Outcomes of Humeral Allograft-Prosthetic Composites with Plate Fixation in Revision Total Elbow Arthroplasty

Background

Traditionally, the reconstruction of severe distal humeral bone loss at the time of revision total elbow arthroplasty (TEA) has used allograft-prosthetic composites (APCs) stabilized with cerclage wires or cables. We have migrated to plate fixation when revision TEA using a humeral APC is performed. This study shows the outcomes of patients treated with a humeral APC with plate fixation during revision TEA.

Methods

Between 2009 and 2019, 41 humeral APCs with plate fixation of distal humeral allograft to the native humerus were performed in the setting of revision TEA. There were 12 male patients (29%) and 29 female patients (71%), with a mean age of 63 years (range, 41 to 87 years). The mean allograft length was 12 cm. All elbows had a minimum follow-up of 2 years (mean follow-up, 3.3 years). Patients were evaluated for visual analog scale pain scores, range of motion, the ability to perform select activities of daily living, and the Mayo Elbow Performance Score (MEPS). Outcomes including reoperations, complications, and revisions were noted. The most recent radiographs were evaluated for union at the allograft-host interface, failure of the plate-and-screw construct, or component loosening.

Results

The mean postoperative flexion was 124° (range, 60° to 150°) and the mean postoperative extension was 26° (range, 0° to 90°); the mean arc of motion was 99° (range, 30° to 150°). The mean MEPS was 58 points (range, 10 to 100 points). Two surgical procedures were complicated by neurologic deficits. The overall reoperation rate was 14 (34%) of 41. Of the 33 patients with complete radiographic follow-up, 12 (36%) had evidence of nonunion at the allograft-host interface with humeral component loosening, 1 (3%) had evidence of partial union, and 1 (3%) had ulnar stem loosening.

Conclusions

Revision TEA with a humeral APC using compression plating was successful in approximately two-thirds of the elbows. Further refinement of surgical techniques is needed to improve union rates in these complex cases.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Extended deltopectoral approach for revision total elbow arthroplasty requiring humeral allograft-prosthetic composites in patients with severely compromised proximal humerus bone stock

Background

Severe humeral bone loss in the setting of failed total elbow arthroplasty (TEA) poses a particularly challenging reconstructive problem. The objective of this study was to review the rationale, indications, contraindications, and detailed surgical technique for using an extended anterior deltopectoral approach to perform a revision TEA when substantially long allografts are required in the presence of severely compromised proximal humerus bone stock.

Methods

The authors developed this exposure and reconstructive strategy for failed elbow arthroplasties where the remaining segment of proximal humerus is extremely short, which makes adequate plate fixation of an allograft-prosthetic composite (APC) to the native bone extremely challenging. From an anterior deltopectoral approach, it is possible to use dedicated long, precontoured proximal humerus locking plates to maximize fixation in any remaining proximal humerus. This exposure still makes it possible to provide adequate access to the coupling mechanism of the humeral and ulnar components for implantation of a linked elbow arthroplasty. This exposure also allows for adequate judgment of humeral length and rotation.

Pitfalls and Challenges

Crucial steps in the surgery include extending the dissection past the elbow flexion crease such that one can obtain circumferential exposure of the distal humerus. It is also important to couple the humeral and ulnar components prior to committing to the length of the APC. Special attention must be paid to gauge appropriate APC rotation and length for proper soft tissue tension. When performing fixation of the proximal humeral plate, screw purchase must be maximized in both the remaining native proximal humerus and the APC. Compression across the allograft-host interface is paramount for healing to occur.

Conclusion

An extended anterior deltopectoral approach to perform a revision TEA when very long APCs are required is a viable option to restore humeral bone stock and regain humeral stem fixation in the setting of failed TEA with extensive humeral bone loss.

Two-stage reimplantation for deep infection after total elbow arthroplasty

Background

Persistent infection rate after 2-stage reimplantation complicating elbow arthroplasty has been reported to be as high as 25%. The purposes of this retrospective study were to determine the infection eradication rates, complications and outcomes in a cohort of patients treated with two-stage reimplantation for deep periprosthetic joint infection (PJI) following total elbow arthroplasty (TEA) and to determine possible associated risk factors for treatment failure.

