Long - Term survivorship and clinical and radiological follow - up of the primary uncemented Delta III reverse shoulder prosthesis.

BACKGROUND: Purpose of this study was to evaluate the long - term survivorship and clinical and radiological results of a primary reverse total shoulder arthroplasty (RTSA) performed with uncemented stems. METHODS: From 2001 until 2006 61 primary uncemented RTSAs were implanted, which were included in a Kaplan-Meier survival analysis. Range of motion, functional scores and radiological follow - up was obtained. 27 patients were available for follow - up. Mean follow-up was 9.2 years (SD 2.4). RESULTS: Mean cumulative survival was 82.4% (95% CI: 50.7-94.6%) of the total construct and 98.3% (CI: 88.8-98.8%) of the uncemented humeral stem after 12.5 years. Five revisions occurred (8.2%). Mean anteflexion improved from 69.3 to 111.9° (p < 0.0001), lateral elevation from 65.9 to 101.3° (p < 0.0001), Constant-Murley score from 39.1 to 66.9 (p < 0.0001), Simple Shoulder Test from 1.5 to 7.1 (p < 0.0001), and VAS-pain from 65.5 to 6.6 at final follow-up (p = 0.0003). Scapular notching was present in 94.1% of the patients. CONCLUSIONS: The present study shows that the long-term clinical results of the primary Delta III RTSA seem very encouraging and survivorship of, in particular, its uncemented humeral stem is good.

Total Elbow Arthroplasty: Why and How.

INTRODUCTION: Elbow arthroplasty is a relatively infrequent orthopaedic procedure that can be performed in multiple ways according to the type of prosthesis that is used and the needs of the individual patient. STEP 1 PREPARATION AND POSITIONING OF THE PATIENT: Place the patient in the lateral decubitus position or in the supine position with the arm draped, allowing for easy manipulation of the elbow during the procedure. STEP 2 INCISION: Palpate and mark the local osseous landmarks, ulnar nerve, and incision, and then make a posterior incision to allow 360° access to the elbow joint as well as to allow decompression or transposition of the ulnar nerve. STEP 3 APPROACH­THE SUPERFICIAL LAYER: Perform the superficial approach, including a decompression of the ulnar nerve, and properly visualize the triceps tendon attachment on the proximal part of the ulna and both epicondyles. STEP 4 APPROACH­THE DEEP LAYER: Mobilize the triceps to allow visualization of the articular surfaces of the ulna, humerus, and radius, while taking care to protect the ulnar nerve. STEP 5 PREPARATION OF THE OSSEOUS STRUCTURES: Prepare the humerus and ulna in conformance with the technique that is described for the prosthesis and take care to restore the anatomical flexion-extension axis of the elbow. STEP 6 PLACEMENT OF THE PROSTHESIS: When all trial components are in place, reduce the joint to test the stability of the elbow. STEP 7 CLOSURE OF THE ELBOW: When all of the definitive components of the total elbow arthroplasty are in place, close the surgical wound in layers as the anatomy is restored. STEP 8 POSTOPERATIVE CARE: After surgery, a wound dressing is applied and physical rehabilitation is started to maximize the functional outcome. RESULTS: In our study of the mid-term results of a convertible total elbow arthroplasty, based on 58 elbow arthroplasties, patients had significant improvement in range of movement, function, and pain at 6 months postoperatively8.

Distal humerus prosthetic hemiarthroplasty: midterm results.

Treatment of comminuted distal humeral fractures remains challenging. Open reduction-internal fixation remains the preferred treatment, but is not always feasible. In selected cases with non-reconstructable or highly comminuted fractures, total elbow arthroplasty has been used, however, also with relatively high complication and failure rates. Distal humerus prosthetic hemiarthroplasty (DHA) may be an alternative in these cases. The purpose of this study was to report the midterm results of six patients that were treated by DHA for acute and salvage treatment of non-reconstructable fractures of the distal humerus. All six patients were treated by DHA for acute and salvage treatment of non-reconstructable fractures of the distal humerus. Medical records were reviewed, and each patient was seen in the office. Mean follow-up was 54 months (range 21-76 months). Implant survival was 100 %. Three were pain free and three had mild or moderate residual pain. Average flexion-extension arc was 95.8° (range 70°-115°) and average pronation-supination arc was 165° (range 150°-180°). In three, there was some degree of instability, which was symptomatic in one. One had motoric and sensory sequelae of a partially recovered traumatic ulnar nerve lesion. According to the Mayo Elbow Performance Score, there were three excellent, one good and two poor results. Four were satisfied with the final result, and two were not. In this case series of six patients with DHA for non-reconstructable distal humerus fractures, favorable midterm follow-up results were seen; however, complications were also observed.

