Mid-Term Follow Up of the Nexel Total Elbow Arthroplasty.

INTRODUCTION: Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at mid-term follow-up. METHODS: Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3 year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via Wrightington method by three independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Dash (QDASH), Patient Rated Elbow Evaluation (PREE), and EuroQoL (EQ5D). RESULTS: 38 consecutive patients (22 female, 16 male) with mean age of 67 underwent TEA via triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with one patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across three observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QDASH, PREE, and EQ5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs. CONCLUSION: At mid-term follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preop to final postop follow-up. Although promising, these results should be interpreted with some caution as long term data regarding this prosthesis are still lacking.

The effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair: a double-blind, randomized controlled trial.

BACKGROUND: Tranexamic acid (TXA) is commonly used in upper and lower limb arthroplasty to limit blood loss and postoperative hematoma formation. The role of TXA in rotator cuff repair (RCR) surgery is less defined. This trial assessed the effect of preoperative TXA on early postoperative pain scores. METHODS: A randomized double-blind trail was conducted in 89 patients undergoing RCR. Patients were randomized to either 2 g of intravenous TXA or placebo at induction. The primary outcome was visual analog scale (VAS)-pain score at day 3 postoperation, with secondary outcomes including VAS-pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores at 2, 8, 24, and 52 weeks. RESULTS: There was no significant difference in VAS-pain scores between groups at day 3 postoperation. Pain scores were significantly better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at 6 months with a reduced rate of secondary adhesive capsulitis. CONCLUSION: TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated greater range of motion at 6 months with lower rates of secondary adhesive capsulitis.

A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Hematoma formation and the need for blood transfusions are commonly reported complications after shoulder arthroplasty. Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to decrease perioperative blood loss. The role of TXA is still being established in shoulder arthroplasty. MATERIALS AND METHODS: We conducted a double-blind randomized controlled trial comparing intravenous TXA vs. placebo in 60 patients undergoing primary anatomic or reverse shoulder arthroplasty. Of these patients, 29 received a placebo whereas 31 received a single dose of 2 g of intravenous TXA. Patient demographic characteristics, as well as drain tube output, blood loss, hematoma formation, transfusion requirement, length of hospital stay, and pain score, were recorded. Patients were followed up for 12 weeks to assess for complications. RESULTS: Patients who received TXA had a lower drain tube output at all time points: 41 mL vs. 133 mL at 6 hours, 75 mL vs. 179 mL at 12 hours, and 94 mL vs. 226 mL at 24 hours (P < .001 for all). They also had a higher postoperative hemoglobin (Hb) level (12.3 g/dL vs. 11.4 g/dL, P = .009), lower change in Hb level (1.7 g/dL vs. 2.3 g/dL, P = .011), lower total Hb loss (0.078 g vs. 0.103 g, P = .042), lower blood volume loss (0.55 L vs. 0.74 L, P = .021), higher postoperative hematocrit level (36.7% vs. 34.6%, P = .020), and lower hematocrit change (5.4% vs. 7.6%, P = .022). There was no significant difference in pain score or length of hospital stay, and no patients required a transfusion. CONCLUSION: A single dose of 2 g of intravenous TXA decreases blood loss and drain tube output in primary anatomic and reverse arthroplasty of the shoulder. No differences were detected in the occurrence of complications, need for transfusion, pain score, or length of hospital stay. With the mounting evidence now available, patients undergoing elective primary shoulder arthroplasty should be given intravenous TXA to decrease perioperative blood loss.

A Biomechanical Comparison of Different Suture Materials Used for Arthroscopic Shoulder Procedures.

