Posttraumatic proximal radioulnar synostosis: Current concepts on the clinical presentations, classifications, and open surgical approaches.

In the forearm, posttraumatic heterotopic ossification usually forms as a proximal radioulnar synostosis. It can occur after soft tissue injury involving the interosseous membrane or after surgery involving the radio and ulna, such as distal biceps tendon repair. It can also be induced by radial head dislocation or fracture. Screening radiography can be used to select the appropriate time for excision. The synostosis can be resected when the ectopic bone margin and trabeculation appear mature on radiographs. An interval of 6-12 months from the injury is generally recommended based on ectopic bone maturity. Selection of the surgical approach depends on site, extension (elbow joint or proximal radioulnar joint), severity of the initial articular surface, and periarticular tissue injury. The posterolateral approach is indicated for synostoses: at or distal to the bicipital tuberosity, at the level of the radial head, and proximal radioulnar joint. The posterior global approach is recommended when the forearm synostosis is associated with complete bony ankylosis of the elbow involving the distal aspect of the humerus. After surgical resection of a proximal radioulnar synostosis, the exposed bone surfaces can be covered with interposition material to minimize recurrence.

Long-terms outcomes of radial head arthroplasty using a bipolar prosthesis.

BACKGROUND: In acute treatment of radial head fractures, a radial head prosthesis can be considered if open reduction and internal fixation are not technically feasible. METHODS: We reviewed the data of 27 consecutive bipolar Judet radial head prostheses implanted in patients with unreconstructable radial head fractures and no other concomitant fractures (coronoid or olecranon factures). The lesions of the lateral collateral ligament were rated according to the McKee classification. Twenty-three patients with more than ten-year follow-up participated in this retrospective study All patients underwent assessments for pain, range of motion and stability using the Mayo Elbow Performance Score, the QuickDash questionnaire and a Visual Analogue Scale for pain. Radiography assessment was performed to determine the correct setting of the implant, presence of periprosthetic loosening, prosthetic disassembly, heterotopic ossification, capitellum and ulnohumeral degenerative changes. RESULTS: Mean follow-up was 149 months (± 12.2). Mean range of motion in flexion-extension was 111° (± 10.55), mean extension was 18° (± 14.32) and mean flexion was 130° (± 11.4). Mean arc of motion in supination-pronation was 150° (± 12.26). The mean Mayo Elbow Performance Score was 88, the mean QuickDash score was 7.3; 86% of the patients were satisfied. Seven patients (26%) required secondary surgery. The most frequent complication was heterotopic ossification, which had negative consequences on the functional result. CONCLUSIONS: Bipolar radial head prostheses are an option for acute treatment of isolated unreconstructable radial head fractures. During follow-up, three patients required implant revision and removal; the capitellum surface presented severe degenerative changes and the prosthesis was not replaced. Another complication was the risk of implant dislocation, in relation to implant design, incorrect positioning of the radial head stem or else to inadequate reconstruction of the lateral collateral ligament. Further work is needed to establish the long-term follow-up results of Judet implants in complex elbow fractures.

Three-dimensional printed models for surgery planning of post-traumatic stiff elbow: Current concepts.

The post-traumatic stiff elbow is a challenge for the surgeon, requiring expertise for the treatment choice and accurate planning. Stiffness can result from traumatic injury involving the periarticular soft tissues and the joint articular surfaces. In this article, we want to assess the impact of three-dimensional (3D) printed models in selecting the appropriate surgical strategy for this pathology. Six cases of increasing complexity regarding post-traumatic stiff elbow were submitted to four expert elbow surgeons who had the possibility to evaluate videos and reports of clinical examination, plain radiograms and CT with 3D reconstruction for each case. After a first treatment proposition given by the experts for each patient, a three-dimensional printed model of each elbow based on the CT was provided to the surgeons, asking them to evaluate again all the cases having the possibility to assess also the 3D models. In the four most complex cases all surgeons found more beneficial the use of three-dimensional representation for treatment planning and rate the risk of complications than the sole CT imaging with 3D reconstruction and many of them changed surgical strategy after analysing the model. 3D printing technology is a useful tool in surgery planning for treating complex cases of post traumatic elbow stiffness, especially in the presence of joint deformity. LEVEL OF EVIDENCE: IV.

The internal joint stabilizer for elbow instability: current concepts.

The management of residual elbow instability is challenging in both acute and chronic injuries. Among the available devices, the hinged external fixator provides an additional joint stabilization while allowing an early motion, but it is clumsy and associated to high rate of pin track complications. To address these issues, an internal joint stabilizer (IJS) has been recently developed. An easier recreation of the axis of rotation coupled to the reduced lever arm of the hinge is the root of the consistent and satisfactory results thus far observed. In addition, the device is more comfortable for the patients being an internal stabilizer. Nonetheless, a second surgery for the device removal is necessary, of which the timing is still not standardized. This current concepts paper describes literature regarding outcomes of the IJS focusing on the rate of maintained radiographic joint reduction, the resultant range of motion, and the associated complication profile.

