Radial head replacement in adults with recent fractures

Radial head fractures are fairly common (20% of all traumatic elbow injuries). Non-operative treatment is indicated in non-displaced fractures, and direct stable internal fixation allowing early elbow mobilisation in most other cases. For severely comminuted fractures precluding stable fixation, replacement of the radial head was introduced in the 1970s as a better alternative to simple radial head resection, which can induce instability of the elbow and/or forearm, most notably in patients who have complex fractures with concomitant lesions to other structures. With contemporary implants (modular or monoblock, with or without a mobile cup), mechanical stability is close to that provided by the native radial head, although appropriate treatment of concomitant lesions remains crucial (e.g., re-attachment of the radial collateral ligament, or distal radio-ulnar stabilisation in patients with Essex-Lopresti fracture). The key technical points are selection of implant size and determination of the optimal implantation height. The two most common complications are capitellar overloading due to excessively high implantation of the prosthetic head, which causes stiffness and pain, and loosening of the stem. These complications may require removal of the implant at a distance from the injury. Studies have demonstrated satisfactory clinical outcomes in 60% to 80% of cases

Persistent non-union of the humeral shaft treated by plating and autologous bone grafting

INTRODUCTION: Surgical treatment of persistent non-union of the humeral shaft is a complex situation because of the risk of failure and surgery-related complications. The primary objective of this study was to evaluate clinical and radiological results of a continuous series of persistent non-union treated with plating and bone grafting. The secondary objective was to expose factors contributing to the failure of prior bone union attempts. MATERIAL AND METHODS: Sixteen patients (average age of 52 years) were treated for persistent non-union of the humeral shaft in our department; six of these patients had predisposing comorbidities or addictions. The persistent non-union was treated by plating with autologous bone graft from the iliac crest in a single-stage procedure in 12 cases and a two-stage procedure in three cases; one case was treated with plating and vascularized fibula graft. RESULTS: At a minimum follow-up of 12 months (average 78 months), four (25 %) failed to heal. The 12 other patients had bone union after an average of eight months. The average QuickDASH score was 48 points (18-72). A retrospective analysis of the prior attempts to treat the non-union revealed three cases of unstable fixation, four cases with no osteogenic supply and seven cases of positive microbiological cultures at the non-union site. CONCLUSION: Plating and autologous bone grafting resulted in union in only 75 % of persistent non-union of the humeral shaft. The persistent nature of the humeral shaft non-union could be attributed to deviating from validated rules for surgical treatment and/or the presence of a surgical site infection

Distal radius fracture malunion: Importance of managing injuries of the distal radio-ulnar joint.

Background: Distal radius malunion is a major complication of distal radius fractures, reported in 0 to 33% of cases. Corrective osteotomy to restore normal anatomy usually provides improved function and significant pain relief. We report the outcomes in a case-series with special attention to the potential influence of the initial management. Material and methods: This single-centre retrospective study included 12 patients with a mean age of 35 years (range, 14–60 years) who were managed by different surgeons. There were 8 extra-articular fractures, including 3 with volar angulation, 2 anterior marginal fractures, and 2 intra-articular T-shaped fractures; the dominant side was involved in 7/12 patients. Initial fracture management was with an anterior plate in 2 patients, Kapandji intra-focal pinning in 5 patients, plate and pin fixation in 2 patients, and non-operative reduction in 3 patients. The malunion was anterior in 10 patients, including 2 with intra-articular malunion, and posterior in 2 patients. Corrective osteotomy of the radius was performed in all 12 patients between 2005 and 2012. In 11/12 patients, mean time from fracture to osteotomy was 168 days (range, 45–180 days). The defect was filled using an iliac bone graft in 7 patients and a bone substitute in 4 patients. No procedures on the distal radio-ulnar joint were performed. Results: All 12 patients were evaluated 24 months after the corrective osteotomy. They showed gains in ranges not only of flexion/extension, but also of pronation/supination. All patients reported improved wrist function. The flexion/extension arc increased by 40◦ (+21◦ of flexion and +19◦ of extension) and the pronation/supination arc by 46◦ (+13◦ of pronation and +15◦ of supination). Mean visual analogue scale score for pain was 1.7 (range, 0–3). Complications recorded within 2 years after corrective osteotomy were complex regional pain syndrome type I (n = 1), radio-carpal osteoarthritis (n = 3), and restricted supination due to incongruity of the distal radio-ulnar joint surfaces (n = 3). This last abnormality should therefore receive careful attention during the management of distal radius malunion. Discussion: In our case-series study, 3 (25%) patients required revision surgery for persistent loss of supination. The main error in these patients was failure to perform a complementary procedure on the distal radio-ulnar joint despite postoperative joint incongruity. This finding and data from a literature review warrant a high level of awareness that distal radio-ulnar joint congruity governs the outcome of corrective osteotomy for distal radius malunion

Ultrasound of the coracoclavicular ligaments in the acute phase of an acromioclavicular disjonction: Comparison of radiographic, ultrasound and MRI findings.

