The Repair, Reconstruction and Replacement of the Coronoid Process

The coronoid process is the most important articular stabilizer of the elbow. While most large coronoid fractures are treated surgically with open reduction and internal fixation, there is limited data on the most effective fixation method. The strengths of five different coronoid fixation methods were assessed using a materials testing machine. Plate fixation proved to be stronger than screw fixation; two screws, regardless of the orientation, were stronger than one; and suture fixation was unreliable. In the setting of an unfixable coronoid fracture, reconstruction of the coronoid using the tip of the olecranon has been described. However, this technique has not been evaluated biomechanically to verify its effectiveness. Using an elbow motion simulator, elbow kinematics were examined after a 40% coronoid deficiency and following reconstruction using the tip of the ipsilateral olecranon. The coronoid deficiency resulted in significant alterations in elbow kinematics, but these were restored after reconstruction. Nonetheless, when coronoid reconstruction is not possible, coronoid replacement may be required. Using the elbow simulator, the effects of coronoid replacement with a novel anatomic and extended tip prosthesis after a 40% coronoid deficiency were examined with the collateral ligaments both repaired and insufficient. When the collateral ligaments were repaired, both prostheses restored stability to the coronoid-deficient elbow. In the setting of ligament insufficiency, an extended prosthesis reduced elbow laxity relative to the anatomic prosthesis, yet was still less stable than the intact elbow with repaired ligaments

Surgical preferences of patients at risk of hip fractures: hemiarthroplasty versus total hip arthroplasty

BACKGROUND: The optimal treatment of displaced femoral neck fractures in patients over 60 years is controversial. While much research has focused on the impact of total hip arthroplasty (THA) and hemiarthroplasty (HA) on surgical outcomes, little is known about patient preferences for either alternative. The purpose of this study was to elicit surgical preferences of patients at risk of sustaining hip fracture using a novel decision board. METHODS: We developed a decision board for the surgical management of displaced femoral neck fractures presenting risks and outcomes of HA and THA. The decision board was presented to 81 elderly patients at risk for developing femoral neck fractures identified from an osteoporosis clinic. The participants were faced with the scenario of sustaining a displaced femoral neck fracture and were asked to state their treatment option preference and rationale for operative procedure. RESULTS: Eighty-five percent (85%) of participants were between the age of 60 and 80 years; 89% were female; 88% were Caucasian; and 49% had some post-secondary education. Ninety-three percent (93%; 95% confidence interval [CI], 87-99%) of participants chose THA as their preferred operative choice. Participants identified several factors important to their decision, including the perception of greater walking distance (63%), less residual pain (29%), less reoperative risk (28%) and lower mortality risk (20%) with THA. Participants who preferred HA (7%; 95% CI, 1-13%) did so for perceived less invasiveness (50%), lower dislocation risk (33%), lower infection risk (33%), and shorter operative time (17%). CONCLUSION: The overwhelming majority of patients preferred THA to HA for the treatment of a displaced femoral neck fracture when confronted with risks and outcomes of both procedures on a decision board

Heterotopic Ossification following Total Elbow Arthroplasty in a Patient with Parkinson’s Disease: Case Report and Literature Review

Introduction. Heterotopic ossification (HO) usually develops following surgery or trauma. Risk factors for HO following elbow fractures include delay to surgery (>7 days), floating fractures, and elbow subluxation. Systemic risk factors for HO include male sex; concurrent cranial, neurological, or abdominal injury; high-energy trauma; previous development of HO; and contralateral fracture. To date, no studies have reported on Parkinson’s disease (PD) as a risk factor for the development of HO. Case Presentation. A 68-year-old female with PD (treated with levodopa-carbidopa) sustained a right closed (OTA type A3) distal humerus fracture and was treated with a total elbow arthroplasty. Postoperatively, development of significant near-ankylosing HO was observed and contributed to significant restriction of elbow motion with activities of daily living. After HO maturation, the osseous growth was excised, and the area irradiated. The patient regained excellent elbow motion with no recurrence of HO. Discussion. A literature review revealed six cases of HO development in PD patients following arthroplasty. Patients with PD have higher serum concentrations of interleukins (IL) and tumor necrosis factor- (TNF-) α. These factors stimulate BMP-2 production which may promote osteogenesis. Levodopa-carbidopa may also influence HO through stimulation of growth hormone and IGF-1. Conclusion. Parkinsonism may promote heterotopic bone growth through the release of osteoinductive factors. HO development may also be mediated by levodopa-carbidopa therapy. Future research should highlight the link between HO and PD and identify if prophylaxis is warranted in PD patients undergoing arthroplasty