Methods

Between 2000 and 2017, 52 elbows underwent a two-stage reimplantation for PJI after TEA. There were 22 males and 30 females with a mean age of 61 (range, 25-82) years. The most common bacterium was Staphylococcus epidermidis (28 elbows). Mayo Elbow Performance Scores were calculated at the latest follow-up. Mean follow-up time was 6 years (range, 2-14 years).

Results

PJI was eradicated in 36 elbows (69%). The remaining 16 elbows were considered treatment failures secondary to recurrent infection. The risk of persistent infection was 3.3 times higher in elbows with retained cement (p 0.04), and 3.5 times higher when the infecting organism was Staphylococcus epidermidis (p 0.06).

Conclusion

Two-stage reimplantation for PJI after TEA was successful in eradicating deep infection in 69% of cases. The eradication of PJI after TEA still needs to be improved substantially.

Classification of Proximal Humerus Fractures According to Pattern Recognition is Associated with High Intraobserver and Interobserver Agreement

Background

The Mayo-Fundación Jiménez Díaz (FJD) classification for proximal humerus fractures aims to identify specific fracture patterns and apply displacement criteria to each pattern. The classification includes 7 common fracture patterns: isolated fractures of the greater or lesser tuberosity, fractures of the surgical neck, impacted fractures involving head rotation in a varus and posteromedial direction or in valgus, and fractures where the humeral head is dislocated (head dislocation), split (head splitting), or depressed (head impaction). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo-FJD classification system using plain radiographs (xR) and computed tomography (CT).

Methods

Three fellowship-trained shoulder surgeons blindly and independently evaluated the xR and CT of 103 consecutive proximal humerus fractures treated at a Level I trauma center. Each surgeon classified all fractures according to the Mayo-FJD classification system on 4 separate sessions at least 6 weeks apart. K values were calculated for intraobserver and interobserver reliability.

Results

The average intraobserver agreement was 0.9 (almost perfect) for xR and 0.9 (almost perfect) for CT scans. The average interobserver agreement was 0.69 (substantial) for xR and 0.81 (almost perfect) for CT scans at the first round, and 0.66 (substantial) for xR and 0.75 (substantial) for CT scans at the second round.

Conclusion

The pattern-based Mayo-FJD classification scheme for proximal humerus fractures was associated with adequate intraobserver and interobserver agreement using both xR and CT scan. Interobserver agreement was best when fractures were classified using CT scans.

Primary Elbow Osteoarthritis: Evaluation and Management

Most patients with primary osteoarthritis of the elbow report a history of heavy lifting with the affected upper extremity . Conservative treatment, including activity modifications, nonsteroidal anti-inflammatory drugs and the occasional intraarticular corticosteroid injection, may provide adequate pain relief in earlier stages . When surgery is required, and despite the presence of cartilage wear, many patients with primary elbow osteoarthritis experience substantial pain improvement with joint preserving procedures . The ulnar nerve needs to be carefully assessed and addressed at the time of surgery . Although open debridement procedures are effective, arthroscopic osteocapsular arthroplasty has emerged as the surgical procedure of choice . Total elbow arthroplasty is very successful in terms of pain relief and function, but it is reserved for patients with end-stage osteoarthritis who are relatively older and have failed joint preserving procedures.

Reverse shoulder arthroplasty for patients with glenohumeral osteoarthritis secondary to glenoid dysplasia

The purpose is to report the clinical and radiographic outcomes, complications and reoperations of reverse shoulder arthroplasty (RSA) for glenoid dysplasia. All patients who had undergone RSA for osteoarthritis secondary to underlying glenoid dysplasia were retrospectively identified. The study included twelve shoulders (11 patients), with a mean (SD) patient age of 62.2 (13.2) years and median (range) clinical follow-up of 28 (24-34) months. RSA resulted in substantial improvements in pain and function. At most recent follow-up, there was a significant improvement in forward flexion range of motion (ROM), a non-significant improvement in internal rotation ROM, and no changes in external rotation ROM. The mean (SD) SST and ASES scores were 7.8 (3.7) and 73.5 (20.4), respectively. There were no reoperations or radiographic loosening. The results were excellent in 1 case, satisfactory in 8, and unsatisfactory in 3. RSA provides acceptable function and good pain relief, though patients should be advised that shoulder rotation may be somewhat limited.