PURPOSE: To evaluate the viscoelastic properties of 4 commercially available cord-like sutures and 2 commercially available suture tapes when subjected to physiological loads, as well as to compare them with each other and to identify the clinically most desirable combination of suture material properties. METHODS: Six suture materials (Ethibond, FiberWire, FiberTape, Orthocord, Ultrabraid, and Ultratape) underwent creep testing (n = 7, 60 N, 10 minutes) to determine specimen stiffness, initial elongation at 60 N of load, static creep (during 10 minutes of loading), and relaxed elongation (material recovery 3 minutes after removal of load). Furthermore, cyclic testing (n = 7, 10-45 N, 0.5 Hz, 500 cycles) was carried out to determine dynamic creep, peak-to-peak displacement, and relaxed elongation. Mechanical testing was conducted on a material testing machine in 37°C phosphate-buffered saline solution. RESULTS: FiberTape showed the greatest stiffness (23.9 ± 3.2 N/mm, P < .001), the smallest amounts of static (0.38 ± 0.10 mm, P < .001) and dynamic (0.16 ± 0.09 mm, P = .003) creep, and the smallest peak-to-peak displacement (0.20 ± 0.02 mm, P < .001). FiberTape and FiberWire showed the smallest initial elongation (1.17 ± 0.17 mm and 1.63 ± 0.25 mm, respectively; P < .001). Ultrabraid showed the greatest relaxed elongation, both statically (4.73 ± 0.73 mm, P < .001) and dynamically (4.18 ± 0.83 mm, P = .002). CONCLUSIONS: FiberTape consistently displayed less creep, greater stiffness, and less extensibility than the other suture types. Ultrabraid showed the largest amount of relaxed elongation on both static and dynamic testing. CLINICAL RELEVANCE: When considering high stiffness in combination with low initial extension and low static creep to be ideal parameters to achieve optimal initial construct stability and considering low dynamic creep in combination with low peak-to-peak displacement to be ideal conditions for the repetitive loading of the construct during the healing process, tapes seem to be superior to cord-like sutures for performing rotator cuff repair.

Accuracy of arthroscopic fluid pump systems in shoulder surgery: a comparison of 3 different pump systems.

BACKGROUND: Extra-articular fluid extravasation is a known complication during shoulder arthroscopy. The risk and amount of extravasation to a large degree is dependent on the fluid pressure delivered to the surgical site. Accurate measurement, knowledge, and control of the pressure delivered is thus important to surgeons, anesthetists, and the patient. The purpose of this study was to compare the pressure measurement accuracy of 3 arthroscopic fluid pumps, with 2 of them having 2 different settings. METHODS: Twenty-five patients (n = 5 per group) undergoing shoulder arthroscopy were selected. Three different arthroscopic fluid pumps (ConMed 24K, Stryker Crossflow, Arthrex Dual Wave) were tested in 5 different operational settings (Stryker, standard and dynamic mode; ConMed, with and without TIPS; Arthrex Dual Wave). In each operation, the set pump pressures and the subsequently delivered intra-articular surgical site fluid pressures were measured by a spinal needle connected to an anesthetic standard pressure transducer attached to the anesthetic machine. Independent measures of the surgical site pressures were obtained before multiple portals were created or extravasation had occurred. Measurements were taken at the beginning of surgery. RESULTS: Measurements of the mean intra-articular pressure were found to not be significantly different from the set pressure for the ConMed 24K with TIPS (0.98 ± 0.02-fold) and Stryker Crossflow in standard mode (0.98 ± 0.02-fold). However, actual pressure was significantly greater than the set pressure for the ConMed 24K without TIPS (by 1.30 ± 0.13-fold), Stryker Crossflow in dynamic mode (by 1.82 ± 0.08-fold), and Arthrex Dual Wave (by 2.19 ± 0.06-fold). CONCLUSION: Independently measured intra-articular pressure can be more than double the set pressure for some arthroscopic pumps. Measuring intra-articular pressure can thus aid in adjusting the set pressure. This could minimize the risk of intraoperative complications.

Comparative analysis of 2 glenoid version measurement methods in variable axial slices on 3-dimensionally reconstructed computed tomography scans.

