Management of the failed radial head arthroplasty.

Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases.The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis.The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA.Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues.In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint. Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055.

Outcomes after revision total elbow arthroplasty: a systematic review.

BACKGROUND: Although revision arthroplasty surgery is a frequently used treatment for failed total elbow arthroplasty (TEA), published results are conflicting. The aim of this systematic review was to provide an overview of the outcomes of revision TEA surgery. METHODS: A systematic literature search was performed in major databases to find articles relating to outcomes after revision of TEA. Two reviewers independently screened the articles for inclusion, and a third reviewer screened them before final inclusion. RESULTS: Twenty-one articles containing 532 cases were included. The mean age at revision was 61 years. The mean interval between primary and revision arthroplasty was 77 months, and the average follow-up period was 65 months. Different types of prostheses were included, with 69% of the revision prostheses having linked designs and 31% having unlinked designs. The visual analog scale score, Mayo Elbow Performance Score, Oxford Elbow Score, and range of motion improved significantly after revision surgery. Complications were reported in 232 of 532 cases (44%), leading to reoperations in 22%. After revision with linked prostheses, the Mayo Elbow Performance Score, range of flexion-extension, and pronation improved significantly more than with unlinked designs. CONCLUSION: Improved functional outcomes can be expected after revision TEA, but the complication rate remains high. Revision TEA should still be considered a salvage procedure for failed TEA. Linked designs for revision TEA result in better outcomes than unlinked designs in the midterm follow-up.

Radiocapitellar arthroplasty: a consecutive case series with 2 to 6 years' follow-up.

BACKGROUND: The aim of this study was to analyze indications, outcomes, and complications in patients treated with radiocapitellar arthroplasty. METHODS: This prospective analysis of clinical and radiographic results included 16 elbows in 15 patients. RESULTS: This study included 4 men and 11 women (mean age, 51.9 years; age range, 32-65 years). The mean follow-up period was 3.4 years (range, 2-6 years). The indications were post-traumatic (n = 10) and primary radiohumeral osteoarthritis (n = 6). A mean of 2 surgical procedures (range, 0-4) had been performed before radiocapitellar arthroplasty. The mean Mayo Elbow Performance Score significantly improved from 46 points to 85 points (P < .01). The arc of motion improved from 106° to 117° (P = .27). Radiographic ulnohumeral degeneration progressed in 40% of cases but was not symptomatic in any. Subsequent surgery was required in 5 elbows (31%). Revision of the radial head component was necessary in 4 patients (25%). In 3 patients this was a result of loosening of the stem. The radial component was subsequently removed because of persistent pain in 1. Radiographic loosening not requiring revision was found in 2 patients. CONCLUSION: The overall Mayo Elbow Performance Score was good to excellent after radiocapitellar arthroplasty. Both the revision and reoperation rates were high, and one should consider this before performing this procedure. Loosening of the radial head component was a problem. An improved fixation technique or an adaptation of the design is needed before this type of surgery can be recommended as a standard procedure.

Valgus instability of the elbow: acute and chronic form.

There has been an increase in thrower-specific elbow injuries in recent years. High valgus stresses during the late cocking and acceleration phases of throwing need to be compensated by the flexor pronator muscles as these can exceed the tensile strength of the medial collateral ligament complex. Prevention of injuries is the priority, with a focus on strengthening, reducing throwing frequency, decreasing force, and promoting a technique. The spectrum of thrower injuries ranges from a simple sprain to complete failure of the valgus stabilizing factors. The medial collateral ligament can stretch, leading to posteromedial impingement and radiocapitellar compression forces. This in turn can result in arthrosis and the formation of osteophytes. Ligament failure may eventually occur, making it impossible for the athlete to continue their throwing activities. The outcome of conservative treatment with strengthening, improvement of technique, and relative rest is often disappointing. Direct repair may no longer be possible in these acute-on-chronic injuries and a reconstruction with a tendon graft may be necessary.

Assessment and decision making in the unstable elbow: management of simple dislocations.

Simple elbow dislocations are usually treated conservatively. Radiographs are negative in simple dislocations. Results are generally good, although a small percentage of patients may develop chronic instability. Ligamentous repair can be indicated in high demand patients or if the elbow remains unstable following a closed reduction. Chronic instability is classified per their direction. Surgery is often indicated in the chronically unstable elbow.

The Unstable Elbow: Current Concepts in Diagnosis and Treatment.