Mid-term radiological results of a cementless short humeral component in anatomical and reverse shoulder arthroplasty

AIMS

Shoulder arthroplasty using short humeral components is becoming increasingly popular. Some such components have been associated with relatively high rates of adverse radiological findings. The aim of this retrospective review was to evaluate the radiological humeral bone changes and mechanical failure rates with implantation of a short cementless humeral component in anatomical (TSA) and reverse shoulder arthroplasty (RSA).

PATIENTS AND METHODS

A total of 100 shoulder arthroplasties (35 TSA and 65 RSA) were evaluated at a mean of 3.8 years (3 to 8.3). The mean age at the time of surgery was 68 years (31 to 90). The mean body mass index was 32.7 kg/m² (17.3 to 66.4).

RESULTS

Greater tuberosity stress shielding was noted in 14 shoulders (two TSA and 12 RSA) and was graded as mild in nine, moderate in two, and severe in three. Medial calcar resorption was noted in 23 shoulders (seven TSA and 16 RSA), and was graded as mild in 21 and moderate in two. No humeral components were revised for loosening or considered to be loose radiologically. Nine shoulders underwent reoperation for infection (n = 3), fracture of the humeral tray (n = 2), aseptic glenoid loosening (n = 1), and instability (n = 3). No periprosthetic fractures occurred.

CONCLUSION

Implantation of this particular short cementless humeral component at the time of TSA or RSA was associated with a low rate of adverse radiological findings on the humeral side at mid-term follow-up. Our data do not raise any concerns regarding the use of a short stem in TSA or RSA. Cite this article: Bone Joint J 2019;101-B:610-614.

Shoulder and Elbow Fractures in Athletes

PURPOSE OF REVIEW

The purposes of this review are to discuss the management of shoulder and elbow fractures in athletes to optimize the return to sport and to highlight treatment impact on the return to play.

RECENT FINDINGS

Fractures of the shoulder and elbow can have profound implications in an athlete career. Recent technique of fractures management trended toward to preserve soft tissue which is critical for an early recovery in athletic population. Arthroscopy presents a strong interest for the treatment of intra-articular fracture, and minimally invasive approach as developed in humeral shaft fracture can be considered to avoid soft tissue damage. Non-articular, stable, and minimally displaced fractures are mainly treated conservatively. However, we encourage a more aggressive approach in shoulder and elbow injuries in the athletes including minimally invasive and stable fixation to preserve vascularity and muscle environment.

Can a reverse shoulder arthroplasty be used to revise a failed primary reverse shoulder arthroplasty?: Revision reverse shoulder arthroplasty for failed reverse prosthesis

AIMS

Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA.

PATIENTS AND METHODS

We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10).

RESULTS

Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01).

CONCLUSION

Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493-98.

Complex elbow instability: surgical management of elbow fracture dislocations

There are three main patterns of complex elbow instability: posterolateral (terrible triad), varus posteromedial (anteromedial coronoid fracture with lateral collateral ligament complex disruption), and trans-olecranon fracture dislocations.Radial head fractures, in the setting of complex elbow instability, often require internal fixation or arthroplasty; the outcome of radial head replacement is dictated by adequate selection of the head diameter, correct restoration of radial length, and proper alignment and tracking.Small coronoid fractures can be ignored. Larger coronoid fractures, especially those involving the anteromedial facet, require fixation or graft reconstruction, particularly in the presence of incongruity.The lateral collateral ligament complex should be repaired whenever disrupted. Medial collateral ligament disruptions seem to heal reliably without surgical repair provided all other involved structures are addressed.The most common mistakes in the management of trans-olecranon fracture dislocations are suboptimal fixation, lack of fixation of coronoid fragments, and lack of restoration of the natural dorsal angulation of the ulna. Cite this article: Sanchez-Sotelo J, Morrey M. Complex elbow instability. EFORT Open Rev 2016;1:183-190.