BACKGROUND: Most glenoid version measurement methods have been validated on 3-dimensionally corrected axial computed tomography (CT) slices at the mid glenoid. Variability of the vault according to slice height and angulation has not yet been studied and is crucial for proper surgical implant positioning. The aim of this study was to analyze the variation of the glenoid vault compared with the Friedman angle according to different CT slice heights and angulations. The hypothesis was that the Friedman angle would show less variability. MATERIALS AND METHODS: Sixty shoulder CT scans were retrieved from a hospital imaging database and were reconstructed in the plane of the scapula. Seven axial slices of different heights and coronal angulations were selected, and measurements were carried out by 3 observers. RESULTS: Mid-glenoid mean version was -8.0° (±4.9°; range, -19.6° to +7.0°) and -2.1° (±4.7°; range, -13.0° to +10.3°) using the vault method and Friedman angle, respectively. For both methods, decreasing slice height or angulation did not significantly alter version. Increasing slice height or angulation significantly increased anteversion for the vault method (P < .001). Both interobserver reliability and intraobserver reliability were significantly higher using the Friedman angle. CONCLUSION: Version at the mid and lower glenoid is similar using either method. The vault method shows less reliability and more variability according to slice height or angulation. Yet, as it significantly differs from the Friedman angle, it should still be used in situations where maximum bone purchase is sought with glenoid implants. For any other situation, the Friedman angle remains the method of choice.

The greater tuberosity angle: a new predictor for rotator cuff tear.

BACKGROUND: The implication of scapular morphology in rotator cuff tears has been extensively studied. However, the role of the greater tuberosity (GT) should be of equal importance. The aim of this study was to propose a new radiographic marker, the GT angle (GTA), which measures the position of the GT in relation to the center of rotation of the humeral head. The hypothesis was that a higher angle value would be associated with a higher likelihood in detecting a rotator cuff tear. METHODS: During 1 year, patients were prospectively recruited from a single institution specialized shoulder clinic in 2 different groups. The patient group consisted of individuals with a degenerative rotator cuff tear involving at least the supraspinatus. The control group consisted of individuals with no rotator cuff pathology. Individuals in both groups with congenital, post-traumatic, or degenerative alterations of the proximal humerus were excluded. The GTA was measured on an anteroposterior shoulder x-ray image with the arm in neutral rotation by 3 observers at 2 different times. RESULTS: The study recruited 71 patients (33 patients, 38 controls). Mean GTA value was 72.5° (range, 67.6°-79.2°) in patients and 65.2° (range, 55.8°-70.5°) for controls (P <.001). A value above 70° resulted in 93-fold higher odds of detecting a rotator cuff tear (P <.001). Interobserver and intraobserver reliability were high. CONCLUSIONS: GT morphology is implicated in rotator cuff tears. The GTA is a reliable radiographic marker, with more than 70° being highly predictive in detecting such lesions.

Low rate of Propionibacterium acnes in arthritic shoulders undergoing primary total shoulder replacement surgery using a strict specimen collection technique.

BACKGROUND: Propionibacterium acnes is a recognized pathogen in postoperative shoulder infections. A recent study reported growth of P acnes in 42% of glenohumeral joints in primary shoulder arthroplasty, concluding that P acnes may cause shoulder osteoarthritis. Whether these results reflect true bacterial infection or specimen contamination is unclear. Our prospective study aimed to determine the rate of P acnes infection in arthritic shoulders using a strict specimen collection technique. METHODS: We used modified Oxford protocol to collect tissue specimens from the glenohumeral joint of 32 consecutive patients undergoing primary shoulder arthroplasty. Specimens were cultured specifically for P acnes. Diagnosis of P acnes infection required 2 or more positive cultures and histopathology compatible with infection. RESULTS: Three of 32 patients had a positive culture for P acnes. Overall, 3.125% of specimens grew P acnes without histologic evidence of infection. There were no patients with P acnes infection. The difference in culture rates between patients with idiopathic osteoarthritis and those with a predisposing cause for osteoarthritis was not significant. CONCLUSIONS: We found a low rate of positive cultures for P acnes, but no P acnes infection and no difference between types of osteoarthritis. These results do not support a cause-and-effect relationship between P acnes and osteoarthritis. The differing results from previous studies are likely explained by our strict specimen collection technique, reflecting different rates of contamination rather than infection. That P acnes contamination occurs in primary shoulder arthroplasty is concerning. Further studies are needed to assess the rates of contamination in shoulder surgery, its clinical effect, and to determine optimal antibiotic prophylaxis.

