Treatment of posteromedial rotational instability of the elbow-what is new in the field?

Coronoid fractures are rare fractures of the elbow joint that can cause acute or chronic posteromedial rotatory instability. During clinical diagnosis, the examiner focuses primarily on assessing joint stability. Because of their size, coronoid fractures can be easily missed on conventional radiography, so further imaging (CT, MRI) is recommended when suspicion is present. In the absence of joint incongruity and fracture displacement, conservative treatment can be an option-especially in patients with low functional demands. Surgical therapy focuses on bony restoration and ligament repair/reconstruction

From radial head to radiocapitellar to total elbow replacement: A case report

INTRODUCTION: Radiocapitellar arthroplasty represents a possible treatment option for isolated osteoarthritis of the radial column. We report the first case of early failure of this procedure. PRESENTATION OF CASE: We present the case of a 41-year old male who sustained a terrible triad injury to his right elbow and subsequently underwent radial head arthroplasty. Due to overstuffing of the radial head prosthesis, capitellar erosion occurred and radiocapitellar arthroplasty was thus performed. Only one year later, conversion of the radiocapitellar replacement to total elbow arthroplasty was required as a result of progressive ulnohumeral osteoarthritis. DISCUSSION: According to the currently limited clinical data, radiocapitellar arthroplasty provides satisfactory results. However, biomechanical analysis shows that available prostheses do not sufficiently reproduce the radiocapitellar anatomy. The design of the prosthesis might thus have contributed to the rapid progression of ulnohumeral erosion following radiocapitellar arthroplasty although the poor outcome may also be attributed to the trauma itself along with the inadequate initial treatment. CONCLUSIONS: The indication for radiocapitellar arthroplasty warrants careful consideration given the results of biomechanical analysis and the early failure due to progressive ulnohumeral erosion seen in the present case. (C) 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability After Failed Common Extensor Origin Release: Outcomes at Minimum 2-Year Follow-up

Background: In patients with chronic lateral epicondylitis who have failed nonoperative treatment, open or percutaneous release of the common extensor origin (CEO) without subsequent reconstruction tends to result in good clinical outcomes. However, surgery can lead to iatrogenic injuries of the lateral collateral ligamentous complex, causing posterolateral rotatory instability (PLRI). Purpose: To determine the clinical outcomes of lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon graft after failed open CEO surgery. Study Design: Case series; Level of evidence, 4. Methods: A total of 103, patients underwent revision surgery at a single institution because of PLRI after failed open release of the CEO (Hohmann procedure) between January 2007 and October 2016. The primary surgery had been performed at other institutions in all cases. Of these patients, 72 were available for follow-up (49 by clinical examination, 23 by telephone interview). Standardized clinical examination; Mayo Elbow Performance Score (MEPS); 11-item version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH); subjective elbow value (SEV); and patient satisfaction were assessed at least 2 years after LUCL reconstruction. Results: The mean age of patients in the study was 46.9 years (range, 21-74 years), and the mean follow-up was 2.8 years after revision surgery. The mean MEPS was 78.9, and the mean QuickDASH score reached 20.4. The mean SEV was 78.6%, and 75% of the patients rated the surgery as good to excellent. Complications were detected in 14% of the patients, and 9 needed revision surgery, primarily owing to graft failure with recurrent instability (n = 5). Conclusion: LUCL reconstruction in patients with PLRI after release of the CEO can restore elbow stability and achieve high patient satisfaction. However, outcome scores and revision rates in this cohort were inferior to published outcomes of primary LUCL reconstruction for treatment of noniatrogenic or traumatic PLRI

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases

Background: Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures. Methods: This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case. Results: The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), debridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision. Conclusions: The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly. (C) 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserve

Fracture Pattern Influences Radial Head Replacement Size Determination Among Experienced Elbow Surgeons

