Evaluation of Functional Outcome of Elbows after Resection Arthroplasty of Failed Total Elbow Replacement.

BACKGROUND: Recovery of elbow function is a challenging problem following resection arthroplasty after failure of total elbow prosthesis. The objective of this study is to evaluate long term functional outcome in a series of such patients. MATERIALS AND METHODS: Nineteen patients with twenty elbows who had failed total elbow arthroplasty (TEA) following the use of Baksi total elbow prosthesis needed removal of prosthesis during the period from 1978 to 2003. As two patients were lost to followup, 17 patients with 18 elbows (bilateral in one) were included in this study with a mean age of 44.3 years. Nine cases had uncontrolled infection, seven cases of aseptic loosening including one occurred after TEA for bilateral postburns ankylosis, and two had broken humeral stems. After removal of the prosthesis and its adjacent surrounding bone cement, the cut ends of humerus and ulna were approximated with number 5 Ethibond suture. Postoperatively, the elbow was immobilized in a plaster slab in 110° elbow flexion for 6 weeks followed by physiotherapy. The patients were evaluated for 15-19.4 (mean 16.3) years where functional results were compared at 10 years and 15 years following resection arthroplasty. RESULTS: The resected elbow initially remained flail but gradually regained stability, especially in the sagittal plane. Both the groups showed overall improvement from preoperative Mayo Elbow Performance Score (MEPS) 26.5 to postoperative mean MEPS at 10 years (69.6) and at 15 years (70) (P = 0.001). Postoperative mean DASH score was 36.62 at 10 years' and 36.38 at 15 years' followup, suggesting persistence of function of resected elbow in the passage of time. The results were good in 9 (50%), fair in 7 (38.8%), and poor in 2 (11.1%) patients. None had recurrence of infection. Transient ulnar nerve palsy was seen in three patients. Postoperatively, power of Biceps recovered up to Medical Research Council grade 4 and Triceps 2-3. CONCLUSION: Resection arthroplasty of elbow provided acceptable functional recovery in our series of patients with failed elbow prosthesis.

Sloppy Hinge Prosthetic Replacement in Old Healed Side Swipe Injuries of Elbow - Long term Results.

BACKGROUND: Sideswipe injuries of elbow often poses significant functional loss resulting from devastating injuries involving osseoligamentous structures as well as multilevel soft tissue injuries around the elbow. Inspite of treatment, no conscientious treatment opinion is available in the literature to provide optimum functional outcome. The objective of this study is to evaluate the results of prosthetic replacement of old healed sideswipe injuries of elbow with gross dysfunctional disabilities resulting from loss of bones and muscles around the joint. MATERIALS AND METHODS: Fourteen patients of 2-3 years old healed sideswipe injuries of the elbow, treated by Baksi sloppy hinge (original version in seven and recent version in seven) prosthetic replacement were evaluated. All had normal neurovascular status except two; one having ulnar nerve deficit the other median nerve in another. The mean age was 42.7 years (range 32-61 years). RESULTS: The average followup period was 13.5 years (range 5.11-23.11 years). Ten patients regained stable 0° to 130° elbow flexion, and four had restricted terminal flexion with arc 10°-115° following V-Y plasty of contracted triceps. Mean supination was 22° and mean pronation was 35°. According to Mayo Elbow Performance Score (MEPS), excellent results were in five (35.7%), good in six (42.8%), and fair in one (7.1%). Two patients (14.2%) needed removal of prosthesis due to intractable delayed infection and considered failure. Following removal, the resected elbow retained relatively stable motions due to mature fibrous tissues connecting the adjacent bone ends and reorientation of muscle balance. Postoperative improvement of MEPS (mean 84) was significant (P = 0.0037) compared to preoperative value (mean 41.7). Two patients had superficial wound infection and five aseptic loosening of which one was symptomatic. CONCLUSION: Prosthetic replacement of elbow is an effective salvage procedure in old healed sideswipe injuries.

Harvesting the free fibular graft: A modified approach.