Sequential Release and Muscle Slide of Irreparable Rotator Cuff Tears Results in Linear Gains in Tendon Mobility.

Purpose: The purposes of this study were to examine the technique of the supraspinatus and infraspinatus muscle slide for the treatment of rotator cuff tears and to quantify the amount of release and resultant tendon excursion at their insertion sites in cadavers. Methods: Twelve shoulders in 6 human cadavers were dissected. Their average age at time of death was 84 years. Though a large open posterior incision, artificial rotator cuff tears were created, if not already present. Standard arthroscopic release was completed. Muscle slide technique was then performed for the supraspinatus and infraspinatus muscles in quartiles, with tendon excursion measured at each interval. Results: The average muscle length from its most medial border to the tendinous insertion was 130 mm and 145.8 mm for the supraspinatus and infraspinatus, respectively. Progressive release of the muscle origin from lateral to medial in 25% increments corresponded to a 6.47-mm lateral shift of the tendon to a maximum of 25.8 mm before complete release of the supraspinatus muscle was achieved. For the infraspinatus, it was an average of 5.38 mm at each 25% interval to a maximum of 21.5 mm. The only restraint to mobility were the motor branches attached to the undersurface of each muscle belly. Conclusions: An additional 25.8 mm (supraspinatus) and 21.5 mm (infraspinatus) of tendon excursion was produced when 100% of the muscle was released from its underlying fossa. At that juncture, tendon excursion was limited by tension placed on each muscle's respective neurovascular supply. Furthermore, sequential release of each muscle resulted in a predictable and consistent gain in tendon mobility, with an average of 6.47 mm and 5.38 mm for each quartile of muscle release in the supraspinatus and infraspinatus from lateral to medial. Clinical Relevance: Tension at the repair site is a contributing factor to poor outcomes after arthroscopic rotator cuff repair of massive rotator cuff tears. This study quantifies the tendon mobility that may be gained following additional muscle slide techniques, and the addition of this technique may contribute to a tension-free repair.

A Shoulder/Elbow Triage and Assessment model of care reduced a public orthopaedic shoulder/elbow clinic waitlist with high patient satisfaction.

BACKGROUND: Patients referred to public orthopaedic clinics can experience long waiting times before assessment. This study aims to evaluate the effectiveness of a collaborative Shoulder/Elbow Triage and Assessment (SHELTA) model of care involving orthopaedic surgeons and physiotherapists to reduce the waitlist and improve service and clinical outcomes for patients on an orthopaedic shoulder/elbow clinic waitlist. METHODS: Patients on the waitlist were triaged by surgeons and physiotherapists and invited to an assessment by experienced physiotherapists. Patients were treated nonoperatively or transferred to orthopaedic management based on clinical discussion. The primary outcome was the number of patients on the waitlist. Secondary outcomes included adverse events, patient satisfaction, re-referral and conversion to surgery rates. Pain, function and patient global impression of change were recorded for participants managed nonoperatively. RESULTS: From July 2019 to December 2019, the waitlist reduced from 451 to 298 patients with no adverse events. Seventy-nine patients could not be contacted and 25 no longer required assessment, and were removed from the waitlist. Nonoperatively managed participants reported satisfaction with the service, a median score of 6 on a 7-point Patient Global Impression of Change scale, change in pain of -2.5/10 (95% CI -3.3, -1.7; P < 0.001) on a numerical pain rating scale, and change in function of -17.4/100 (95% CI: -24.1, -10.8; P < 0.001) on the QuickDASH, indicating improvement. CONCLUSIONS: The SHELTA model of care effectively reduced the number of patients on an orthopaedic shoulder/elbow clinic waitlist with good service and clinical outcomes.