Background: Correct sizing is challenging in radial head replacement and no consensus exists on the implant’s optimal height and width to avoid elbow stiffness and instability. Studies exists, suggesting how to appropriately choose the implant size, but the manner by which the fracture pattern influences the surgeons’ operative choices was not investigated. Methods: The radial heads of four fresh-frozen cadaveric specimens were excised, measured, and fractured to simulate four patterns: three fragments (A); four fragments (B); comminuted (C); comminuted with bone loss (D). Nine examiners were asked to indicate first the maximum diameter of the radial heads with the help of dedicated sizing dishes and then the appropriate implant size with trial implants. Accuracy and precision were determined. A coefficient of variation was calculated and agreement was evaluated with the Bland–Altman method. Results: Accuracy and precision of radial head diameter estimation with dedicated sizing dish were 96.73% and 93.64%, (best pattern, D; worst, C). Accuracy and precision of radial head diameter estimation with trial implants were 99.71% and 90.66% (best pattern, A; worst, D). Frequent modifications occurred between the initial radial head size proposal based on the sizing dish and the radial head size chosen after use of the trial implants (47.2%). Conclusions: Diameter estimation of radial heads with dedicated sizing dishes may be underestimated in comminuted fractures; when bone loss is present, this may lead to an overestimation, especially when using trial implants. Care is essential to determine the optimal size of the implant and to avoid overlenghtening and oversizing, which can be responsible for implant failure. Level of Evidence: Basic Science Study. Clinical Relevance: Knowledge of the manner by which the fracture pattern influences radial head replacement size estimation can help preventing overlenghtening and oversizing during this procedure

Modified anteromedial and anterolateral elbow arthroscopy portals show superiority to standard portals in guiding arthroscopic radial head screw fixation

Purpose Arthroscopic fixation of radial head radial head fractures is an appealing alternative to open reduction and internal fixation, which presents the advantage of minimal surgical trauma. The aim of this study was to evaluate if modifications to the standard anteromedial (AM) and anterolateral (AL) portals could allow screw placement for radial head fracture osteosynthesis closer to the plane of the radial head articular surface. Methods Eight fresh-frozen specimens were prepared to mimic arthroscopic setting. Standard AL (ALst) and AM (AMst) and distal AL (ALdi) and AM (AMdi) portals were established. Eleven independent examiners were asked to indicate the optimal trajectory, when aiming to place a cannulated screw parallel to the radial head surface for radial head osteosynthesis. A three-dimensional digital protractor was used to measure the angle between the indicated position and a Kirschner wire placed parallel to the radial head articular surface (alpha). The Shapiro-Wilk normality test was used to evaluate the normal distribution of the samples. Means, standard deviations, and 95% confidence intervals (95% CI) were calculated for each portal. A coefficient of variation (CoV) was calculated to determine agreement among observers and intra-observer variability. Results Mean alpha angles were 25.1 +/- 11.5 degrees for AMst, 13.8 +/- 4.8 degrees for AMdi, 17.1 +/- 13.4 degrees for ALst, -2.6 +/- 9.2 degrees for ALdi. No overlapping in the 95% CI of ipsilateral standard and distal portals was observed, indicating that the difference between these means was statistically significant. The distal portals showed smaller inter-observer CoV as compared to the standard ones (AMst: 10.0%; AMdi: 4.6%; ALst: 12.5%; ALdi: 10.6%). Intra-observer CoV was similar for all portals (AMst: 5.5%; AMdi: 6.1%; ALst: 7.7%; ALdi: 7.1%). Conclusions The use of distal AM and AL portals permits to obtain alpha angles closer to the radial head articular surface than standard AM and AL portals. This is expected to allow screw placement in a flatter trajectory, which should correlate with a superior biomechanical performance of fixation. Good reproducibility of Kirschner wire placement from distal portals was observer among different examiners. Modifications to the standard AM and AL elbow arthroscopy portals allow to place screws for radial head fracture osteosynthesis in a position which should guarantee superior biomechanical performance of fixation