Complications in reverse shoulder arthroplasty

The reported rate of complications of reverse shoulder arthroplasty (RSA) seems to be higher than the complication rate of anatomical total shoulder arthroplasty.The reported overall complication rate of primary RSA is approximately 15%; when RSA is used in the revision setting, the complication rate may approach 40%.The most common complications of RSA include instability, infection, notching, loosening, nerve injury, acromial and scapular spine fractures, intra-operative fractures and component disengagement.Careful attention to implant design and surgical technique, including implantation of components in the correct version and height, selection of the best glenosphere-humeral bearing match, avoidance of impingement, and adequate management of the soft tissues will hopefully translate in a decreasing number of complications in the future. Cite this article: Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev 2016;1:72-80. DOI: 10.1302/2058-5241.1.160003.

Intra-articular implantation of collagen scaffold carriers is safe in both native and arthrofibrotic rabbit knee joints

Objectives

Sustained intra-articular delivery of pharmacological agents is an attractive modality but requires use of a safe carrier that would not induce cartilage damage or fibrosis. Collagen scaffolds are widely available and could be used intra-articularly, but no investigation has looked at the safety of collagen scaffolds within synovial joints. The aim of this study was to determine the safety of collagen scaffold implantation in a validated in vivo animal model of knee arthrofibrosis.

Materials and Methods

A total of 96 rabbits were randomly and equally assigned to four different groups: arthrotomy alone; arthrotomy and collagen scaffold placement; contracture surgery; and contracture surgery and collagen scaffold placement. Animals were killed in equal numbers at 72 hours, two weeks, eight weeks, and 24 weeks. Joint contracture was measured, and cartilage and synovial samples underwent histological analysis.

Results

Animals that underwent arthrotomy had equivalent joint contractures regardless of scaffold implantation (-13.9° versus -10.9°, equivalence limit 15°). Animals that underwent surgery to induce contracture did not demonstrate equivalent joint contractures with (41.8°) or without (53.9°) collagen scaffold implantation. Chondral damage occurred in similar rates with (11 of 48) and without (nine of 48) scaffold implantation. No significant difference in synovitis was noted between groups. Absorption of the collagen scaffold occurred within eight weeks in all animals

Conclusion

Our data suggest that intra-articular implantation of a collagen sponge does not induce synovitis or cartilage damage. Implantation in a native joint does not seem to induce contracture. Implantation of the collagen sponge in a rabbit knee model of contracture may decrease the severity of the contracture.

Cite this article: J. A. Walker, T. J. Ewald, E. Lewallen, A. Van Wijnen, A. D. Hanssen, B. F. Morrey, M. E. Morrey, M. P. Abdel, J. Sanchez-Sotelo. Intra-articular implantation of collagen scaffold carriers is safe in both native and arthrofibrotic rabbit knee joints. Bone Joint Res 2016;6:162–171. DOI: 10.1302/2046-3758.63.BJR-2016-0193.

Infection in total elbow arthroplasty with stable components

Aims

We describe the use of a protocol of irrigation and debridement (I& D) with retention of the implant for the treatment of periprosthetic infection of a total elbow arthroplasty (TEA). This may be an attractive alternative to staged re-implantation.

Patients and Methods

Between 1990 and 2010, 23 consecutive patients were treated in this way. Three were lost to follow-up leaving 20 patients (21 TEAs) in the study. There were six men and 14 women. Their mean age was 58 years (23 to 76). The protocol involved: component unlinking, irrigation and debridement (I& D), and the introduction of antibiotic laden cement beads; organism-specific intravenous antibiotics; repeat I& D and re-linkage of the implant if appropriate; long-term oral antibiotic therapy.

Results

The mean follow-up was 7.1 years (2 to 16). The infecting micro-organisms were Staphylococcus aureus in nine, coagulase-negative Staphylococcus in 13, Corynebacterium in three and other in six cases. Re-operations included three repeat staged I& Ds, two repeat superficial I& Ds and one fasciocutaneous forearm flap. One patient required removal of the implant due to persistent infection. All except three patients rated their pain as absent or mild. Outcome was rated as good or excellent in 15 patients (mean Mayo Elbow Performance Score 78 points, (5 to 100) with a mean flexion-extension arc of 103° (40° to 150°)).

Conclusion

A staged protocol can be successful in retaining stable components of an infected TEA. Function of the elbow may compare unfavourably to that after an uncomplicated TEA. Cite this article: Bone Joint J 2016;98-B:976–83.

