Mechanical failure of the Coonrad-Morrey linked total elbow arthroplasty: A case report

AbstractSemiconstrained (linked design) total elbow arthroplasty is indicated in a wide variety of cases. Long-term survival is better than with non-linked prostheses. However, mechanical failure of the hinge mechanism is a complication that may occur during follow-up. We report a case of failure of the axle assembly of a Coonrad-Morrey elbow prosthesis 8years after implantation for nonunion of a supracondylar distal humerus fracture. Initial revision surgery included changing the axle and the polyethylene bushings. Revision surgery was necessary 1year later when the axle failed again. A custom-designed locking axle had to be used to stabilize the hinge mechanism. After 3years follow-up, the hinge was intact, there was no loosening of the components and function of the elbow was good

Bilateral clavicle fracture external fixation

SummaryFractures of the middle third of the clavicle are frequent and their conservative treatment ends in bone union in nearly 95% of cases. Surgical treatment is unanimously indicated with open fractures or in cases of cutaneous damage, neurovascular complications, and impaction of the shoulder stump syndromes. We report herein a case of bilateral fractures of the clavicle that required double stabilization with an external fixator following major cutaneous damage appearing after the initial conservative management. The intraoperative discovery of Propionibacterium acnes infection and bone union obtained within the classical time frame, with a satisfactory functional result, all retrospectively proved the soundness of this indication

Outcomes of bipolar radial head prosthesis to treat complex radial head fractures in 22 patients with a mean follow-up of 50 months

AbstractBackgroundRadial head replacement is indicated to treat complex proximal radial fractures that are not amenable to internal fixation.HypothesisImplantation of a bipolar radial head prosthesis after radial head excision ensures stability of the elbow and forearm, thereby promoting ligament healing and restoring elbow function.Material and methodsTwenty-two patients managed with implantation of a bipolar radial head prosthesis (Guepar®) were evaluated after a mean follow-up of 50 months. The procedure was performed in the acute setting in 16 patients, including 13 with associated injuries; and at the stage of sequelae in 6 patients.ResultsProsthesis removal was required in 4 patients. Of the remaining 18 patients, 14 (77%) had satisfactory Mayo Elbow Performance Score values, 14 (77%) little or no functional impairment, and 11 (61%) little or no pain. Mean motion arcs were 100° in flexion-extension and 143° in pronation-supination. Mean elbow strength in flexion and mean wrist strength were 67% and 86%, respectively, of those on the contralateral normal side. Radio-lucent lines were visible around the prosthesis in 5 patients, radial neck osteolysis in 10 patients, and capitellar erosion in 7 patients. Seven patients each experienced a complication. Early revision surgery to treat elbow instability was required in 6 patients.DiscussionOutcomes after Guepar® bipolar radial head prosthesis implantation were disappointing in patients with complex radial head fractures seen in the acute or chronic setting. The associated injuries to bones and ligaments and the measures taken to repair them influence the prognosis. The complication rate is non-negligible and seems to increase over time.Level of evidenceIV, retrospective study

Skin preparation before hip replacement in emergency setting versus elective scheduled arthroplasty: Bacteriological comparative analysis

SummaryIntroductionHip arthroplasty needs to be performed in an emergency setting after intracapsular femur neck fracture, whereas pain makes preoperative skin preparation of the limb difficult and it may therefore be incomplete. To date no study has analyzed the patient's skin bacteriological status in these surgical conditions.HypothesisThe skin's bacterial flora is quantitatively and qualitatively different in the trauma context compared to an elective scheduled arthroplasty for chronic hip disease.Materials and methodsTwo groups of patients, undergoing hip arthroplasty and having the same preparation at the time of surgery but different skin preparation procedures the day before and the day of surgery, were prospectively compared: 30 patients operated on in an emergency setting for fracture (group A) had no skin preparation and 32 patients operated on in scheduled surgery (group B). Group A had no skin disinfection before going into surgery, whereas group B followed a predefined protocol the day before surgery. Skin samples were taken on gelose at three different stages of skin preparation at the time of surgery (before and after detersive cleaning, and at the end of the surgery) and on two sites (inguinal and greater trochanter). The bacteriological analysis took place after 48hours of incubation.ResultsBefore detersive cleaning, group A had 3.6times more bacteria than group B in the trochanter region and 2.7times more in the inguinal area. After detersive cleaning, the contamination rate in the trochanter area was similar in both groups (group A: 10%; group B: 12.5%), but different in the inguinal region (group A: 33%; group B: 3%; P=0.002). At the end of the surgery, no difference was identified. Coagulase-negative Staphylococcus and Bacillus cereus accounted for 44% and 37%, respectively, of the bacteria isolated. In addition, the frequency of pathogenic non-saprotrophic bacteria was higher in group A (38%) compared to group B (6%). At a mean follow-up of 9.7months (range: 8–11months), no infection of the surgical site was identified.ConclusionThe dermal flora is more abundant and different when the patient is managed in an emergency context. Although effective in the trochanter area, cutaneous detersive cleaning in the operating room is insufficient in the inguinal area and the frequency of pathogenic bacteria warrants identical rigor in preoperative preparation in all situations.Level of evidenceIII. Prospective case – control study