Post-traumatic humero-ulnar synostosis.

A humero-ulnar synostosis is a bony connection between the humerus and the ulna. This is a very rare finding and it results in a serious disability of the elbow. Usually, a synostosis of the elbow occurs as a congenital anomaly. In this case, a 6-year-old girl was seen with a post-traumatic humero-ulnar synostosis, which has never been reported in the literature before. Surgical resection of the humero-ulnar synostosis was performed. Along with rapid intensive physical therapy, almost full recovery of function was achieved. The short-term result is very satisfactory, but the long-term results and recurrence rate are still unknown.

An extensive posterior approach of the elbow with osteotomy of the medial epicondyle.

BACKGROUND: This study describes a posterior approach to the elbow for placement of a total elbow prosthesis. METHODS: Release of the medial collateral ligament is achieved by performing an osteotomy of the medial epicondyle. This allows anatomic refixation of the origin of the medial collateral ligament. A description of the posterior approach is given. Standard radiographs were used to analyze the bone-to-bone refixation of the osteotomy of the medial epicondyle in 13 elbows. RESULTS: Radiographs showed proper bone healing in all elbows, with restoration of the anatomic origin of the medial collateral ligament. DISCUSSION: The described approach provides a good exposure of the elbow necessary for the placement of modern total elbow prostheses, without compromising the stability of the elbow. Refixation of stabilizing structures is relatively easy and results in an anatomic position of the ligaments.

Stability of the unlinked Latitude total elbow prosthesis: a biomechanical in vitro analysis.

BACKGROUND: The purpose of this study is to assess the valgus and varus laxity of the unlinked version of the Latitude total elbow prosthesis and the effects of radial head preservation or replacement. METHODS: Biomechanical analysis of the valgus and varus laxity of the unlinked Latitude was performed in fourteen upper limb specimens in the following conditions: (1) native elbow, (2) native elbow after the surgical approach and closing all layers again, (3) elbow with humeral and ulnar component implanted, unlinked, with the native radial head preserved, (4) elbow with humeral and ulnar component implanted, unlinked, with the native radial excised, (5) elbow with humeral, ulnar, and radial head component implanted. FINDINGS: After implantation of the Latitude total elbow prosthesis both the valgus and varus laxity slightly increase from mid to maximal flexion when compared to the native elbow after surgical approach. The unlinked Latitude total elbow prosthesis provides both valgus and varus stability in elbows with intact ligamentous constraints. With intact ligamentous constraints the radial head component only slightly contributes to the stability of the elbow after implantation of the unlinked Latitude total elbow prosthesis. INTERPRETATION: The unlinked Latitude total elbow prosthesis provides both valgus and varus stability in elbows with intact ligamentous constraints. The radial head component contributes only slightly to the stability.

Linking of total elbow prosthesis during surgery; a biomechanical analysis.

BACKGROUND: Presently, 2 types of elbow prostheses are used: unlinked and linked. The Latitude total elbow prosthesis allows the surgeon to decide during the implantation whether the prosthesis is placed unlinked or linked, and whether the native radial head is retained, resected, or replaced. The purpose of this study is to assess and to compare the varus and valgus laxity of the unlinked and linked version of the latitude total elbow prosthesis with: (1) the native radial head preserved, (2) the native radial head excised, and (3) the native radial head replaced by a radial head component. METHODS: Biomechanical testing was performed on 14 fresh-frozen upper limb specimens. RESULTS: Linking the prosthesis predominantly influences the valgus laxity of the elbow. DISCUSSION/CONCLUSION: Linking the Latitude total elbow prosthesis results in increased valgus stability. In the linked version of the total elbow prosthesis, the radial head only plays a small part in both valgus and varus stability. An unlinked situation is not advised in absence of a native radial head or in case of inability to replace the radial head.

[Shoulder pain due to suprascapular neuropathy]. / Schouderpijn door suprascapularisneuropathie.

