The role of arthroscopy in the management of adult elbow trauma.

Fractures around the elbow are often challenging to treat and in most cases require an extensive approach. Since the development of elbow arthroscopy, most authors have pointed out the potential advantages of a less invasive technique that can be useful for visualization and reduction of the articular fragments with an eventual percutaneous fixation. Arthroscopic techniques provide a limited exposure that may lead to a faster wound healing, lower rate of complications and thus, better recovery of range of motion. However, elbow arthroscopy is also a demanding technique, especially in a swollen and fractured joint, and it is not exempt of risks. The overall rate of complications has been rated from 1.5% to 11% and nerve injury rates from 1.26-7.5%.The objective of this review is to present the arthroscopic setup and general surgical technique for the management of elbow trauma and to define some clear indications. Patient positioning and operating room display is key in order to obtain success. In addition to the arthroscopic equipment, fluoroscopy is almost always necessary for percutaneous fixation and precise preparation is mandatory. In the last decade, literature regarding new portals or surgical tips for arthroscopic treatment of elbow fractures have been published.The main indications for fracture arthroscopic-assisted fixation are those articular fractures involving the coronoid, distal humerus shear fractures in the coronal plane (trochlear and capitellum fractures) and, more controversially, those affecting the radial head. The treatment of these type of fractures all arthroscopically is exponentially demanding as it might also require ligament repair. For coronoid fractures, it can be useful in Morrey type II and III, and O´Driscoll anteromedial facet fractures associated to a posteromedial instability pattern that also require a repair of the LCL. Although excellent results have been published, comparative series are scarce. Radial head fractures can also be approached arthroscopically in simple non-comminute fractures that can be fixed percutaneously.In conclusion, arthroscopy of the elbow is an excellent tool to better understand and visualize articular fractures of the elbow. However, despite the advances in surgical technique, whether it improves clinical and radiological results is still to be proven.

[Translated article] Comparative biomechanical study of two configurations of cemented screws in a simulated proximal humerus fracture fixed with locking plate.

INTRODUCTION: Screw tip augmentation with bone cement for fixation of osteoporotic proximal humerus fractures seems to improve stability and to decrease the rate of complications related to implant failure. However, the optimal augmentation combinations are unknown. The aim of this study was to assess the relative stability of two augmentations combinations under axial compression load in a simulated proximal humerus fractures fixed with locking plate. MATERIAL AND METHODS: A surgical neck osteotomy was created in five pairs of embalmed humeri with a mean age of 74 years (range 46-93 years), secured with a stainless-steel locking-compression plate. In each pair of humeri, on the right humerus were cemented the screws A and E, and in the contralateral side were cemented screws B and D of the locking plate. The specimens were first tested cyclically in axial compression for 6000 cycles to evaluate interfragmentary motion (dynamic study). At the end of the cycling test, the specimens were loaded in compression force simulating varus bending with increasing load magnitude until failure of the construct (static study). RESULTS: There were no significant differences in interfragmentary motion between the two configurations of cemented screws in the dynamic study (p=0.463). When tested to failure, the configuration of cemented screws in lines B and D demonstrated higher compression load to failure (2218N vs. 2105, p=0.901) and higher stiffness (125N/mm vs. 106N/mm, p=0.672). However, no statistically significant differences were reported in any of these variables. CONCLUSIONS: In simulated proximal humerus fractures, the configuration of the cemented screws does not influence the implant stability when a low-energy cyclical load is applied. Cementing the screws in rows B and D provides similar strength to the previously proposed cemented screws configuration and could avoid complications observed in clinical studies.

Comparative biomechanical study of two configurations of cemented screws in a simulated proximal humerus fracture fixed with locking plate. / Estudio biomecánico comparativo de dos configuraciones de tornillos cementados en una fractura simulada de húmero proximal fijada con placa y tornillos bloqueados.