Elbow instability is common and may occur after a variety of injuries, including falls or direct blows. Instability can be classified as either acute or chronic. Acute instability is classified as simple (without fracture) or complex (with associated fracture). Chronic instability is classified as a chronically dislocated or recurrently unstable elbow. Recurrent instability commonly presents as isolated medial or lateral collateral ligament insufficiency. A chronically dislocated elbow is often more complex, involving both osseous and ligamentous injuries. The treatment of simple dislocations typically involves closed reduction and nonsurgical management. Chronic recurrent lateral and medial collateral ligament insufficiencies have very different clinical characteristics, but definitive treatment frequently involves ligament reconstruction. Complex instability usually requires surgery, which includes open reduction and internal fixation of coronoid and olecranon fractures, repair or replacement of radial head fractures, and lateral collateral ligament repair. Medial collateral ligament repair and/or external fixation are rarely required to restore stability. It is important for surgeons to understand current concepts in the diagnosis and management of acute and chronic elbow instability as well as the preferred surgical treatments and techniques for the management of these injuries.

Biomechanical considerations in the pathogenesis of osteoarthritis of the elbow.

Osteoarthritis is the most common joint disease and a major cause of disability. Distinct biological processes are considered crucial for the development of osteoarthritis and are assumed to act in concert with additional risk factors to induce expression of the disease. In the classical weightbearing joints, one such risk factor is an unfavourable biomechanical environment about the joint. While the elbow has long been considered a non-weightbearing joint, it is now assumed that the tissues of the upper extremity may be stressed to similar levels as those of the lower limb, and that forces across the elbow are in fact very high when the joint is extended from a flexed position. This review examined the available basic science, preclinical and clinical evidence regarding the role of several unfavourable biomechanical conditions about the elbow on the development of osteoarthritis: post-traumatic changes, osteochondritis dissecans, instability or laxity and malalignment. Post-traumatic osteoarthritis following fractures is well recognized, however, the role of overload or repetitive microtrauma as risk factors for post-traumatic osteoarthritis is unclear. The natural course of untreated cartilage defects in general, and osteochondritis dissecans at the elbow in particular, remains incompletely understood to date. However, larger lesions and older age seem to be associated with more symptoms and radiographic changes in the long term. Instability seems to play a role, although the association between instability and osteoarthritis is not yet clearly defined. No data are available on the association of malalignment and osteoarthritis, but based on force estimations across the elbow joint, it seems reasonable to assume an association.

Comparison of two percutaneous volar approaches for screw fixation of scaphoid waist fractures: radiographic and biomechanical study of an osteotomy-simulated model.

BACKGROUND: When a surgeon uses a percutaneous volar approach to treat scaphoid waist fractures, central screw placement is complicated by the shape of the scaphoid and by obstruction by the trapezium. In this study, we used radiographs and biomechanical tests to compare the standard volar percutaneous approach with the transtrapezial approach, with regard to central screw placement at the distal pole of the scaphoid. METHODS: Fourteen matched pairs of cadaveric wrists were randomly assigned to two treatment groups. Under fluoroscopic control, a guidewire was drilled into the scaphoid, either through a transtrapezial approach or through a standard volar approach that avoided the trapezium. Guidewire position was measured in the coronal and sagittal planes. A transverse osteotomy was performed along the scaphoid waist, and this was followed by the insertion of the longest possible cannulated headless bone screw. Each specimen was placed into a fixture with a pneumatically driven plunger resting on the surface of the distal pole. Load was applied by using a load-controlled test protocol in a hydraulic testing machine. RESULTS: All guidewires were inside the central one-third of the proximal pole. The guidewire positions at the distal pole differed significantly between the transtrapezial and standard volar approach groups (p < 0.001). The load to 2 mm of displacement and the load to failure averaged, respectively, 324.4 N (standard error of the mean [SEM] = 73.5 N) and 386.4 N (SEM = 65.6 N) for the transtrapezial approach group compared with 125.7 N (SEM = 22.6 N) (p = 0.002) and 191.4 N (SEM = 36.30 N) (p = 0.005) for the standard volar approach group. CONCLUSIONS: The data suggest that, in a cadaveric osteotomy-simulated scaphoid waist fracture model, the transtrapezial approach reliably achieves central positioning of a screw in the proximal and distal poles. This position offers a biomechanical advantage compared with central placement in only the proximal pole.

Semiconstrained total elbow arthroplasty for posttraumatic arthritis or deformities of the elbow: a prospective study.

PURPOSE: To report the short-term results for posttraumatic total elbow arthroplasty. METHODS: We included patients presenting to our hospital with symptomatic chronic posttraumatic arthritis or deformities of the elbow, aged 55 to 90 years. All patients had reconstruction with a Coonrad-Morrey prosthesis. We performed clinical follow-up after 2, 6, 12, 24, and 36 months, consisting of physical examination, standard radiographs, and calculation of the Mayo elbow performance index. RESULTS: A total of 17 patients were enrolled in this study and had a mean follow-up of 32 months. Mean preoperative flexion arc was 67° and 105° postoperatively. The mean preoperative Mayo elbow performance index score was 54 (range, 30-80) and improved to a postoperative score of 93 (range, 60-100). We encountered 6 complications in 5 patients. Four complications required surgical intervention and 2 minor complications were treated noninvasively. CONCLUSIONS: Short-term functional outcomes after total elbow arthroplasty in this prospective cohort of patients with posttraumatic arthritis or deformities of the elbow were good according to mean postoperative measurements.

