Management of the radial head and linked total elbow arthroplasty.

HYPOTHESIS: In properly selected patients, the radial head need not be resected in linked elbow replacement. BACKGROUND: For linked prostheses, whether the radial head is addressed is a function of the specific pathology present. We reviewed our management of the radial head in linked elbow arthroplasty (TEA) to determine the frequency and indication for subsequent surgery if not resected at the time of the primary procedure. MATERIALS AND METHODS: We reviewed indications in 709 patients who underwent TEA to determine how the radial head was managed. Indications for secondary resection as a result of radial head impingement were identified. Significant differences between the rheumatoid and post-traumatic groups were tested with χ(2) analysis. RESULTS: Of 381 rheumatoid patients who underwent TEA, the radial head was addressed surgically in 169 (44%); of which 68 patients (17.8%) in the rheumatoid arthritis group required complete radial head resection and 101 (27%) had a "radiusing" debridement procedure. Post-traumatic disease was present in 328 patients, and 38 (13%) underwent radial head resection, 5 underwent a debridement radiusing. The radial head was addressed surgically more often in the rheumatoid arthritis group (P = .001). Only 4 of the 709 patients (0.6%) required a secondary resection for radial head impingement, all with good results. CONCLUSIONS: Most often the radial head can be preserved with this linked prosthesis. Rheumatoid arthritis carries a higher prevalence of radial head disease, and hence requires attention more commonly, usually with simple debridement. If impingement symptoms of radial head develop, secondary resection yields good results.

Reverse Delta-III total shoulder replacement combined with latissimus dorsi transfer. A preliminary report.

BACKGROUND: Reverse total shoulder arthroplasty allows the restoration of active overhead elevation in patients with a massive rotator cuff tear and pseudoparesis of elevation. However, it does not restore active external rotation, the lack of which can also constitute a substantial functional handicap and compromise the outcome of this arthroplasty. Latissimus dorsi tendon transfer reliably restores control of active external rotation in rotator-cuff-deficient shoulders. In this preliminary study, we assessed the results of the combination of a latissimus dorsi transfer to the greater tuberosity and a reverse total shoulder arthroplasty in the presence of lost active external rotation. METHODS: Twelve shoulders in eleven patients (ten women and one man; average age, seventy-three years) with combined pseudoparesis of anterior elevation and external rotation were enrolled in the study. All demonstrated severe dysfunction of the teres minor with an external rotation lag sign, a hornblower's sign, and fatty degeneration of the teres minor classified as stage 2 or greater according to the system of Goutallier et al. or Fuchs et al. All were treated with a reverse total shoulder arthroplasty and a latissimus dorsi transfer during one operative procedure. One patient had a postoperative infection necessitating removal of the prosthesis. Another patient could not be examined because of an unrelated medical disability, leaving ten shoulders in nine patients available for evaluation on the basis of the history, results of a physical examination, and patient-based outcomes. RESULTS: On the average, forward flexion improved from 94 degrees preoperatively to 139 degrees at the time of follow-up (p = 0.028), abduction improved from 87 degrees to 145 degrees (p = 0.007), and strength improved from 0.25 to 4.12 kg (p = 0.005). The subjective shoulder value increased from 23% to 64% (p = 0.005), the relative Constant score increased from 47% to 93% (p = 0.005), and the pain score improved from 6.1 to 10.9 points (p = 0.012). While improvement in active external rotation with the arm at the side (from 12 degrees to 19 degrees ) was not significant, the score for functional active external rotation improved from 4.6 to 8.2 of 10 points according to the system of Constant and Murley (p = 0.024). The score for activities of daily living improved from 2.3 to 7.9 of 10 points (p = 0.005). CONCLUSIONS: In the presence of severe loss of active elevation and external rotation, combined latissimus dorsi transfer and reverse total shoulder arthroplasty can restore elevation and external rotation, at least in the short term.

Pedicled flaps for lower extremity reconstruction in the elderly: a retrospective study of 16 cases.

We reviewed a consecutive series of 16 patients above 60 years of age (mean age 71 years) who underwent reconstruction with pedicled flaps in the lower extremity. The soft tissue defects ranged from 9 to 50 cm and were caused in 11 patients (70%) by surgical complications from previous surgeries. Of these, 5 patients underwent a total joint replacement of the knee (4 cases) and of the ankle (1 case). Surgery consisted of 19 muscular flaps, and 3 fasciocutaneous flaps. Six patients were treated with a combination of 2 flaps. The overall surgical complication rate after reconstruction was 44%. There was no perioperative mortality and there were no medical complications. One patient required an above-the-knee amputation because of uncontrollable postoperative bleeding. A thrombectomy was performed in another patient to treat a postoperative popliteal artery occlusion with critical ischemia of the leg. Other complications included recurrent total joint replacement infections (2 cases), marginal flap necrosis (4 cases), and skin necrosis at the donor site (1 case). The mean hospitalization stay was 46 days. All patients but 1 completely healed, although secondary surgery was performed in 7 patients. The occurrence of complications was not correlated with the preoperative morbidity or an age above 75 years. The local complication rate was higher than reported for free flap in the same age category, but the lack of perioperative mortality and medical complications make it a low-risk option for reconstruction of small- to middle-sized defects in the elderly.