Implication of bone morphology in degenerative rotator cuff lesions: A prospective comparative study between greater tuberosity angle and critical shoulder angle.

BACKGROUND: Degenerative rotator cuff tear is a frequent and multifactorial pathology. The role of bone morphology of the greater tuberosity and lateral acromion has been validated, and can be measured with two plain radiographic markers on true anteroposterior views: the greater tuberosity angle (GTA) and the critical shoulder angle (CSA). However, the interdependence of both markers remains unknown, as well as their relationship with the level of professional and sports activities involving the shoulder. The aim of this prospective comparative study was to describe the correlation between the GTA and CSA in patients with degenerative rotator cuff tears. HYPOTHESIS: GTA and CSA are independent factors from one another and from demographic factors, such as age, dominance, sports, or professional activities. PATIENT AND METHODS: All patients presenting to a shoulder specialized clinic were assigned to two groups. The first consisted of patients with a symptomatic degenerative rotator cuff tear visible on MRI and the control group consisted of patients with any other shoulder complaints and no history or visible imaging of any rotator cuff lesion. RESULTS: There were 51 shoulders in 49 patients in the rotator cuff tear group (RCT) and 53 shoulders in 50 patients in the control group. Patient demographics were similar in both groups. Mean GTA was 72.1°±3.7 (71.0-73.1) in the RCT group and 64.0°±3.3 (63.1-64.9) in the control group (p<0.001). Mean CSA was 36.7°±3.7 (35.7-37.8) in the RCT group, and 32.1°±3.7 (31.1-33.1) in the control group (p<0.001). A summation of GTA and CSA values over 103° increased the odds of having a rotator cuff tear by 97-fold (p<0.001). There was no correlation between GTA and CSA, nor between GTA or CSA and age, sex, tear size, or dominance. Patients with different levels of professional and sports activities did not have significantly different GTA or CSA values. CONCLUSION: GTA and CSA are independent radiologic markers that can reliably predict the presence of a degenerative rotator cuff tear. A sum of both values over 103° increases the odds of having a rotator cuff tear by 97-fold. These markers are not correlated with patient demographic or environmental factors, suggesting that the variability of the native acromion and greater tuberosity morphology may be individual risk factors for rotator cuff tear. LEVEL OF EVIDENCE: II; diagnostic study.

Wrist-mounted accelerometers provide objective evidence of disease and recovery in patients with frozen shoulder.

BACKGROUND: Commercially available wrist-mounted exercise monitors may offer objective data on disease and recovery. This study is the first to evaluate the potential of such devices in the assessment of frozen shoulder and the effects of treatment. METHODS: Twenty-one patients with isolated, unilateral frozen shoulder wore a wrist-mounted accelerometer (Fitbit Fire II, Fitbit Inc. 2007, California, USA) on each wrist for two separate seven-day periods, one week before and six months after treatment. The monitors produced an activity count for each 24-hour period, accounting for all movements of the upper limb. Three values were calculated for each time period: (1) the mean activity count for each limb, (2) the total activity count for both limbs, and (3) an activity count ratio calculated by dividing the activity of the frozen limb by the unaffected limb. Constant score, American Shoulder and Elbow Surgeons, visual analog scale-pain, and range of movement were recorded before and after treatment. RESULTS: Mean activity counts were significantly lower in the frozen shoulder limb than those in the unaffected limb over the initial seven-day period (6066 vs. 7516; P = .04). The activity count ratio significantly improved after treatment (0.83 vs. 096; p 0.01), whereas the mean total activity count remained similar before and after treatment (14915 vs. 12371; P = .18), demonstrating that activity transferred from the unaffected limb back to the previously frozen limb. Range of movement (P < .01), Constant (P < .01), American Shoulder and Elbow Surgeons (P < .01), and visual analog scale-pain (P < .01) scores all significantly improved after treatment, but there was no correlation with the data from the activity monitor. DISCUSSION: Wrist-mounted accelerometers are sufficiently sensitive to detect a difference in limb activity in patients affected by frozen shoulder. The movement deficit between the affected and unaffected limbs improved by 14% after treatment. These data could be used in conjunction with subjective scores to offer a clearer insight into patient disease burden and recovery.