Thermal capsulorrhaphy in internal shoulder impingement: a 7-year follow-up study.

UNLABELLED: This study aimed to evaluate the long-term results of arthroscopic thermal shrinkage of the anterior capsule in athletes with internal shoulder impingement. In recent years, opinion with regards to the aetiology of internal shoulder impingement has changed significantly. The traditional treatment of internal impingement consisted of debridement of labral and/or undersurface cuff lesions. The use of concomitant thermal capsulorrhaphy, based on the concept of anteroinferior laxity, has also been advocated with excellent short-term results. In this study we investigated the long-term effects of this technique. Twelve overhead athletes with internal impingement underwent traditional arthroscopic treatment plus thermal capsulorrhaphy for internal impingement. All patients were evaluated 1, 2 and 7 years postoperatively using a questionnaire regarding their sports activity, and the modified Rowe score. At 1, 2 and 7 years postoperatively there was a significant improvement in the modified Rowe score when compared to the preoperative scores. However, follow-up at 7 years showed a significant deterioration of the initial 1 and 2 year results (p < 0.001), with only 25% of the athletes able to perform sports at their preoperative level. CONCLUSION: Excellent short-term results with thermal capsulorrhaphy, in addition to traditional arthroscopic treatment, in patients with internal shoulder impingement were not sustained over time. After 7 years, only 25% of the athletes were able to perform sports at their preoperative level.

Results of surgical treatment of athletes with sportsman's hernia.

Chronic groin pain in athletes is a difficult diagnostic and therapeutic condition. Between March 2004 and December 2009, 241 male athletes (mean age: 25.8 years, range: 16-41) in whom chronic sportsman's hernia was diagnosed, were surgically treated using a standardised technique. In this retrospective study, charts were analyzed for preoperative duration of symptoms and prior treatment. Perioperative complications were noted. Patients were contacted and were asked to answer a telephone questionnaire: 162 patients agreed to be questioned as part of the current study. A surgical intervention with reinforcement of the posterior inguinal wall and tenotomy of the adductors has lead to satisfactory results in over 90% of athletes with chronic groin pain who failed to improve with conservative treatment.

Volar percutaneous transtrapezial fixation of scaphoid waist fractures: surgical technique.

Percutaneous screw fixation of scaphoid fractures has gained popularity over the years. The disadvantages of a long period of cast immobilisation are avoided and this technique allows a more rapid return to work and sports activities than conservative treatment. Consequently, percutaneous screw fixation is appealing for the young and active population. Biomechanical studies showed that greater fixation strength is obtained when the screw is placed centrally than eccentrically. Central screw placement can however be technically demanding. In the use of a volar percutaneous approach, the trapezium and the shape of the scaphoid impede central screw placement. Different approaches are available to overcome this difficulty. The volar percutaneous transtrapezial approach facilitates and allows more accurate central screw placement compared to approaches that try to avoid the trapezium. The surgical technique of this approach is described.

Successful closed reduction of refractured wrist with a bent volar distal radius plate.

A case is presented of a 78-year-old woman who sustained a re-fracture of the distal radius after initial fixation with a volar locking plate. The fracture was located in the mid-portion of the volar plate with palmar apex bending of the plate and signs of median nerve compression. A successful closed reduction was performed without hardware failure. The fracture united uneventfully.

The long term effect of an intra-articular injection of corticosteroids in the acromioclavicular joint.

BACKGROUND: A prospective study was established to assess the effect of an intra-articular injection of corticosteroid and local anaesthetic into the acromioclavicular (AC) joint. METHODS: Fifty-eight patients with isolated AC joint symptoms were included. Clinical tests were repeated immediately following the injection, as well as at 1-month follow-up. If symptoms failed to improve at this time, arthroscopic surgery was offered. All other patients were dismissed from standard care and contacted for this study. Both American Shoulder and Elbow Surgeons (ASES) and University of California at Los Angeles (UCLA) scores were obtained at final follow-up. RESULTS: Sixteen patients had improved sufficiently. Between the 1 month and average final follow-up of 42 months, 1 patient had arthroscopic resection of the distal clavicle. Four of the 15 patients reported occasional mild pain. Average visual analogue scale (VAS) score for pain was 0.5 (0-3). Average ASES score was 94.1 (70-100) and average UCLA score was 33.9 (28-35). DISCUSSION: Pain relief achieved with an injection into the AC joint has both a diagnostic and therapeutic value. The decrease of pain with clinical testing affirms the correct position of the injection. Only a minority of patients has sufficient pain relief from the injection at 1 month follow-up; however, this is sustained at the longer-term follow-up in the patients that have a positive reaction. CONCLUSION: The diagnostic value of the injection of a local anaesthetic in the AC joint is immediate. Only 28% have a clear positive result at 1 month; but, this result is sustained at long-term follow-up. There were no complications.