Effectiveness of rosiglitazone in reducing flexion contracture in a rabbit model of arthrofibrosis with surgical capsular release: A biomechanical, histological, and genetic analysis

AIMS

Animal models have been developed that allow simulation of post-traumatic joint contracture. One such model involves contracture-forming surgery followed by surgical capsular release. This model allows testing of antifibrotic agents, such as rosiglitazone.

METHODS

A total of 20 rabbits underwent contracture-forming surgery. Eight weeks later, the animals underwent a surgical capsular release. Ten animals received rosiglitazone (intramuscular initially, then orally). The animals were sacrificed following 16 weeks of free cage mobilisation. The joints were tested biomechanically, and the posterior capsule was assessed histologically and via genetic microarray analysis.

RESULTS

There was no significant difference in post-traumatic contracture between the rosiglitazone and control groups (33° (standard deviation (sd) 11) vs 37° (sd14), respectively; p = 0.4). There was no difference in number or percentage of myofibroblasts. Importantly, there were ten genes and 17 pathways that were significantly modulated by rosiglitazone in the posterior capsule.

DISCUSSION

Rosiglitazone significantly altered the genetic expression of the posterior capsular tissue in a rabbit model, with ten genes and 17 pathways demonstrating significant modulation. However, there was no significant effect on biomechanical or histological properties.Cite this article: M. P. Abdel. Effectiveness of rosiglitazone in reducing flexion contracture in a rabbit model of arthrofibrosis with surgical capsular release: A biomechanical, histological, and genetic analysis. Bone Joint Res 2016;5:11-17. doi: 10.1302/2046-3758.51.2000593.

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.

Short-stem uncemented primary reverse shoulder arthroplasty

Short uncemented humeral stems can preserve humeral bone stock and facilitate revision surgery but may be prone to malalignment or loosening, especially when used in reverse total shoulder replacement (TSR). We undertook a retrospective review of 44 patients with a mean age of 76 years (59 to 92) who underwent primary reverse TSR with a short uncemented humeral stem. There were 29 females. The indications for joint replacement included cuff tear associated arthropathy (33), avascular necrosis (six), post-traumatic arthritis (two), and inflammatory arthritis (three). At a mean follow-up of 27 months (24 to 40), pain was rated as mild or none in 43 shoulders (97.7%). The mean active elevation improved from 54° (sd 20°) to 142° (sd 25°) and the mean active external rotation from 14° (sd 13°) to 45° (sd 9°). The outcome, as assessed by the modified Neer score, was excellent in 27 (61.3%), satisfactory in 15 (34.1%), and unsatisfactory in two shoulders (4.5%). Stems were well-positioned, without evidence of significant valgus or varus malalignment in 42 TSRs (95.5%). There was no radiological evidence of loosening of the humeral stem in any patient; 13 TSRs (29.5%) had evidence of proximal humeral remodelling and scapular notching was noted in three (6.8%).

Cite this article: Bone Joint J 2014;96-B:526–9.

Intra-articular decorin influences the fibrosis genetic expression profile in a rabbit model of joint contracture

OBJECTIVES

The goal of this study was to determine whether intra-articular administration of the potentially anti-fibrotic agent decorin influences the expression of genes involved in the fibrotic cascade, and ultimately leads to less contracture, in an animal model.

METHODS

A total of 18 rabbits underwent an operation on their right knees to form contractures. Six limbs in group 1 received four intra-articular injections of decorin; six limbs in group 2 received four intra-articular injections of bovine serum albumin (BSA) over eight days; six limbs in group 3 received no injections. The contracted limbs of rabbits in group 1 were biomechanically and genetically compared with the contracted limbs of rabbits in groups 2 and 3, with the use of a calibrated joint measuring device and custom microarray, respectively.

RESULTS

There was no statistical difference in the flexion contracture angles between those limbs that received intra-articular decorin versus those that received intra-articular BSA (66° vs 69°; p = 0.41). Likewise, there was no statistical difference between those limbs that received intra-articular decorin versus those who had no injection (66° vs 72°; p = 0.27). When compared with BSA, decorin led to a statistically significant increase in the mRNA expression of 12 genes (p < 0.01). In addition, there was a statistical change in the mRNA expression of three genes, when compared with those without injection.