Knee arthodesis using a modular customized intramedullary nail

SummaryIntroductionArthrodesis of the knee, particularly in infectious situations, can be achieved using either an external fixator or an intramedullary device. The objective of this study is to report the clinical, functional, and radiographic outcomes of a continuous series of 19 cases of knee arthrodesis using a customized modular intramedullary nailing system.HypothesisThe modular intramedullary nail offers a satisfactory functional result while maintaining limb length, in spite of a nonunion risk, since acting like a true endoprosthesis.Material and methodsIn our retrospective series of 19 patients, the main source of patients were infected total knee replacements. The nail was customized from assembling a dual surface-sanded titanium component (femoral and tibial). The Lequesne Algofunctional score and the WOMAC score were recorded, as well as the length discrepancy between the lower extremities. Arthrodesis consolidation and the nail's fit in the shaft were verified on anterior-posterior (AP) and lateral radiographs.ResultsFive complications were observed: one anterior cortical break, one excessive tibial rotation, two cases of delayed union, and one nail revision due to residual nail instability. The postoperative Lequesne Algofunctional score was 13/24 and the WOMAC score 57/100. The nonunion rate was 32%. From a functional point of view, the patients who did not achieve complete union and those who did had similar scores. The subjective results were not as good in patients who did not achieve final consolidation.DiscussionModular intramedullary nailing simplifies the technique, shortens the procedure, and reduces the amount of blood loss at surgery. Our nonunion rate was high, although the functional result did not seem compromized by such nonunion. The risk of long-term implant failure was not studied and requires longer follow-up studies.Level of evidenceLevel IV therapeutic study

Trochanteric locking nail versus arthroplasty in unstable intertrochanteric fracture in patients aged over 75 years

SummaryIntroductionIn trochanteric fracture, whatever its anatomic type, internal fixation is currently the standard attitude, with arthroplasty as a relatively unusual option.HypothesisHip implants are an excellent alternative to osteosynthesis in unstable trochanteric fracture in patients aged over 75 years.Patients and methodsA non-randomised prospective multicenter study compared osteosynthesis by trochanteric nailing (n=113) to hip arthroplasty (n=134) in unstable trochanteric fracture (AO types 31 A2.2 and 3 and A3.3) in 247 patients over the age of 75 years. The series was recruited during 2007 in seven centres, four of which included only arthroplasties, two only osteosyntheses and one both. The two groups were comparable in age, sex, preoperative Parker score, pre-fracture place of residence, fracture type, time to surgery and preoperative comorbidity. The sole difference was in operators, with more senior surgeons in arthroplasty (62% versus 27%).ResultsThree-month mortality was identical in the two groups (21.2% versus 21%). General complications did not differ, although mechanical complications were more frequent in the nailing group (12.5% versus 2.8%). Functional results (Parker and PMA scores) were better in the implant than in the nail group.DiscussionThe present study validated hip arthroplasty in these indications. Cemented stems associated to a dual-mobility acetabular component gave the best results.Type of studyProspective, level of evidence III

Periprosthetic osteolysis due to metastatic renal cell carcinoma: a case report

Failure of total hip arthroplasty through septic or aseptic loosening, periprosthetic fracture, or recurrent dislocation is well recognized and understood. We present an unusual cause of failure of total hip replacement which occurred on a 79 year old gentleman: that of prosthetic loosening secondary to malignant infiltration around components. Our aim is to highlight the fact that malignant infiltration should be considered as part of the differential diagnosis in aseptic and septic loosening of prosthetic implants

Results with a minimum of 10 years follow-up of the Coonrad/Morrey total elbow arthroplasty

SummaryIntroductionFew series have evaluated the long-term results of total elbow arthroplasty (TEA).Materials and methodsFifteen patients with a Coonrad/Morrey total elbow implant were reviewed with a minimum follow-up of 10 years. There were nine women and six men with a mean age of 55 years at surgery. The aetiology was rheumatoid arthritis in eight cases, post-traumatic arthritis in five, psoriatic arthritis in one, and sequelae of neonatal septic arthritis in one. The TEA was performed as primary surgery in ten cases and during a revision surgery in four.ResultsAt 136 months average follow-up (120–160), MEPS was 82±14 points (range 60–100) with a Quick DASH score of 41 points (range 13–83). Fourteen patients had no or slight pain and six had a functional range of motion. Elbow function was normal in eight of 15 patients. Radiolucent lines were found around the humerus in six cases (all of them incomplete) and around the ulnar component in eight (five of them complete) with loosening and migration of the ulnar stem occurring in two cases. Wear of the bushings was moderate in five cases and severe in two. There were ten complications with a revision needed in three cases. Revision-free survival rate for the implant was 100% at 5 years and 90% at 10 and 13 years.DiscussionThe Coonrad/Morrey total elbow gives long-term satisfactory results. Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for this total elbow arthroplasty implant.Level of evidenceIV