Elbow stiffness: Interview with professor Bernard Morrey.

Stiff elbow is a complex condition whose diagnosis and management are sometimes quite a challenge. Compared to the other joints, the elbow is disproportionately affected by loss of motion following trauma or surgery. It is unclear why the elbow tends to develop stiffness; its anatomical complexity, namely the presence of three highly congruent joints in the same capsule and synovial space, the tautness of the lateral and medial collateral ligaments through the whole range of motion, and the very close relationship among tendons, muscles, and skin 2 may account for this characteristic. In a stiff elbow, it is critical to assess the possible involvement of articular and periarticular tissues, particularly the degree of preservation of the articular surfaces and joint congruency. Morrey et al have classified post-traumatic stiff elbow into three types: 1) extrinsic contracture, which involves the soft tissue around the joint (capsule, ligaments, muscles) and heterotopic ossification across the joint, 2) intrinsic contracture, secondary to intra-articular fractures that have altered the anatomy of the articular surface, and 3) mixed contracture, combining intrinsic and extrinsic contracture. In the preoperative clinical assessment, we assume capsule contracture to be present in all patients with a stiff elbow. Two main associated lesions can affect prognosis and surgical management: heterotopic ossification and an altered bone joint anatomy. According to Morrey et al, most activities of daily living can be accomplished within an arc of motion from 30° to 130° in extension and flexion and of 50° in pronation and supination. The elbow arc of motion is not compensated for by the wrist and shoulder, thus loss of extension impairs the use of the hand in the space around the body and loss of flexion limits its use for grooming and self-care. The elbow should carefully be tested for deformity of the axial bone alignment (varus and valgus deformity) and rotational stability. Several treatment options are available for stiff elbow, from conservative management with a dedicated rehabilitation program to surgical treatment and from arthroscopic capsulectomy to joint replacement.

Elbow hemiarthroplasty in distal humeral fractures: Indication, surgical technique and results.

The surgical management of distal humerus fractures in adults generally consists in open reduction internal fixation (ORIF) or total elbow arthroplasty (TEA). Hemi humeral hemiarthroplasty (EHA) is a treatment option for unreconstructable intra-articular distal humerus fractures. It is a reasonable option in patients over the fifth decade and its potential advantages are to eliminate the complications related to the ulnar component such as wear of the hinge (busching wear) or the aspetic loosening of the ulnar component. The potential disadvantages are the risk of instability with the possibility of a wear and progressive joint osteoarthrosis. The aims of this manuscript are to evaluate the indications in which we used the EHA, analyzing the correct surgical technique and describe the outcomes in medium and long-term follow-ups. Between 2006 and 2019, we performed 51 EHAs at the Hesperia Hospital in Modena and at the Rizzoli Orthopedic Institute. Taking into consideration only the cases of acute fractures, 27 patients (27 elbows) with a minimum follow-up of 12 months were identified. The patient's mean age at the time of surgery was 64 years old (range from 45 to 78 years old) and they were 78% female (21 out of 27). The Latitude Tornier implant was used in all the patients of our group. The mean MEPS was 89.3 points (from 50 to 100 pts) with excellent results in 19 patients, good in 5, one fair and 2 poor;the mean DASH was 12.6 (from 3.3 to 45.8); the mean OES was 42.3 (from 22 to 47). Complications, were found in 12 patients and any patients required a TEA conversion. Distal humerus hemiarthroplasty from our experience is a good option for the surgical management of unrecostructible distal humeral fractures in selected patients. It is important to perform a precise surgical technique; preserve the triceps insertion, preserve or repair the collateral ligaments, fix the condylar bones implant the prosthesis at the correct size, depth and rotation. The majority of the complication that we observed are related to the stiffness and not to the progressive degenerative changes of the articular surface.

Elbow hemiarthroplasty for acute distal humeral fractures and their sequelae: medium- and long-term follow-up of 41 cases.