CONCLUSIONS

In this model, when administered intra-articularly at eight weeks, 2 mg of decorin had no significant effect on joint contractures. However, our genetic analysis revealed a significant alteration in several fibrotic genes. Cite this article: Bone Joint Res 2014;3:82-8.

Triceps insufficiency after the treatment of deep infection following total elbow replacement

Treatment of an infected total elbow replacement (TER) is often successful in eradicating or suppressing the infection. However, the extensor mechanism may be compromised by both the infection and the surgery. The goal of this study was to assess triceps function in patients treated for deep infection complicating a TER. Between 1976 and 2007 a total of 217 TERs in 207 patients were treated for infection of a TER at our institution. Superficial infections and those that underwent resection arthroplasty were excluded, leaving 93 TERs. Triceps function was assessed by examination and a questionnaire. Outcome was measured using the Mayo Elbow Performance Score (MEPS).

Triceps weakness was identified in 51 TERs (49 patients, 55%). At a mean follow-up of five years (0.8 to 34), the extensor mechanism was intact in 13 patients, with the remaining 38 having bone or soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a mean functional score of 18 (0 to 25) of a possible 25 points.

Infection following TER can often be eradicated; however, triceps weakness occurs in more than half of the patients and may represent a major functional problem.

Cite this article: Bone Joint J 2014;96-B:82–7.

Revision of an unstable hemiarthroplasty or anatomical total shoulder replacement using a reverse design prosthesis

Instability after arthroplasty of the shoulder is difficult to correct surgically. Soft-tissue procedures and revision surgery using unconstrained anatomical components are associated with a high rate of failure. The purpose of this study was to determine the results of revision of an unstable anatomical shoulder arthroplasty to a reverse design prosthesis. Between 2004 and 2007, 33 unstable anatomical shoulder arthroplasties were revised to a reverse design. The mean age of the patients was 71 years (53 to 86) and their mean follow-up was 42 months (25 to 71). The mean time to revision was 26 months (4 to 164). Pain scores improved significantly (pre-operative visual analogue scale (VAS) of 7.2 (sd 1.6); most recent VAS 2.2 (sd 1.9); p = 0.001). There was a statistically significant increase in mean active forward elevation from 40.2° (sd 27.3) to 97.0° (sd 36.2) (p = 0.001). There was no significant difference in internal (p = 0.93) or external rotation (p = 0.40). Radiological findings included notching in five shoulders (15%) and heterotopic ossification of the inferior capsular region in three (9%). At the last follow-up 31 shoulders (94%) were stable. The remaining two shoulders dislocated at 2.5 weeks and three months post-operatively, respectively. According to the Neer rating system, there were 13 excellent (40%), ten satisfactory (30%) and ten unsatisfactory results (30%). Revision of hemiarthroplasty or anatomical total shoulder replacement for instability using a reverse design prosthesis gives good short-term results.

Cite this article: Bone Joint J 2013;95-B:668–72.

The contribution of the coronoid and radial head to the stability of the elbow

We undertook this study to determine the minimum amount of coronoid necessary to stabilise an otherwise intact elbow joint. Regan-Morrey types II and III, plus medial and lateral oblique coronoid fractures, collectively termed type IV fractures, were simulated in nine fresh cadavers. An electromagnetic tracking system defined the three-dimensional stability of the ulna relative to the humerus. The coronoid surface area accounts for 59% of the anterior articulation. Alteration in valgus, internal and external rotation occurred only with a type III coronoid fracture, accounting for 68% of the coronoid and 40% of the entire articular surface. A type II fracture removed 42% of the coronoid articulation and 25% of the entire articular surface but was associated with valgus and external rotational changes only when the radial head was removed, thereby removing 67% of the articular surface. We conclude that all type III fractures, as defined here, are unstable, even with intact ligaments and a radial head. However, a type II deficiency is stable unless the radial head is removed. Our study suggests that isolated medial-oblique or lateral-oblique fractures, and even a type II fracture with intact ligaments and a functional radial head, can be clinically stable, which is consistent with clinical observation.

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.

