Outcomes of Revision Unlinked Total Elbow Arthroplasty for Rheumatoid Elbow.

Background: Although unlinked total elbow arthroplasty (TEA) is a treatment option for end-stage rheumatoid arthritis (RA) of the elbow, its long-term outcomes were inferior. Moreover, revision TEA could be technically challenging. The unlinked TEA procedure comprises the ease of implant removal at revision and advantage of bone preservation. This study evaluated the clinical outcomes in patients who underwent revision TEA using primary unlinked TEA for rheumatoid elbows. It also aimed to determine whether selecting the unlinked prosthesis for the primary TEA would make revision more accessible and successful. Methods: We retrospectively reviewed data of 13 consecutive patients (14 elbows) who underwent revision TEAs for implant failure due to different aetiologies, excluding septic loosening. Three different unlinked TEA implants were used: the Kudo type-5 with all-polyethylene (AP) ulnar component, Kudo type-5 with metal-backed (MB) ulnar component and K-Now TEA. We evaluated the patients' pre- and postoperative outcomes, including the range of motion, pain score and Mayo Elbow Performance Index (MEPI). Results: Among the 14 elbows, 11 were revised using the Kudo type-5 ulnar component (nine and two with AP and MB ulnar component, respectively), and three using the K-Now. We found that each model of TEA had different tendencies to indication for revision surgery. Three more resulted in further failure. The clinical outcomes were assessed in the 11 surviving elbows. Eight of the 11 elbows showed no pain at the final follow-up. However, the remaining three showed only mild pain. The MEPI revealed that seven cases were excellent, two were good and two were fair. Conclusions: The mode of implant failure was largely dependent on the implant design. Furthermore, partial revision with the same implant design was sufficient in managing implant failure in the early phase. However, conversion from unlinked to linked design could be recommended in patients with progressive failure or instability. Level of Evidence: Level IV (Therapeutic).

Plantar Partial Pressure Analysis in a Patient with Reverse Extensor Digitorum Brevis Flap for the Treatment of Hallux Injury.

INTRODUCTION: An extensor digitorum brevis (EDB) flap can be used to cover a small soft-tissue defect and has been widely used as pedicled flap to cover defects around the ankle and foot. However, its post-operative functional recovery is unknown. Few reports have evaluated gait after foot flap surgeries, although gait assessment is considered to be necessary for functional evaluation after foot reconstruction. We performed a reverse EDB flap to treat a right hallux injury and conducted a plantar partial pressure (PPP) analysis as a postoperative functional evaluation. CASE REPORT: A 30-year-old laborer suffered an injury resulting in necrosis of the distal phalanx and soft-tissue defect of the proximal phalanx. After amputation, the proximal phalanx was covered with a reverse EDB flap. PPP analysis involved a 4-m-long platform system (P-Walk) and was conducted 3- and 12-month post-surgery. Walking velocity and the single-support phase on the affected limb had increased markedly after 12 months. After 12 months, the PPP of the first metatarsal head was greater than on the unaffected side, and the cadence and single-leg support rate were equal to the unaffected side. CONCLUSION: A nearly normal gait was obtained by covering the basal part of the hallux with an EDB flap and preserving the metatarsophalangeal joint.

Macroscopic investigation of failed Kudo type 5 total elbow arthroplasty.

BACKGROUND: On the basis of the intra-articular findings during Kudo type 5 elbow prosthesis revision surgery, we infer the mechanisms leading to implant failure. MATERIALS AND METHODS: We performed primary Kudo type 5 total elbow arthroplasty on 60 rheumatoid elbows in 45 patients between 1994 and 2003. Revision surgery was performed in 8 patients (9 elbows) because of implant failure. We radiographically assessed their status before this surgical procedure and then assessed the surgical intra-articular findings based on surgery records and photographs. RESULTS: In all cases, revision surgery was necessitated by failure of the ulnar component. There were 2 types of implant failure: fracture of the ulnar component neck (n = 3) and loosening of the ulnar component (n = 6). In the latter group, 2 elbows exhibited valgus deformity of the retrieved ulnar component. There were no cases of metallosis or wear of the articular surface. CONCLUSION: This study describes the types of implant failure in unlinked Kudo type 5 total elbow arthroplasties with all-polyethylene ulnar components based on the intra-articular findings. Failure of the all-polyethylene ulnar component could have been caused by ulnar neck distortion that occurred prior to polyethylene wear on the joint surface. In addition, valgus stress on the elbow joint may have contributed to these implant failures.

Arthroscopic reduction of complex dorsal metacarpophalangeal dislocation of index finger.

Complex dorsal dislocation of the metacarpophalangeal joint is an uncommon injury, typically caused by entrapment of the volar plate within the joint space. Closed reduction of the dislocation is not effective; instead, open reduction is necessary to release the soft tissues interposed between the metacarpal head and the proximal phalanx. However, an operative risk of digital nerve injury exists because of intricate displacement of the normal anatomy. We successfully reduced a dislocation by arthroscopic release of the entrapped volar plate. The case involved an 11-year-old boy with a complex dorsal dislocation of the metacarpophalangeal joint of the right index finger that had failed closed reduction. This technique allowed for reliable joint reduction, enabling observation of the structures obstructing the reduction; was less invasive; and avoided the risk of neurovascular injury. It is a reasonable method to use when the volar plate prevents reduction of the dislocation.