BACKGROUND: Shoulder complaints are caused by suprascapular neuropathy in 1-2% of patients. This rare condition is characterised by slowly progressing shoulder pain, which has as a consequence restriction of movement and loss of strength. The most frequent causes are tear of the rotator cuff or a space occupying lesion. CASE DESCRIPTION: A 30-year-old man presented with slowly arising shoulder pain with subsequent also loss of strength and atrophy of the shoulder. A MRI scan of the shoulder showed a cyst in the glenoid cavity. Using EMG suprascapular neuropathy was diagnosed. The cyst was removed by operation and the patient recovered well. CONCLUSION: The diagnosis 'suprascapular neuropathy' was made using EMG. Space occupying lesions of the shoulder can be excluded by X-ray and MRI. The treatment is primarily conservative, with physiotherapy and pain management.

Survivorship of the KUDO total elbow prosthesis--comparative study of cemented and uncemented ulnar components: 89 cases followed for an average of 6 years.

BACKGROUND: The Kudo total elbow prosthesis (TEP) is a well-established implant with good mid-term results. The ulnar component can be placed with or without cement, and the humeral component is normally placed without cement. METHODS: 89 Kudo type-5 total elbow prostheses were evaluated after a mean follow-up of 6 (1.7-11) years. The indication for joint replacement was rheumatoid arthritis in all cases. 49 prostheses were placed without cement. In 40 cases, the ulnar component was cemented and the humeral component was uncemented. RESULTS: In the uncemented group, 7 revisions had taken place. 3 of these ulnar components were shortstemmed and 4 were long-stemmed. No revisions had been performed in the hybrid group. In the uncemented group another 7 patients showed progressive radiolucencies, while 3 patients in the hybrid group showed progressive radiolucencies. INTERPRETATION: In this group of RA patients, the survivorship of the cemented ulnar component was better than that of the uncemented ulnar component.

Failure mechanisms in uncemented Kudo type 5 elbow prosthesis in patients with rheumatoid arthritis: 7 of 49 ulnar components revised because of loosening after 2-10 years.

BACKGROUND: Both components of the Kudo type 5 elbow prosthesis can be inserted with or without the use of cement. There have been no reports on the use of this prosthesis with all components uncemented in patients with rheumatoid arthritis. PATIENTS AND METHODS: We reviewed 49 primary uncemented Kudo type 5 elbow prostheses, inserted in 36 patients with rheumatoid arthritis, after mean 6 (2-10) years. Patients were assessed clinically both pre- and postoperatively (pain, instability, motion, ulnar neuropathy) and radiographically. Furthermore, at the time of follow-up clinical outcome was assessed using the Elbow Function Assessment Scale. RESULTS: At review, 7 of 49 elbows had undergone revision because of symptomatic loosening of the ulnar component. In 42 unrevised elbows, clinical outcome was excellent in 29, good in 7, fair in 5, and poor in one. 31 of 42 elbows had no pain; 11 were painful at rest (VAS 1-2) and/or as a result of activity (VAS 1-8). With revision as endpoint, survival was 86% at 6 years. Intraoperative malpositioning of the ulnar component with a valgus or varus alignment of < 5 degrees was associated with worse survival. INTERPRETATION: We found an unexpectedly high rate of loosening of the ulnar component, which was associated with intraoperative malpositioning of the prosthesis. The ulnar component of this prosthesis should not be inserted without cement in patients with rheumatoid arthritis.

Treatment of sequelae of radial head fractures with a bipolar radial head prosthesis: good outcome after 1-4 years follow-up in 11 patients.

BACKGROUND: In the presence of additional disruption of the distal radioulnar ligaments, the interosseous membrane, or the lateral- and/or medial collateral ligament, radial head fractures treated by resection will result in valgus elbow instability, proximal radial migration and/or posterolateral rotatory instability. Radial head replacement has been used to treat or prevent this. We report our experience with the Judet CRF II radial head prosthesis. PATIENTS AND METHODS: We treated 11 patients with a bipolar radial head prosthesis because of elbow instability after previous treatment for Mason-Johnston type III or IV radial head fractures. The outcome was assessed clinically using two standardized elbow function assessment scales, and radiographically after a mean follow-up of 2 years. RESULTS: Clinical outcome was either good or excellent in all patients; all elbows were stable. Radiographically, there were no signs of loosening, fracture or heterotopic ossification. 2 patients required reoperation for subluxation of the prosthesis; both were treated by reducing the size of the modular head of the prosthesis. There was erosion of the capitellum in 1 patient. INTERPRETATION: Bipolar radial head replacement can be used successfully for treatment of the sequelae of radial head fractures. The long-term outcome is, however, unknown.