Failure of metal radial head replacement

There is little information available at present regarding the mechanisms of failure of modern metallic radial head implants. Between 1998 and 2008, 44 consecutive patients (47 elbows) underwent removal of a failed metallic radial head replacement. In 13 patients (13 elbows) the initial operation had been undertaken within one week of a fracture of the radial head, at one to six weeks in seven patients (seven elbows) and more than six weeks (mean of 2.5 years (2 to 65 months)) in 22 patients (25 elbows). In the remaining two elbows the replacement was inserted for non-traumatic reasons. The most common indication for further surgery was painful loosening (31 elbows). Revision was undertaken for stiffness in 18 elbows, instability in nine, and deep infection in two. There were signs of over-lengthening of the radius in 11 elbows. Degenerative changes were found in all but one. Only three loose implants had been fixed with cement. Instability was not identified in any of the bipolar implants.

Revision of the humeral component for aseptic loosening in arthroplasty of the shoulder

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88 degrees to 107 degrees (p < 0.01); and the mean external rotation from 37 degrees to 46 degrees (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty.

Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow

We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15). Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04). Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability.

Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow

We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15).

Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04).

Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability.

Surgical techniques for reconstruction of chronic insufficiency of the triceps

Seven patients with chronic insufficiency of the triceps were treated by either a rotation flap using anconeus (4) or an allograft of tendo Achillis (3). The latter procedure was selected for patients with a large defect in whom the anconeus muscle had been devitalised. Five disruptions were in patients who had previously undergone an elbow replacement. The patients were assessed for subjective satisfaction, pain, range of movement and strength, and the results were graded using the Mayo Elbow Performance Score (MEPS). The mean follow-up was for 33 months (9 to 63).

One rotation flap failed six months after operation. At the most recent follow-up, the remaining six patients had no or slight pain, restoration of a functional arc of movement and normal or slightly decreased power of extension. All six were satisfied with the outcome and were able to resume their daily activities with no limitations other than those imposed by the previous elbow replacement. The final MEPS was 100 points in five patients and 75 in one.

Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency

BACKGROUND

Hemiarthroplasty for the treatment of shoulders with glenohumeral arthritis and severe rotator cuff deficiency has been reported to provide reasonable clinical results. The purposes of this study were to determine the clinical and radiographic results of hemiarthroplasty for this condition and to identify pathological and technical factors that may influence its outcome.

METHODS

Thirty patients (thirty-three shoulders) managed with hemiarthroplasty because of glenohumeral arthritis and a massive, irreparable tear of the rotator cuff were followed for an average of five years (range, two to eleven years). Eight shoulders had undergone a prior acromioplasty and resection of the coracoacromial ligament. A small prosthetic head was used in three shoulders; a medium head, in twenty-six; and a large head, in four. Clinical results were graded according to the limited-goals criteria of Neer et al.

RESULTS

The mean pain score decreased from 4.2 points preoperatively to 2.2 points at the time of the most recent follow-up (p = 0.0001). However, at the time of the most recent follow-up, nine shoulders (27%) had moderate pain at rest (four shoulders) or pain with activity (five shoulders). Mean active elevation improved from 72 degrees (range, 30 degrees to 150 degrees) to 91 degrees (range, 40 degrees to 165 degrees) (p = 0.008). Anterosuperior instability occurred in seven shoulders and was associated with a history of subacromial decompression (p = 0.04). The result was graded as successful for twenty-two shoulders (67%).

CONCLUSIONS

Shoulder hemiarthroplasty provides marked pain relief in three-quarters of patients with glenohumeral arthritis and severe rotator cuff deficiency. It is a reconstructive option that provides durable results, but it may be complicated by instability and progressive bone loss.

Radiographic assessment of cemented humeral components in shoulder arthroplasty

Forty-three shoulder arthroplasties performed with the use of cemented Neer II humeral components and followed radiographically for a mean of 6.6 years (range, 2-20 years) were analyzed. A humeral component was considered radiographically "at risk" for clinical loosening when a radiolucent line 2 mm or greater in width was present in 3 or more zones or tilt or subsidence was identified on sequential radiographs by 2 or 3 of the 3 independent observers. None of the components was considered to have tilted or subsided. Radiolucent lines of any size were present in 16 shoulders and were wider than 2 mm in 9 shoulders. They were limited to 1 zone in 8 shoulders and to 2 zones in 7 shoulders. Only 1 component (2%) with a 2-mm radiolucent line in 3 zones was judged to be "at risk." The incidence, extent, and thickness of humeral radiolucent lines were significantly higher in total arthroplasties than in hemiarthroplasties (P <.05). Clinically important changes around cemented Neer II humeral components are uncommon. Humeral radiolucent lines develop more frequently in the presence of a glenoid component. Data from this study can be used as one benchmark to compare with alternate methods of humeral component fixation.