BACKGROUND: The earliest distal humeral hemiarthroplasty (or elbow hemiarthroplasty [EHA]) implants, which date back to the late 1940s, were performed in patients with severe elbow joint injuries as an alternative to arthrodesis. After some clinical reports and case studies with a short follow-up, published in the 1990s, a new "anatomically convertible" EHA model was introduced in 2005 and became a common surgical option to treat complex elbow fractures and their sequelae. We describe the mid- and long-term outcomes of EHA performed to treat acute intra-articular fractures or their sequelae. METHODS: From 2006 to 2017, 51 patients underwent EHA for acute intra-articular fractures or their sequelae. A total number of 41 patients (80.5% female) with a minimum follow-up of 2 years, 24 with acute lesions and 17 with sequelae, were identified retrospectively. Clinical evaluation was according to the Disabilities of the Arm, Shoulder, and Hand (DASH) score (subjective), and the Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS) (objective). Radiographic follow-up was with standard radiographs. RESULTS: Mean follow-up was 92.2 months (range, 24-151). Mean patient age at surgery was 62.8 years (range, 45-81). The mean MEPS was 87.1 points, with excellent results in 26 cases, good results in 9 cases, fair in 2, and poor results in 4. The mean DASH score was 15.9 and the mean OES was 40.5, with satisfactory results in 30 cases. Twenty patients experienced complications and 2 required revision surgery. DISCUSSION: EHA is a valuable surgical option in selected patients with comminuted distal humeral joint fractures that cannot be reconstructed with stable fixation and in those with malunion of the articular surface of the humerus. EHA offers potential advantages, especially in active elderly patients and in those aged less than 70 years. It is essential to achieve joint stability, restoring medial and lateral ligament function besides the integrity of the coronoid process. An intact olecranon surface without signs of degenerative changes is also critical for EHA success. CONCLUSION: Our mid- and long-term experience with EHA is favorable, with a high proportion of satisfactory results and long survival rates for both lesion types. In selected patients with acute and post-traumatic injuries, EHA is a valuable surgical option.

A new posterior triceps approach for total elbow arthroplasty in patients with osteoarthritis secondary to fracture: preliminary clinical experience.

BACKGROUND: During the past decade, total elbow arthroplasty (TEA) procedures have increased because of an increase in the number of trauma patients. Even though most current posterior approaches to the elbow provide excellent joint exposure, they involve the risk of extensor mechanism injury and of eventual insufficiency, particularly in patients with osteoarthritis (OA) secondary to fracture. I describe a new triceps exposure approach for TEA, the anconeus-triceps lateral flap, which has proved valuable in patients with distal humeral and olecranon fracture malunion, and its preliminary results at a minimum follow-up of 24 months. METHODS: Twenty consecutive patients with OA due to distal humeral and olecranon fracture malunion underwent TEA by the anconeus-triceps lateral flap approach, which preserves the olecranon insertion of the medial portion of the triceps proper tendon. RESULTS: At a mean follow-up of 33 months, the mean Mayo Elbow Performance Score rose from 41.3 to 94.3. The mean pain score on the visual analog scale fell from 7.1 to 1.1. There were no patients with insufficiency, secondary detachment of the triceps tendon, or grade 4 to 5 of the Medical Research Council scale. DISCUSSION: These preliminary data suggest that preservation of the insertion of the medial portion of the triceps proper tendon enables earlier active rehabilitation. Moreover, the new approach provides optimum exposure of the olecranon also in patients with OA secondary to intra-articular fracture of the distal humerus and olecranon, where scarring and bone deformity usually hamper joint exposure.

The acute bipolar radial head replacement for isolated unreconstructable fractures of the radial head.

For the acute treatment of radial head fractures, radial head arthroplasty can be considered if open reduction and internal fixation is not technically possible and if simple radial head resection is contraindicated. We report our experience with a bipolar Judet radial head prosthesis. After a mean follow-up of 41.7 months, 16 patients were assessed following radial head replacement. The outcome was assessed clinically, functionally, and radiographically. Outcome was satisfactory in 87.5% of cases. The mean post-operative ranges of motion were greater than the functional arcs both in flexion-extension and in pronation-supination, and the results did not appear to be influenced in a significant way by the type of original lesion. All elbows were stable. The main complication was the development of heterotopic ossifications. Bipolar radial head prosthesis represents a suitable option for acute treatment of unreconstructable radial head fractures, either isolated or associated with elbow dislocation and in the absence of other bony lesions.

The outcome of examination (manipulation) under anesthesia on the stiff elbow after surgical contracture release.

HYPOTHESIS: We have used a technique of elbow examination under anesthesia in select patients after surgical release to assess the smoothness of the articulation, evaluate stability, and to stretch the flexion and rotation arcs. MATERIALS AND METHODS: The study comprised 51 consecutive patients who underwent an examination under anesthesia between January of 1996 and December of 2001. RESULTS: The examination occurred a mean of 40 days after surgery. Forty-four patients with a minimum of 12 months follow-up revealed a mean pre-examination arc of 33 degrees , which improved to 73 degrees at the final assessment. Three patients had no appreciable change (<10 degrees ) in the total arc, and 1 patient lost motion. Four patients underwent a second examination under anesthesia at a mean of 119 days after the first examination. The average pre-examination arc of 40 degrees increased to 78 degrees at the final assessment (mean improvement, 38 degrees ). The only complication was worsening of ulnar paresthesias in 3; with 2 resolving spontaneously, and 1 patient requiring anterior ulnar nerve transposition. CONCLUSIONS: Examination (manipulation) under anesthesia can be a valuable adjunctive procedure to help regain the motion obtained at the time of surgical release. Because this was not a controlled series, additional studies might be conducted to refine those not benefiting from this procedure. In our series no permanent complications were noted.