Clinical outcomes and safety of distal biceps repair using a modified entry point.

BACKGROUND: The purpose of this study is to determine the safety of a one-incision technique for distal biceps repair with modified repair entry point in regards to the distance from the posterior interosseous nerve (PIN). Secondly, we present the clinical results of patients having undergone this procedure. METHODS: Ten cadaveric specimens were dissected to reveal the radial tuberosity. Two 1.6-mm guidewires were inserted into the radial tuberosity, one centrally, and one 5-mm more proximal. Both guidewires penetrated the dorsal cortex, and posterior dissection revealed their exit points. The distance from the PIN and each wire was determined using a vernier calliper. The functional outcomes of 10 patients' post repair were reviewed. Performance was determined using strength and range of motion (ROM) measurements. Functional impairment was assessed using the disability of the arm, shoulder and hand outcome measure (DASH score). The uninjured side was used as a control. RESULTS: The mean distance from the centre of the radial tuberosity to the PIN was 7.33 mm with a centrally placed wire, compared with 10.92 mm when measuring from the proximal guidewire (P < 0.05). Supination and flexion strengths were 83 and 90% of the uninjured side, respectively. There was a mean of 1.5° loss of flexion and 0° loss of extension. Loss of pronation and supination ROM were 0.5° and 4.5° on average, respectively. Average DASH score was 6.3. CONCLUSION: We recommend a 5-mm more proximal entry point for insertion of the guidewire during distal biceps repair. This poses less risk to the PIN without significant functional impairment. Our outcomes are comparable with those reported in the literature.

Contamination of the Surgical Field with Propionibacterium acnes in Primary Shoulder Arthroplasty.

BACKGROUND: Propionibacterium acnes is a common pathogen identified in postoperative shoulder infection. It has been shown to be present in culture specimens during primary shoulder arthroplasty; however, recent work has suggested that it is most likely to be a contaminant. Our aim was to identify the potential sources of contamination in shoulder arthroplasty. METHODS: Tissue swabs were obtained for microbiological analysis from consecutive patients undergoing primary shoulder arthroplasty. Routine surgical technique was maintained, and 5 specimens were taken from different sites: (1) the subdermal layer, (2) the tip of the surgeon's glove, (3) the inside scalpel blade (used for deeper incision), (4) the forceps, and (5) the outside scalpel blade (used for the skin incision). RESULTS: Forty patients (25 female patients and 15 male patients) were included. Thirteen (33%) of the 40 patients had at least 1 culture specimen positive for P. acnes. Two (8%) of the 25 female patients and 11 (73%) of the 15 male patients had ≥1 culture specimen positive for P. acnes. The most common site of growth of P. acnes was the subdermal layer (12 positive samples), followed by the forceps (7 positive samples), the tip of the surgeon's glove (7 positive samples), the outside scalpel blade (4 positive samples), and the inside scalpel blade (1 positive sample). There were 27 of 75 swabs that were positive on culture for P. acnes in male patients compared with 4 of 125 swabs in female patients. Male patients had 66 times (95% confidence interval, 6 to 680 times) higher odds of having a positive culture indicating subdermal colonization compared with female patients (p < 0.001). CONCLUSIONS: P. acnes is a common contaminant of the surgical field in primary shoulder arthroplasty. The subdermal layer may be the source of this contamination, and the prevalence of P. acnes in the surgical wound may be due to the surgeon's manipulation with gloves and instruments. Our findings are consistent with those regarding the increased rates of P. acnes bacterial load and intraoperative growth in male patients compared with female patients. CLINICAL RELEVANCE: P. acnes is likely to be spread throughout the surgical field from the subdermal layer via soft-tissue handling by the surgeon and instruments. Strategies need to be utilized to minimize this contact and to reduce the chance of colonization.

