-up was 20 months. Metalwork was covered and preserved in 16 cases (57%). The remainder had persistent discharging sinuses or overt sepsis despite survival of the overlying flap. The results of this series are discussed in relation to the pre-operative microflora and the duration of metal exposure.

Adolescent↗
PubMedDate not supplied

Joint replacement for arthritis.

BACKGROUND: Joint replacement is most commonly performed at the hip and knee for osteoarthritis. It is also possible to replace joints such as: the shoulder, elbow, metacarpophalangeal joints and ankle, but usually only when the joint has been destroyed by rheumatoid arthritis. While the main benefit of joint replacement is the resolution of arthritic pain, range of movement and function can also be improved and the length of the limb or alignment of the joint may be restored. OBJECTIVE: In this article we address the indications for joint replacement, and how the patient is assessed. The results of joint replacements of varying joints are considered and we discuss some topical current concepts in joint replacement surgery.

Arthritis↗
PubMed1993

Successful voluntary grasp and release using the cookie crusher myoelectric hand in 2-year-olds.

We examined the ability of two 2-year-old children with limb deficiency to demonstrate grasp and release while using the cable-operated voluntary opening hook-hand and the externally powered single-site myoelectric Cookie Crusher system. The Cookie Crusher circuit is an electronic package that causes the prosthetic hand to open in response to muscle contraction and closes (as if crushing a cookie) when the muscle is relaxed. Both children were consistently good prosthetic wearers, beginning with their initial passive devices and progressing through their cable-operated hooks and hands. However, before they began to use the Cookie Crusher (Subject 1 at 25 months, Subject 2 at 30 months), neither had developed voluntary grasp or release in spite of 3 to 12 months' use of cable-operated voluntary opening prehensors. Both children developed a voluntary grasp and release for the first time within minutes of starting to use the Cookie Crusher. The more adept of the two children, a girl with a traumatic above-elbow amputation, showed prehensile function with the Cookie Crusher during play. The spontaneous use of the Cookie Crusher may be related to the predominance of associated reactions in young children. As children play bimanually, associated movements of the nondominant extremity often occur and, in the case of children with limb deficiencies fitted with Cookie Crusher prehensors, these associated reactions result in successful grasp and release. We will continue to follow the choice of effective control schemes in these children as they mature.

Amputation, Traumatic↗