OBJECTIVES: Acromioclavicular joint injuries are typically diagnosed by clinical and radiographic assessment with the Rockwood classification, which is crucial for treatment planning. The purpose of this study was to describe how the ultrasound findings of acromioclavicular joint injury compare with radiography and MRI findings. METHODS: Forty-seven patients with suspected unilateral acromioclavicular joint injury after acute trauma were enrolled in this prospective study. All patients underwent digital radiography, ultrasound and 3T MRI. A modified Rockwood classification was used to evaluate the coracoclavicular ligaments. The classifications of acromioclavicular joint injuries diagnosed with radiography, ultrasound and MRI were compared. MRI was used as the gold standard. RESULTS: The agreement between the ultrasound and MRI findings was very good, with a correlation coefficient of 0.83 (95 % CI: 0.72-0.90; p < 0.0001). Ultrasound detected coracoclavicular ligament injuries with a sensitivity of 88.9 %, specificity of 90.0 %, positive predictive value of 92.3 % and negative predictive value of 85.7 %. The agreement between the ultrasound and radiography findings was poor, with a correlation coefficient of 0.69 (95 % CI: 0.51-0.82; p < 0.0001). CONCLUSION: Ultrasound is an effective examination for the diagnostic work-up of lesions of the coracoclavicular ligaments in the acute phase of an acromioclavicular injury. KEY POINTS: • Ultrasound is appropriate for acute acromioclavicular trauma due to its accessibility. • Ultrasound contributes to the diagnostic work-up of acute lesions of the coracoclavicular ligaments. • Ultrasound is appropriate in patients likely to benefit from surgical treatment. • Ultrasound could be a supplement to standard radiography in acute acromioclavicular trauma

Is the Latarjet procedure risky? Analysis of complications and learning curve.

Purpose The purpose of this study was to analyse the learning curve and complication rate of the open Latarjet procedure. Methods The first 68 Latarjet procedures performed by a single surgeon for chronic anterior shoulder instability were reviewed retrospectively. The standard open surgical technique was followed faithfully during each procedure. Post-operative complications were taken from patient medical records. Post-operative evaluation consisted of clinical and radiological assessments. Results The rate of early (<3 months) clinical complications was 7.4 % (5.9 % haematoma, 1.5 % neurological deficit), and the delayed complication rate was 7.3 %. Early complication rate, duration of surgery (mean 65 min; 35–135) and hospital stay (mean 3 days; 1–4) were significantly reduced as experience increased (respectively; P = 0.03, ρ = − 0.3; P = 0.009, ρ = − 0.3; P < 0.0001, ρ = − 0.6). On the radiographs, the bone block was healed and in perfect position in 87 % of cases, with no effect of surgical experience (P = 0.3, ρ = 0.1). The rate of complications on radiographs was 17 %: 11 % partial lysis, 2 % complete lysis and 4 % non-union. No recurrence of instability was found after an average follow-up of 21 months

Postoperative pain after arthroscopic versus open rotator cuff repair. A prospective study

Introduction: Although the arthroscopic technique is becoming the gold standard for rotator cuff tendon repair, there is no proof that this technique results in less postoperative pain compared to open repair. The aim of this study was to prospectively compare the postoperative pain level after arthroscopic or open rotator cuff repair and to define factors that could influence its course. Materials and methods: Between January 2012 and January 2013, 95 patients were operated for a rotator cuff tear: 45 using an arthroscopic technique and 50 an open technique. Daily analgesic use and self-evaluation of pain level using a visual analogic scale were recorded preoperatively and twice a day postoperatively during the first 6 weeks. These data were compared between the two groups and analyzed according to patients’ demographic data and preoperative evaluation of the tear. Results: The preoperative pain level was equivalent in the two groups (P = 0.22). Postoperatively, level-2 analgesic medication use was greater in the arthroscopic group after the 4th week (P = 0.01). A painfree shoulder was obtained before the 6th week in 75% and 66% of the patients after arthroscopic or open repair, respectively (P = 0.34). There was a positive correlation between the preoperative and postoperative pain level (r = 0.25; P = 0.02). Work compensation patients experienced more pain postoperatively (P = 0.08). Level-III analgesic medication use was greater for patients with massive rotator cuff tear (P = 0.001). Conclusion: No evidence was found on the superiority of arthroscopy versus open repair of rotator cuff tear concerning the postoperative pain level. The choice of the surgical technique should not be based on this argument

Complications and revisions after semi-constrained total elbow arthroplasty: a mono-centre analysis of one hundred cases.