Total elbow arthroplasty in patients forty years of age or less.

BACKGROUND: It is generally accepted that prosthetic elbow replacement should be avoided in young patients because of an anticipated high rate of early failure. The purpose of this paper was to define the success, prosthetic survival rate, and problems encountered in patients who were treated with a semiconstrained total elbow arthroplasty when they were forty years of age or less. METHODS: We retrospectively reviewed the records of 758 patients who had undergone primary arthroplasty with the Coonrad-Morrey total elbow prosthesis for any reason between 1982 and 2003. We identified fifty-five total elbow arthroplasties that had been performed in forty-nine patients (thirty-eight women and eleven men) who were forty years of age or less (mean, thirty-three years) at the time of the operation and that had been followed for a minimum of five years. Six patients had a bilateral procedure. The indication for the arthroplasty was inflammatory arthritis in thirty patients and posttraumatic arthritis in nineteen. Patients with hemophilia or a neoplasm were excluded. The medical record data were used to calculate the preoperative and postoperative Mayo Elbow Performance Score. RESULTS: The mean duration of follow-up was ninety-one months. During this period, twelve (22%) of the elbows had undergone a subsequent surgical procedure: four because of loosening, three because of triceps weakness, three because of wear, and two because of deep infection. On the basis of the Mayo Elbow Performance Score at the last review, thirty-six results (65%) were considered to be excellent; fifteen (27%), good; three (5%), fair; and one (2%), poor. CONCLUSIONS: Semiconstrained total elbow arthroplasty in young patients was associated with a 22% revision rate at a mean of ninety-one months, and the rate of revision was significantly higher for patients with posttraumatic arthritis. Despite this revision rate, fifty-one elbows (93%) had a good or excellent Mayo Elbow Performance Score.

Two peculiar conditions following a coma: a clinical case of heterotopic ossification concomitant with keloid formation.

The etiology and formation pattern of heterotopic ossifications (HO) are still unknown. They occur in soft tissues in which bone does not normally form, near one or more proximal joints. In this article, the authors report a peculiar case of a 31-year-old patient affected by scapulo-humeral ankylosis that occurred about 6 months after a coma, in which two unusual concomitant conditions were observed: HO formation in the scapulo-humeral region and the development of keloids during wound repair. The scapulo-humeral ankylosis was resolved surgically with the removal of the HO, which was then studied morphologically to understand its formation pattern. By light microscopy and transmission electron microscopy, it was observed that heterotopic bone displays the normal microscopic structure of primary bone, in which two types of bone tissue were recognized, i.e., woven-fibered bone, deeply located and produced first, and lamellar bone. This suggests that the pattern of HO formation retraces the ontogenetic steps that normally occur during intramembranous ossification. The authors also discuss the peculiar concomitance of HO formation and keloid development, speculating that, although they are different conditions localized in dissimilar regions, they might be hypothetically triggered by a common event, such as the release of factors likely issued during the coma status.

Triceps insufficiency following total elbow arthroplasty.

BACKGROUND: Over the past decade, the indications for total elbow arthroplasty have increased. One complication that is well recognized but is poorly described in the literature is insufficiency of the extensor mechanism involving complete or partial rupture, or avulsion, of the triceps tendon. We therefore reviewed the records of patients who had undergone surgery for the treatment of triceps insufficiency following total elbow arthroplasty to determine the management options and outcomes of intervention for this problem. METHODS: The records on 887 total elbow arthroplasties performed between 1982 and 2001 were assessed to identify patients who had undergone a subsequent procedure on the triceps. Patients in whom triceps insufficiency developed after débridement for infection were excluded, leaving sixteen elbows in fourteen patients. A Mayo Elbow Performance Score was calculated and elbow extension strength against gravity was measured at the time of final follow-up. RESULTS: There were seven male and seven female patients. The mean age was fifty-four years. The mean duration of follow-up after the triceps reconstruction was sixty-seven months. Three basic techniques were used to repair or reconstruct the extensor mechanism; these included direct suture in seven elbows, anconeus rotation in four, and use of an Achilles tendon allograft in four. The capacity to extend against gravity was restored to fifteen of the sixteen elbows. According to the Mayo Elbow Performance Score, eleven elbows had an excellent outcome, three had a good outcome, and two were considered a clinical failure. CONCLUSIONS: In most patients with triceps insufficiency following total elbow arthroplasty, it is possible to reconstruct the triceps mechanism with a procedure appropriately selected on the basis of tissue quality, tendon retraction, and the status of the olecranon.

Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft.

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.