Magnetic resonance imaging in radial head fractures: most associated injuries are not clinically relevant.

BACKGROUND: Recent studies report that magnetic resonance imaging (MRI) shows a high incidence of associated injuries in patients with a radial head fracture. This retrospective study describes the clinical relevance of these injuries. MATERIALS AND METHODS: Forty patients with 42 radial head fractures underwent a MRI scan after a mean of 7.0 days after trauma and were reviewed after a mean of 13.3 months. RESULTS: MRI showed 24 of 42 elbows had a lateral collateral ligament (LCL) lesion, 1 had a medial collateral ligament (MCL) and LCL lesion, 16 had an injury of the capitellum, 1 had a coronoid fracture, and 2 had loose osteochondral fragments. Clinical evaluation after a mean of 13.3 months showed that 3 elbows had clinical MCL or LCL laxity, of which 2 elbows had no ligamentous injuries diagnosed with MRI. One elbow with a loose osteochondral fragment showed infrequent elbow locking. The mean Mayo Elbow Performance Scale was 97.5 (range, 80-100) after a mean of 13.3 months after trauma, with no significant difference between patients with and without associated injuries (P = .8). CONCLUSION: Most injuries found with MRI in patients with radial head fractures are not symptomatic or of clinical importance in short-term follow-up.

Clinical evaluation of acromioclavicular joint pathology: sensitivity of a new test.

BACKGROUND: A prospective study was established to assess the sensitivity of the newly described Bell-van Riet (BvR) test for isolated AC pathology, and compare with 4 commonly used clinical tests. MATERIALS AND METHODS: The BvR test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the BvR test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The BvR test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of truly positive tests. RESULTS: The BvR test showed a sensitivity of 98%. All 4 other tests were less sensitive. CONCLUSION: The BvR test is a highly sensitive test in patients presenting with isolated AC related symptoms, and demonstrates AC joint pathology better than other accepted tests.

Placement of the stemless humeral component in the Total Evolutive Shoulder System (TESS).

Humeral implant design in shoulder arthroplasty has evolved over the years. The third generation shoulder prostheses have an anatomic humeral stem that replicates the 3-dimensional parameters of the proximal humerus. The overall complication rate has decreased as a result of these changes in implant design. In contrast, the rate of periprosthetic humeral fractures has increased. To avoid stem-related complications while retaining the advantages of the third generation of shoulder implants, the stemless total evolutive shoulder system has been developed. The indications, the surgical technique, and the complications of this humeral implant in shoulder arthroplasty will be described.

Delayed treatment of elbow pain and dysfunction following Essex-Lopresti injury with metallic radial head replacement: a case series.

BACKGROUND: Chronic longitudinal radioulnar dissociation has been associated with unpredictable and generally unfavorable outcomes. Metallic radial head replacement may address this treatment deficiency. METHODS: Eight patients were treated with a metallic radial head replacement for chronic longitudinal radioulnar dissociation. The average treatment delay was 3.3 years. All eight patients were seen for a clinical and radiographic assessment. RESULTS: Five of the 8 failed after a mean of 3 years (range, 1-5.7). Revision to bipolar metallic radial head replacement was successful in the short term in 2 of 3 that failed from aseptic loosening. One of 2 failures due to painful radiocapitellar arthritis was salvaged with a capitellar replacement. DISCUSSION: Reconstruction for symptoms following an Essex-Lopresti injury remains problematic. A metallic radial head implant appears to be an effective adjunct, but not a perfect solution in all patients. Recognition of the negative impact of residual lateral ulnar collateral ligament laxity is an important observation and should be specifically addressed with the reconstructive procedure. CONCLUSION: Metallic monoblock radial head replacement did not reliably address the functional deficiency from chronic radioulnar dissociation primarily due to malalignment and implant loosening. A cemented bipolar radial head implant may provide a better alternative as a long-term solution. Regardless, ligamentous integrity at the elbow should also be addressed at the time of the reconstruction.

Magnetic resonance imaging findings in 46 elbows with a radial head fracture.

BACKGROUND AND PURPOSE: Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. PATIENTS AND METHODS: 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. RESULTS: Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. INTERPRETATION: The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.