Indications and outcomes of radial head excision: A systematic review

© 2019 The British Elbow & Shoulder Society. Background: Radial head excision has historically been a common surgical procedure for the operative management of radial head fractures and post-traumatic conditions. With recent advances in other surgical techniques, controversy exists regarding its indications. This review evaluates the indications and outcomes of radial head excision in traumatic and non-traumatic elbow pathology. Methods: Multiple databases were searched for studies involving radial head excision. Screening and data abstraction were conducted in duplicate. Only studies reporting outcomes for radial head excision were included. Results: Twenty-seven studies with 774 radial head excision patients were included. The most common indications involved acute excision of comminuted radial head fractures (n = 347) and rheumatoid arthritis (n = 201). Post-operative functional scores after acute excision were reported to be good to excellent. In the chronic setting of rheumatoid disease, radial head excision resulted in improved range of motion, although pain was not effectively relieved. Discussion: Outcomes of radial head excision for acute fracture are good to excellent; however, it should not be performed when concurrent or ligamentous injuries are present. Although some studies compared excision to open reduction and internal fixation or replacement, more data are needed to make proper conclusions. The strength of these conclusions is limited by the quality of included literature

Reconstruction of the coronoid process using the tip of the ipsilateral olecranon

Background: Autograft reconstruction of the coronoid using the tip of the olecranon has been described as a treatment option for comminuted coronoid fractures or coronoid nonunions that are not repairable. The purpose of this in vitro biomechanical study of the coronoid-deficient elbow was to determine whether coronoid reconstruction using the tip of the ipsilateral olecranon would restore elbow kinematics. Methods: An elbow motion simulator was used to perform active and passive extension of six cadaveric arms in the horizontal, valgus, varus, and vertical orientations. Elbow kinematics were quantified with use of the screw displacement axis of the ulna with respect to the humerus. Testing was performed with an intact coronoid, a 40% coronoid deficiency, and a coronoid reconstruction using the tip of the ipsilateral olecranon. Results: Creation of a 40% coronoid deficiency resulted in significant changes (range, 3.6° to 10.9°) in the angular deviations of the screw displacement axis relative to the intact state during simulated active and passive extension in the varus orientation with the forearm in pronation and in supination (p \u3c 0.05). Reconstruction of the coronoid using the ipsilateral olecranon tip restored the angular deviations to those in the intact state (p \u3e 0.05) with the arm in all orientations except valgus, in which there was a small but significant difference (0.4° ± 0.2°, p = 0.04) during passive motion with forearm supination. Conclusions: Reconstruction of the coronoid using the tip of the ipsilateral olecranon was an effectivemethod for restoring normal kinematics over a range of elbow motion from 20° to 120° in a cadaveric model of an elbow with a 40% coronoid deficiency. This reconstruction technique may prove beneficial for patients with elbow instability due to coronoid deficiency. Clinical Relevance: This study supports the biomechanical concept of coronoid reconstruction using the ipsilateral olecranon tip for coronoid fractures or nonunions involving 40% of the coronoid process. Copyright © 2014 by the Journal of Bone and Joint Surgery, Incorporated

A biomechanical assessment of fixation methods for a coronoid prosthesis

© 2015 Elsevier Ltd. Background The coronoid process is an integral component for maintaining elbow joint stability. When fixation of a fracture is not possible, prosthetic replacement may be a feasible solution for restoring stability. The purpose of this in-vitro biomechanical study was to compare fixation methods for a coronoid implant. Methods A coronoid prosthesis was subjected to distally-directed tip loading after implantation using four fixation methods: press-fit, anterior-to-posterior screws, posterior-to-anterior screws, and cement. Testing was performed on seven fresh-frozen ulnae in a repeated-measures model. Rounds of cyclic loading were applied at 1 Hz, for 100 cycles, increased in 50 N increments up to a maximum of 400 N. Micro-motion of the implant was quantified using an optical-tracking system. Outcome variables included total displacement, distal translation, gapping, anterior translation and axial stem rotation. Findings Cement fixation reduced implant micro-motion compared to screw fixation, while the greatest implant micro-motion was observed in press-fit fixation. Comparing screw-fixation techniques, posterior-anterior screws provided superior stability only in distal translation. The implant did not experience displacements exceeding 0.9 mm with screw or cement fixation. Interpretation Cement fixation provides the best initial fixation for a coronoid implant. However, the stability provided by both methods of screw fixation may be sufficient to allow osseous integration to be achieved for long-term fixation. Large displacements were observed using the press-fit fixation technique, suggesting that modifications would need to be developed and tested before this technique could be recommended for clinical application