Acute radial head replacement with bipolar prostheses: midterm results.

In irreparable radial head fractures, especially if primary stabilizers of the elbow are damaged, the prosthetic replacement prevents instability and stiffness. Concerns have arisen over the use of bipolar press-fit prostheses due to the frequent finding of osteolysis and the risk of instability if compared to monopolar implants. Our aim was to assess midterm clinical and radiological outcomes of bipolar implants and the influence of osteolysis on proximal pain. Seventeen patients with irreparable fractures of the radial head, treated in acute with the same prosthetic model (rHEAD recon SBI/Stryker) between January 2015 and December 2018, were enrolled. Clinical assessment was performed using MEPS and DASH scores; a radiographic study was done to identify heterotopic ossifications and periprosthetic osteolysis. Outcomes at the last follow-up, according to MEPS, were excellent in 10 cases, good in 5 and fair in 2; none of the patients had severe pain or instability. In 3 cases, it was necessary to remove the implant, mainly because of early loosening. Radiological findings of osteolysis were detected in 9 cases, but no statistical correlation was found with MEPS and proximal pain. The use of bipolar implants is reliable if an accurate repair of ligament tears is performed and provides a good stability. Nevertheless, the risk of early aseptic loosening in uncemented implants is not negligible, and the follow-up of the patient must be strict. Late osteolysis does not seem to have clinical relevance, but further prospective studies are necessary to clarify this topic.

Simple and stable elbow dislocations: results after conservative treatment.

BACKGROUND AND AIM OF THE WORK: In adults, elbow dislocations are second in frequency after shoulder dislocations. They are often the result of a trauma due to accidental falls on the palm of the hand with the elbow flexed. In most cases this mechanism produces a posterior dislocation of the radius and ulna with respect to the humerus. The therapeutic approach was usually conservative in the past and it was characterized by manual reduction and plaster immobilization. More recently, as consequence of biomechanic and pathophysiology studies, the management of these injuries has gradually changed. The current trend is to immobilize the elbow only for few days and to evaluate its stability several times. In case of instability surgery may be indicated. The aim of this study was to assess the outcomes of simple stable elbow dislocations treated conservatively between january 2012 and december 2018. METHODS: Twenty-six patients were included. All subjects underwent to a follow-up visit, in which clinical functional tests were performed in order to evaluate any stiffness in flexion-extension, prono-supination and instability in varus-valgus. In addition, patients were asked to complete three questionnaires (DASH, MEPS, SF-36) to evaluate how much the pathology interfered with ADL's. RESULTS: Outcomes showed that prolonged immobilization increased stiffness in flexion and extension with the need of longer reabilithation. The recovery of prono-supination was instead always optimal. ADL's migth be influenced by the traumatic event and its management. CONCLUSIONS: Results of conservative treatment of simple elbow dislocation are generally satisfactory. A precise flow-chart of the patient management after trauma is essential in order to detect unstable lesions and.

Monteggia-like lesions: preliminary reports and mid-term results of a single center.

Background and aim of the work Monteggia-like lesions are complex and rare elbow injuries. A detailed classification and a proper surgical treatment can provide quite good functional and radiological outcomes. The aim of this retrospective study was to evaluate the mid-term results of Monteggia-like lesions surgical treatment. The other purpose was to investigate whether the complexity of ulna and radius fractures could be prognostic factors of insufficient functional results. Methods Seven women and five men, with a mean age of 59,25 years who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QUICK-DASH) score were used for evaluation at a mean of 17,5 months postoperatively (12-26). The range of movement (ROM), patients' satisfaction and neurological symptoms were also investigated. Osteolysis, implant loosening and heterotopic ossification were graded. Pearson's test was used to correlate the different classification systems used (AO/OTA, Bado and Jupiter, PURCCS, Mason) with MEPS and QUICK-DASH score. Results The mean MEPS was 84,92 (65 to 100). The mean QUICK-DASH score was 18,75 (0 to 34,1). The mean active pronation and supination was 72,5° and 59,17°, respectively. The mean active ROM of the elbow was 101,43°. Heterotopic ossifications were absent in six cases but were found in six. No statistically significant correlation was found between the analyzed variables. Conclusions Quite good functional results can be obtained in Monteggia-like lesions if injury pattern is recognized and each component of the injury is addressed. Further studies are needed to determine any prognostic factors.

How to approach Monteggia-like lesions in adults: A review.