Radial head replacement with pyrocarbon prosthesis: early clinical results.

BACKGROUND: Comminuted radial head fractures are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is a favourable technique for the treatment of complex radial head fractures. The purpose of this study was to evaluate the functional and radiological outcomes of radial head arthroplasty using modular pyrocarbon radial head prosthesis. METHODS: We retrospectively reviewed 21 consecutive patients requiring radial head arthroplasty for unreconstructible radial head fractures between July 2003 and July 2009. Patients completed a Short Form-36 (SF-36), the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Mayo Elbow Performance Index. Patients were independently physically examined and their post-operative radiographs were reviewed. RESULTS: Twenty-one patients (nine males and 12 females) were reviewed at a minimum of 12 months follow-up. The mean Disabilities of the Arm, Shoulder and Hand score was 10.8 (0-34.1), mean SF-36 physical score was 76.9 (35-96), mean SF-36 mental score was 83.8 (60-94), and their Mayo Elbow Performance Index score was 86.4 (70-100). Patients maintained 90% of their grip strength when compared with their uninjured arm and had 17.5° of fixed flexion in the affected arm. Radiologically, 14 cases had some degree of post-traumatic osteoarthritis, 12 cases had evidence of heterotrophic ossification, five had some evidence of periprosthetic lucency and three patients were radiologically, but not functionally 'overstuffed'. CONCLUSION: Radial head arthroplasty with pyrocarbon radial head prosthesis is an acceptable option when treating unreconstructable radial head fractures yielding good functional and radiological outcomes.

Long-term outcome of resection arthroplasty for the failed total elbow arthroplasty.

BACKGROUND: Elbow resection is a salvage procedure typically considered as a last resort in the case of refractory infection following total elbow arthroplasty. The goal of this study was to evaluate the long-term outcome of patients following resection arthroplasty for the treatment of a failed total elbow replacement. METHODS: Between 1975 and 2005, fifty-one consecutive elbows (fifty patients) were treated with resection for a deep infection following total elbow arthroplasty with either linked or unlinked implants. The average age at the time of arthroplasty was fifty-two years, and the average age at the time of elbow resection arthroplasty was fifty-nine years. Twenty-nine patients (thirty elbows) were contacted at an average of eleven years (range, 2.7 to twenty-eight years) postoperatively, and their outcomes were graded with use of the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The remaining twenty patients (twenty-one elbows) had either died (sixteen elbows) or declined follow-up (five elbows) and so were included only in the analysis of complications and early outcome. RESULTS: Elbow resection resulted in an improvement in the Mayo Elbow Performance Score, from a preoperative value of 37 points to a final follow-up value of 60 points (a poor to fair result) for the twenty-nine patients contacted at long term (p < 0.05). Most of the increase in the Mayo Elbow Performance Score resulted from improvements in the pain component of the score. Of the thirty elbows in patients who had been followed long term, eight had good results; eleven, fair results; and eleven, poor results. The DASH score averaged 71 points (range, 51 to 91 points). Complications were common and included infections in twenty-four elbows (47%), intraoperative fractures in eighteen (35%), and permanent nerve injury in nine elbows (18%). Stability after resection correlated with a better long-term Mayo Elbow Performance Score (p < 0.05). CONCLUSIONS: Resection arthroplasty is a salvage option in patients with refractory infection after a total elbow arthroplasty and should be considered only when all other attempts to eradicate the infection have failed.