BACKGROUND: The conventional technique of free non-vascularized fibular grafting is attended with some amount of morbidity and a long scar. We report a technique with little interference to the surrounding soft tissues to harvest more than one-third of whole length fibula. PATIENTS AND METHODS: Thirty four patients of average age 23.5 years (range 8 to 51 years) having various pathologies like simple bone cysts (n=9), fibrous dysplasias (n=6), giant cell tumors (n=7), fracture non-union (n=10) and aneurysmal bone cysts (n=2) were taken up for the study. The fibula were harvested by two separate incisions, 1 cm each at proximal and distal extent of proposed donor site for taking out of graft after elevating the periosteum circumferentially using a periosteum stripper. Compression bandage and above knee plaster immobilization was applied to reduce the dead space collection. RESULTS: The mean followup is 34 months. The patients were evaluated clinicoradiology. Thirty three patients showed good results. One patient had fair result due to delayed wound healing from hematoma which was treated surgically. CONCLUSION: The approach of harvesting fibula suggested by author reduces donor site morbidity and is safer than conventional approach.

Prosthetic replacement of elbow for intercondylar fractures (recent or ununited) of humerus in the elderly.

Forty-one patients with an intercondylar fracture of the humerus (21 recent and 20 ununited) were treated by total elbow arthroplasty using Baksi's recent version of the sloppy hinge from January 2003 to April 2009. Twelve were AO classification type C2 and nine were type C3 recent closed fractures of seven days' mean duration according to Muller classification. Patient's mean age was 64 years. There were 20 nonunions (nine untreated nonunions of a mean of 11 months duration and 11 following failed internal fixation of a mean of 14 months duration); mean patient age was 58 years. The follow up period was 12-88 (mean 55.5) months. Mean arc of postoperative elbow flexion was 25-130° obtained in 39 (95.1%) patients. Mean arc of 65° pronation and 60° supination was obtained in 33(80.5%) patients. According to the Mayo elbow performance score, in the fresh-fracture group, excellent results were seen in 19 (90.5%), good in one (4.8%), and failure in one (4.8%), whereas in the nonunion group, excellent results were obtained in 17 (85%), good in two (10%), and failure in one (5%). Failure in the two patients was due to deep infection requiring prosthesis removal. Other complications were transient ulnar neurapraxia in three, disassembly of the prosthesis in one, patchy heterotopic ossification in two and localised radiolucency around the flanges of the humeral stem in one.

Long-term results of decompression and muscle-pedicle bone grafting for osteonecrosis of the femoral head.

In this paper, 152 patients with 187 osteonecrotic femoral heads (83 idiopathic, 56 corticosteroid induced, 40 post-traumatic, seven alcohol abuse and one associated with gout) were classified according to the staging by Ficat and Arlet (Ischemia and necroses of bone, Williams and Wilkins, Baltimore, Maryland, pp 171-182, 1980); four were in Stage I, 82 in Stage II and 101 in Stage III. The majority of the patients were young (average age 35.5 years). Multiple drilling, curettage of the necrotic bone and muscle-pedicle bone grafting using tensor fascia lata was carried out in all patients except in six adolescents, where sartorius grafting was performed. Cheilectomy of the femoral head and subcutaneous adductor tenotomy were also performed in the advanced stages. During the follow up of 10 to 21.5 years (average 16.5 years), radiological improvement was noted in 81.3% of patients in Stage II and 70.1% of patients in Stage III cases. Excellent and good results according to the Hospital for Special Surgery (HSS) score were obtained in 100% of cases in Stage I, 92% in Stage II and 80.4% in stage III, with a survivorship of 91% in Stage II and 82% in Stage III cases. The patients having an HSS score below 20 (non-survival) were recommended for total hip replacement (THR) therapy.

Prosthetic replacement of elbow in postburn bony ankylosis: long-term results.

Fifteen patients with 17 post-burn bony ankylosed elbows (two bilateral) fixed at a mean of 72.5 degrees +/- 27.5 degrees flexion were treated with Baksi sloppy hinge elbow arthroplasty. All patients agreed to avoid strenuous use of their replaced elbows. There were four males and 11 females whose ages varied from 21 to 48 years (average 31.6 years). One of the five patients who had severe anterior skin contracture required release. One patient died during the early follow-up period. During the follow-up studies which ranged from 11 to 23 years (average 14.1), eleven patients (68.7%) regained painless stable motion with mean recovery of arc of flexion from 20 degrees +/-10 degrees to 107.5 degrees +/-17.5 degrees with mean range of flexion 90 degrees +/-20 degrees . Good forearm motion was retained in all cases. According to the assessment score (Morrey BF, The elbow and it's disorder, 2nd edn. W.B. Saunders, Philadelphia, 1993), nine (56.2%) patients were recorded as excellent, two (12.5%) as good, and five (31.5%) as poor who were considered as failures. The five failures required removal of the prosthesis but retained acceptable elbow function due to periprosthetic fibrosis connecting the adjacent bone ends.