INTRODUCTION: Screw tip augmentation with bone cement for fixation of osteoporotic proximal humerus fractures seems to improve stability and to decrease the rate of complications related to implant failure. However, the optimal augmentation combinations are unknown. The aim of this study was to assess the relative stability of two augmentations combinations under axial compression load in a simulated proximal humerus fractures fixed with locking plate. MATERIAL AND METHODS: A surgical neck osteotomy was created in five pairs of embalmed humeri with a mean age of 74 years (range 46-93 years), secured with a stainless-steel locking-compression plate. In each pair of humeri, on the right humerus were cemented the screws A and E, and in the contralateral side were cemented screws B and D of the locking plate. The specimens were first tested cyclically in axial compression for 6,000 cycles to evaluate interfragmentary motion (dynamic study). At the end of the cycling test, the specimens were loaded in compression force simulating varus bending with increasing load magnitude until failure of the construct (static study). RESULTS: There were no significant differences in interfragmentary motion between the two configurations of cemented screws in the dynamic study (p=0.463). When tested to failure, the configuration of cemented screws in lines B and D demonstrated higher compression load to failure (2218N vs. 2105, p=0.901) and higher stiffness (125N/mm vs. 106N/mm, p=0.672). However, no statistically significant differences were reported in any of these variables. CONCLUSIONS: In simulated proximal humerus fractures, the configuration of the cemented screws does not influence the implant stability when a low-energy cyclical load is applied. Cementing the screws in rows B and D provides similar strength to the previously proposed cemented screws configuration and could avoid complications observed in clinical studies.

Heterotopic ossification after surgery for distal humeral fractures.

We retrospectively reviewed 89 consecutive patients (45 men and 44 women) with a mean age at the time of injury of 58 years (18 to 97) who had undergone external fixation after sustaining a unilateral fracture of the distal humerus. Our objectives were to determine the incidence of heterotopic ossification (HO); identify risk factors associated with the development of HO; and characterise the location, severity and resultant functional impairment attributable to the presence of HO. HO was identified in 37 elbows (42%), mostly around the humerus and along the course of the medial collateral ligament. HO was hazy immature in five elbows (13.5%), mature discrete in 20 (54%), extensive mature in 10 (27%), and complete bone bridges were present in two elbows (5.5%). Mild functional impairment occurred in eight patients, moderate in 27 and severe in two. HO was associated with less extension (p = 0.032) and less overall flexion-to-extension movement (p = 0.022); the flexion-to-extension arc was < 100º in 21 elbows (57%) with HO compared with 18 elbows (35%) without HO (p = 0.03). HO was removed surgically in seven elbows. The development of HO was significantly associated with sustaining a head injury (p = 0.015), delayed internal fixation (p = 0.027), the method of fracture fixation (p = 0.039) and the use of bone graft or substitute (p = 0.02).HO continues to be a substantial complication after internal fixation for distal humerus fractures.

The pattern of the fracture and displacement of the fragments predict the outcome in proximal humeral fractures.

Our aim was to determine the effect of the initial pattern of fracture and the displacement of fragments on the outcome of proximal humeral fractures treated conservatively. We followed 93 consecutive patients prospectively for one year. Final movement and strength were compared with those of the contralateral side. The final American Shoulder and Elbow Society score and the Disabilities of Arm, Shoulder and Hand and Short-Form 36 questionnaires were compared with those provided by the patient on the day of the injury. Radiographs and CT scans with three-dimensional reconstruction were obtained in all patients. The pattern of the fracture and the displacement of individual fragments were analysed and correlated with the final outcome. There were two cases of nonunion and six of avascular necrosis. The majority of the fractures (84 patients; 90%) followed one of the following four patterns: posteromedial (varus) impaction in 50 patients (54%), lateral (valgus) impaction in 13 (14%), isolated greater tuberosity in 15 (16%), and anteromedial impaction fracture in six (6%). Head orientation, impaction of the surgical neck and displacement of the tuberosity correlated strongly with the outcome. In fractures with posteromedial impaction, a poor outcome was noted as the articular surface displaced inferiorly increasing its distance from the acromion. A poorer outcome was noted as a fractured greater tuberosity displaced medially overlapping with the posterior articular surface. Lateral impaction fractures had a worse outcome than other patterns of fracture.