Monteggia-like lesions encompass a wide spectrum of fractures of the forearm and elbow associated with dislocations, subluxations and ligamentous lesions. Many attempts have been made to classify these injuries, not only to understand their pathology but also to develop optimal treatments. Unfortunately, although some of these classifications are complete, they are either complex, not immediately usable, or not exhaustive. An orthopedic surgeon who aims to rapidly treat this kind of injury needs a visual classification, and knowledge of the best surgical approach. Monteggia like lesions do not allow for mistakes during surgery, as even a minor error could be prove detrimental to performing and completing all surgical steps. In this paper, based on our extensive experience in treating these rare lesions, we suggest a practical guide to the best surgical approach for various types of Monteggia like lesions. Some technical tips and pitfalls are also described.

Single ray amputation in traumatic injury of the hand: review of literature.

BACKGROUND AND AIM OF THE WORK: ring avulsion are relatively common hand lesions and are associated with significant disability, especially in hand-workers. The treatment choice is still debatable. We sought to conduct a detailed systematic review in attempt to collate evidence on functional, cosmetic and patient-reported outcomes (PROs) following ray amputation for the management of traumatic hand injury and ring avulsion injury. METHODS: using the PubMed database we made a systematic search for articles regarding single ray amputation after traumatic hand lesion. Nine articles met our including criteria and were analysed. RESULTS: most of the included studies suggest that for those worse cases ray amputation still represent a good option. Indeed ray resection can eliminate the gap, remove a cumbersome or painful digit and guarantes better cosmesis but reduces grip and pinch strength (from 15% to 30%) and decreased palm width. CONCLUSIONS: different surgical techniques are available, almost all of them results in a loss of strength but ensure good both functional and cosmetic results.

Apophyseal avulsion fractures of the pelvis. A review.

BACKGROUND AND AIM OF THE WORK: Fractures of the pelvis classically occur in adolescent during sports activities with forceful and repetitive contractions or passive lengthening acting on not yet ossified growth plates. Their misdiagnosis lead to disability, chronic pain and decrease of performances. Evidence based treatment guidelines do not exist; aim of this paper is to point out clinical outcomes, return to sport rates and complications of surgical and conservative approach. METHODS: A systematic search based on MEDLINE database was performed in August 2017 to identify all published articles from 2010 to 2017 reporting outcomes, return to sport and complications rates after surgical and non-operative treatment of avulsion fractures of the pelvis. RESULTS: Mean age was 14,5 years with anterior inferior iliac spine avulsion representing the most common injury (46%), followed by anterior superior iliac spine avulsion (32%), ischial tuberosity avulsion (12%) and iliac crest avulsion (11%). Rates of excellent outcome and return to sports at pre-injury levels were higher after surgical treatment; surgery has a higher risk of heterotopic ossification (9%) compared to conservative treatment (1,8%), whereas the risk of non-unions is lower (0% versus 2,5%). CONCLUSIONS: Surgery is preferred for major dislocations and fragment sizes, providing a faster return to pre-injury level of activity, decreasing the risk of pseudoarthrosis. Conservative treatment is advisable for minimally displaced fractures when a rapid recovery is not required; patient and his family should be informed on the risk of non-unions and the eventuality of a delayed surgical approach.

Modified Mason type III and IV radial head fractures: results of different surgical treatments.

BACKGROUND AND AIM: Fractures of the radial head account for 4% of all fractures and 33 % of all elbow fractures. Their treatment is somewhat challenging and diversified, especially in more complex fractures (type III and IV of modified Mason's classification). The aim of this study was to identify the best surgical treatment for patients having sustained these latter lesions and outline possible predictive factors of worse outcomes. MATERIAL AND METHODS: Data were retrospectively collected for 63 patients affected by radial head fracture and operated between 2006 and 2014 at the University Hospital of Parma. In 34 patients open reduction and internal fixation (ORIF) was used, in 20 radial head arthroplasty (RHA) was the treatment choice and radial head resection (RHR) was done in the remaining 9. Clinical and radiographic  assessments were done at a minimum follow-up of 1 year. Clinical evaluation was performed with the Mayo Elbow performance Score (MEPS). RESULTS: No statistical differences were observed in either type between the MEPS of affected and unaffected elbow. Multiple regression analysis showed that modified Mason IV fractures were a predictive factor of worse outcome and that an associated coronoid fracture can lead to a higher instability of elbow. Mason IV fractures treated with primary RHA are associated to better outcomes. CONCLUSION: According to this retrospective clinical study, it was not possible to identify the optimal surgical treatment for Mason type III fractures. However, RHA seems to be the preferred choice for Mason type IV fractures. These latter types of lesions are associated to worse outcomes.