Epidemiology of instability after total hip replacement

This article reviews the epidemiology of dislocation after total hip arthroplasty. The overall prevalence, prevalence as a function of time after arthroplasty, and prevalence of recurrent dislocation are reviewed. Risk factors for dislocation are reviewed according to patient characteristics, implant design characteristics, and factors related to surgical technique.

Radiographic assessment of uncemented humeral components in total shoulder arthroplasty

Seventy-two total shoulder arthroplasties performed using Neer II press-fit humeral components and followed for an average of 4.1 years (range, 2-7.8 years) were analyzed radiographically. A humeral component was considered radiographically at risk for clinical loosening when a radiolucent line > or =2 mm in width was present in > or =3 zones or tilt or subsidence was identified on sequential radiographs by 2 of 3 or 3 of 3 independent observers. Forty components (55.6%) were judged to be at risk. There were no identifiable characteristics associated with the development of an at-risk humeral component except longer average follow-up of the at-risk group (4.7 years vs 3.3 years, P =.001). Humeral components at risk had a higher rate of endosteal erosion (P =.04) and greater number of zones with sclerosis. Radiographic changes around Neer II uncemented humeral components are common. Data from this study can be used as 1 benchmark to compare with alternate methods of humeral component fixation.

Low-friction arthroplasty in patients younger than 40 years old: 20- to 25-year results

A total of 67 low-friction arthroplasties were performed from 1971 through 1978 in patients <40 years old and followed an average of 21.7 years. There have been 33 cup loosenings and 17 stem loosenings. The average rate of wear of the cup was 0.12 mm/y for the entire series and 0.16 mm/y for the revised cups. Although the preoperative diagnosis leading to low-friction arthroplasty commonly reflected some deficiency in bone structure, particularly in the acetabulum, there were no primary osteoarthrosis cases. The femoral stem proved to be durable, but acetabular cups gave poorer results in younger patients than in older patients. The 2 major factors limiting the longevity of the cemented cup were acetabular bone quality and wear.

Treatment of fractures of the distal radius with a remodellable bone cement

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks.

Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year.

We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment.

Treatment of fractures of the distal radius with a remodellable bone cement: a prospective, randomised study using Norian SRS

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year. We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment.

Results of acute excision of the radial head in elbow radial head fracture-dislocations

OBJECTIVES

To evaluate the results of radial head excision for the treatment of elbow fracture-dislocations with an unsalvageable comminuted radial head fracture and no other associated fractures.

DESIGN

Retrospective study.

SETTING

University Hospital.

PATIENTS AND INTERVENTION

Ten elbow fracture-dislocations with a comminuted radial head fracture treated with radial head excision in our institution between 1990 and 1996 and followed a mean of 4.62 years.

MAIN OUTCOME MEASUREMENTS

Clinical results were graded using the Mayo index and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Radiographs were evaluated for proximal radius migration, elbow angulation, degenerative changes, and ectopic bone.

RESULTS

Final clinical results were excellent in four patients, good in five patients, and fair in one patient. Pain was absent in six patients, mild in three patients, and moderate in one patient. Mean flexion arc was 7.5 to 140 degrees, and mean pronation and supination were 85.5 and 83.5 degrees, respectively. Average strength loss was 15 percent. No elbow was unstable. The raw DASH score ranged from 39 to 62 points (normalized values, 0.66 to 15,79 points). On average, the carrying angle increased 5.4 degrees. Degenerative changes were absent in two, Grade I in four, and Grade II in four patients. Ectopic bone, mainly residual fracture fragments, was evident in four patients. Proximal migration of the radius averaged 1.6 millimeters; the two patients with over four millimeters of migration had mild wrist pain.

CONCLUSIONS

Acute radial head excision for the treatment of elbow fracture-dislocations provides satisfactory short-term clinical results when there are no other associated intraarticular fractures. However, the long-term significance of the early degenerative changes is not known.