Background The complication rate after total elbow arthroplasties is higher than for other arthroplasties. Purpose The purpose of this study was to evaluate the complications and revision rate after 100 semi-constrained total elbow arthroplasties from various types of aetiologies performed in our university hospital. Methods One hundred linked semiconstrained total elbow arthroplasties were performed and were reviewed with 24 months minimum follow-up. Indications were rheumatoid arthritis (45), trauma (33), revisions (16) and others (6). Results At five years average follow-up (range, 2–11), the complication rate was 37 %. Most frequent complications were ulnar nerve involvement (9 %) and triceps insufficiency (7 %). Five implants were aseptically loosed. The infection rate was 4 % with loosening of the implant in two. Four fract humerus proximal or distal to the stem. The radial nerve was injured in two cases. Failure of the locking system of the prosthesis was noted in one case and a fracture of the ulnar component was found in another patient. A revision surgery was performed in 13 cases (13 %). At follow-up 94 prostheses were still in place and the survival rate was 98 % at five years and 86 % at ten years. Conclusion Total elbow arthroplasty remains a difficult procedure with sometimes a high rate of complications necessitating revision procedures. Selection of the patients, a rigorous surgical technique, and a systematic follow-up are prerequisite to limit this incidence

Proximal femoral fractures in centenarians. A retrospective analysis of 39 patients

BACKGROUND: A corollary of the current population ageing in France is an increase in proximal femoral fractures (PFFs), particularly among centenarians. The outcomes of PFFs in centenarians in France are unknown. We therefore conducted a retrospective study of centenarians with PFFs both to assess: (1) assess clinical outcomes according to geriatric and trauma scores, (2) and to determine whether routine surgery is warranted. HYPOTHESIS: Morbidity and mortality in a single-centre cohort of centenarians with surgically treated PFFs are consistent with previous reports. MATERIAL AND METHOD: We retrospectively reviewed the data of 33 women and 6 men aged 100 years or over who were treated surgically for PFFs at a single-centre between 2008 and 2014. Of the 39 patients, 15 were living at home and 24 in an institution at the time of the injury. Mean (range) values were 3.30 (0-7) for the Parker Mobility Score, 5.84 (0-12) for the Katz index, and 7.46 (2-12) for the Mini Nutritional Assessment (MNA). Mean time from injury to surgery was 1.7 days (0-12). The 26 extra-capsular fractures were managed by internal fixation and the 13 intra-capsular fractures by hip arthroplasty (n=12) or screw fixation (n=1). RESULTS: After a mean follow-up of 23±14 months (6-60 months), 29 patients had died, including 3 within 48h, 10 within 3 months, and 15 within 1 year. Sequential mortality rates were 33.3% within the first 3 months, 26.9% from months 4 to 9, and 42.2% within the first year. Early dislocation occurred in 3 patients and surgical-site infection in 2 patients. Other complications were heart failure (n=1), confusional state (n=2), pneumonia (n=2), and pyelonephritis (n=2). DISCUSSION: A PubMed search identified five studies of PFFs in more than 10 centenarians, of which only 2 provided detailed information on postoperative general and local morbidity related to the surgical treatment. Our hypothesis was confirmed for 3-month and 1-year mortality rates, which were at the lower ends of previously reported ranges. Local complications related directly to surgery were considerably more common in our study. PFFs in centenarians carry a high risk of death. Despite the absence of a control group, our data support surgery as the best treatment option. LEVEL OF EVIDENCE: IV, retrospective study

Correlations between effective permeability and marrow contact channels surface of vertebral endplates

Homeostasis of the intervertebral disc relies on nutrient supply and waste clearance through the dense capillary network that is in contact with the cartilage endplate (CEP). We developed a micro-computerized tomography (micro-CT) method to quantify the marrow contact channel surface (MCCS) with the CEP and to validate the hypothesis according to which MCCS was correlated to the effective permeability of the vertebral endplate (VEP) and influenced by the mechanical stimuli. The influence of compression loading on local vascularization was investigated. Six 4-week-old skeletally immature pigs were instrumented with left pedicle screws and rod at both T5-T6 and L1-L2 levels to create asymmetrical spine tethers. After 3 months of growth, three cylindrical specimens of the VEP (one central and two lateral right and left) were obtained from both the instrumented and the control levels. We used a previously validated method for measuring permeability. Micro-CT analysis (resolution 12 mu m) yielded a gray-scale 2D-image of the discal end of each specimen converted into a binary 2D-image to derive the MCCS. Correlations between MCCS and effective permeability were assessed. Effective permeability and MCCS were significantly decreased compared to the control group especially on the tethered side (-41..5%, p = 0.004 and -52.5%, p = 0.0009, respectively). Correlations were significant and showed maximal value (r(2) = 0.430, p < 0.0001) on the tethered side involving maximal compressive loadings. Mechanical stimuli, due to unbalanced growth, altered the vascularization and the convective properties of the CEP. The cascade of mechanobiological events should offer perspectives for research on disc degeneration and attempted treatment. (C) 2010 Orthopaedic Research Society

Radial head arthroplasty: a historical perspective

There has been lively debate regarding the rationale behind the use of radial head arthroplasty (RHA) for more than 80 years. Currently, its primary indication is for treatment of non-reconstructible RH fractures. The first RH implant, released in 1941, was a ferrul cap used to prevent heterotopic ossification. Biomechanical studies in the 1980s stimulated a revolution in RHA design by promoting modular implants that replicated the native bony anatomy of the elbow. Subsequent data-driven evolution in design led to the creation of a variety of devices that also accommodated for common ligamentous injuries occurring at the time of RH fracture. Despite significant advances in our understanding of complex elbow instability, improvements in implant design have to make RHA the gold standard for treatment of non-reconstructible RH fractures. The challenge in the coming years will be to perform high-level clinical studies in order to obtain consensus regarding the most appropriate treatment for comminuted RH fractures