Total shoulder replacement for osteoarthritis in patients 80 years of age and older.

This study was performed to review the safety and outcome of total shoulder replacements in patients who are > or = 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery. Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives.

Tratamiento de las lesiones del aparato locomotor del paciente politraumatizado en un hospital universitario español de tercer nivel / Treatment of musculoskeletal injuries of multiple-trauma patients in a spanish tertiary referral hospital

Objetivo. Analizar el proceso diagnóstico y tratamiento del paciente politraumatizado con lesiones del aparato locomotor en un hospital español de tercer nivel sin unidad específica estructurada funcionalmente para la atención de estos pacientes.Material y método. Estudio observacional retrospectivo. Se incluyeron todos los pacientes ingresados en la Unidad de Cuidados Intensivos (UCI) bajo el diagnóstico de politraumatismo con lesiones del aparato locomotor entre enero de 2001 y mayo de 2003, 135 enfermos, de los cuales 120 pudieron ser evaluados. Se procedió al estudio de las historias clínicas, registrándose el mecanismo causal, diagnósticos, cálculo del ISS (Injury Severity Score) y NISS (New Injury Severity Score), tratamientos aplicados y el momento en el que se realizaron, complicaciones desarrolladas y mortalidad.Se utilizó el software SPSS 11.0 para el análisis de losdatos.Resultados. La edad media fue 38 (rango 15-75 años). Noventa y cinco (80%) eran hombres. Los mecanismos causales principales fueron el accidente de tráfico y el atropello (65%). La estancia media en UCI fue 13,5 días (rango 1-130). El 33% fue intervenido de las lesiones del aparato locomotor. La demora media en la estabilización de las fracturas fue 9,3 días (rango 1-70). Treinta y tres pacientes (28%) desarrollaron complicaciones sistémicas inflamatorias, y 37 (31%) presentaron infecciones graves. Veintiún pacientes (18%) fallecieron en una media de 8,5 días (rango 1-50 días) después de ingresar.Conclusiones. La comparación con los protocolos y resultados publicados por unidades específicas para politraumatizados en otros países demuestra la conveniencia de una mayor protocolización y coordinación multidisciplinar para mejorar la atención de la patología osteoarticular de estos pacientes en centros de referencia

Purpose. To analyze the diagnostic and therapeutic protocol used in multiple-trauma patients with musculoskeletal injuries at a Spanish tertiary referral hospital that lacks a specific unit endowed with the functional structure to treat these patients.Materials and methods. Retrospective observational study.All patients admitted to the Intensive Care Unit (ICU) between January 2001 and May 2003 with a diagnosis of multiple trauma to the musculoskeletal system were included. There were a total of 135 patients, of which 120 could be evaluated. The patients’ clinical records were analyzed and a record was made of the mechanism of injury, ISS (Injury Severity Score) and NISS (New Injury Severity Score) calculations, treatment administered in each case and time of administration, any ensuing complications and mortality rate. The SPSS 11.0 software was used for data analysis.Results. Mean age was 38 (range: 15-75 years). Ninety-five (80%) were male. The main mechanisms of injury were road accidents and pedestrian-motor vehicle collisions (65%). Mean ICU stay was 13.5 days (range: 1-130). Thirty-three percent were operated on for their musculoskeletal lesions. Main time-to-fracture stabilization was 9.3 days (range: 1-70). Thirty-three patients (28%) developed inflammatory systemic complications and 37 (31%) had serious infections.Twenty-one patients (18%) died 8.5 days (range 1-50days) after their admissionConclusions. A comparison with protocols and results published by dedicated multiple-trauma units from other countries reveals the need for a greater degree of protocolization and multidisciplinary coordination to improve the treatment of the bone and joint pathologies of these patients in referral hospitals (AU)