Higher rates of fully preserved posterior cruciate ligament in total knee arthroplasty using a double tibial cut: a prospective randomized controlled trial.

PURPOSE: In cruciate retaining total knee arthroplasty, posterior cruciate ligament damage may occur during tibial cutting. A prospective randomized study was conducted to investigate whether a novel tibial cutting technique was more effective than the currently used techniques. MATERIALS AND METHODS: Patients undergoing cruciate retaining total knee arthroplasty were recruited in a prospective, randomized, controlled trial. In 25 patients (group 1) the tibial cut was performed using a double tibial cut technique; in 25 (group 2) and 25 (group 3) patients, the bone island and en bloc resection techniques were performed, respectively. Posterior cruciate ligament integrity and femoral rollback were assessed at the end of surgery. The Oxford Knee Score, WOMAC score and range of motion were assessed postoperatively. RESULTS: Posterior cruciate ligament was completely preserved in 92% of patients in group 1 and in 64% in group 2 and 3, respectively (p = 0.03). The Oxford Knee Score and WOMAC scores did not differ between groups (p = 0.4). The mean knee flexion was 126.4°, 121.5° and 123.9° in groups 1, 2 and 3, respectively (p = 0.04). The femoral rollback at 120° flexion was 80.7%, 72.2% and 75.4% in groups 1, 2 and 3, respectively (p = 0.01). CONCLUSIONS: The double cut technique preserves the posterior cruciate ligament at significantly higher rates than the bone island or en bloc resection techniques. Better posterior cruciate ligament preservation may improve the femoral rollback and knee flexion. LEVEL OF EVIDENCE: Prospective randomized controlled trial, Level I.

Assessment of progression and clinical relevance of stress-shielding around press-fit radial head arthroplasty.

Aims: The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance. Methods: A total of 97 patients with RHA were analyzed: 56 received a bipolar RHA (Group 1) while 41 received an anatomical implant (Group 2). Radiographs were performed postoperatively and after three, six, nine, and 12 weeks, six, nine, 12, 18, and 24 months, and annually thereafter. PRNR was measured in all radiographs in the four radial neck quadrants. The Mayo Elbow Performance Score (MEPS), the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the patient-assessed American Shoulder and Elbow Surgeons score - Elbow (pASES-E) were used for the clinical assessment. Radiological signs of implant loosening were investigated. Results: The mean follow-up was six years (2 to 14). PRNR started after a mean of 7.5 weeks (SD 2.1) and progressed significantly during the first two years, by the end of which the bone resorption stabilized. PRNR was detected in 81% (n = 45) of patients in Group 1 and 88% (n = 36) in Group 2. The final mean PRNR was 3.0 mm (SD 2.3) in Group 1 and 3.7 mm (SD 2.5) in Group 2. The mean MEPS, QuickDASH, and pASES-E were 95.9 (SD 11.5), 4.4 (SD 9.2), and 94.8 (SD 10.9) in Group 1 and 92.2 (SD 16.2), 9.9 (SD 21.5), and 90.8 (SD 15) in Group 2, respectively. No significant differences were observed between groups in the clinical and radiological outcomes. No correlations were found between PRNR and the clinical results. Conclusion: PRNR after press-fit RHA is a common radiological finding that develops in the first 24 months before stabilizing definitively. PRNR does not affect the clinical results or implant survival in the mid term.

Pelvic ring reconstruction with tibial allograft, screws and rods following enneking type I and IV resection of primary bone tumors.

INTRODUCTION: Surgery of primary malignant tumors involving the sacroiliac joint requires wide resection, which often interrupts the pelvic ring. Nowadays, restoration of the pelvic ring to provide stability and which technique is most fitting remain subject to debate. The aim of this study is to evaluate the results of pelvic reconstruction with pedicle screw instrumentation and tibial allograft following Enneking Type I-IV resections. PATIENTS AND METHODS: All patients who underwent reconstruction with tibial allograft, screws and rods after resection of areas I and IV for primary bone tumors between 2017 and 2022 were reviewed. Clinical and radiological characteristics, fusion rate and functional results were analyzed. The MSTS score and the TESS were used to evaluate functional results. RESULTS: Seven patients were included in the study. Chondrosarcoma was the most common histology. Only four patients reported pain. No fractures were observed at tumor diagnosis. Computer-assisted navigation was used in six cases. Reconstruction was performed in four cases with a screw inserted in the homolateral L5 pedicle and in the ischium, in two cases with a screw in the homolateral L4 pedicle and another in the homolateral L5 pedicle, in the last case with two screws inserted in L4 and L5, one screw in the ischium and another one in the residual iliac wing. In this case a contralateral stabilization was also carried out. The spine screws and the iliac screws were connected with a rod. The mean follow-up for all 7 patients was 37 months. One patient (16.6%) died due to general complications not directly related to the surgery; while the others are alive and apparently free of disease. Complete fusion was obtained in four out of seven patients and the average time for fusion was 9 months. The average MSTS score and TESS were 58.7% and 57.8%, respectively. DISCUSSION: The need for reconstruction is thoroughly debated in literature. The advantages of restoring posterior pelvis stability are the prevention of long-term pain associated with limb shortening and secondary scoliosis. Re-establishment of the pelvic ring can be achieved through synthetic, biologic or hybrid reconstructions. CONCLUSIONS: More studies that assess the surgical consequences at long-term follow-up and help clarify the indications for reconstruction and the specific technique are necessary to confirm our preliminary results.

Morphometric analysis of the lateral column of the distal humerus with an interest on radio-capitellar arthroplasty design. A computed tomography anatomical study on 50 elbows.

PURPOSE: To perform a morphometric analysis of the distal humerus lateral column medullary canal (LCMC). METHODS: Fifty computed tomography(CTs) from 24 males and 26 females were examined. Two observers measured: (1) the capitellum sagittal (RS) and axial (RT) radii of curvature; (2) the sagittal(Sd) and coronal(Cd) diameters of the LCMC in 5 different disto-proximal sites spaced 4 mm apart; (3) the capitellum and LCMC axis offsets on the sagittal (capSO,axSO) and coronal (capCO,axCO) planes; (4) the sagittal (Si) and coronal (Ci) inclination of the LCMC axis. RESULTS: The mean RS and RT were 1.07 cm (SD, 0.11) and 1.30 cm (SD, 0.11), respectively. The mean Sd and Cd values were 1.17 cm (SD, 0.17) and 1.58 cm (SD, 0.24), respectively, with a disto-proximal decrease on both planes. The capSO, capCO, axSO and axCO mean values were 0.76 (SD, 0.21), 1.60 (SD, 0.27), - 0.16 (SD, 0.30) and 0.79 cm (SD, 0.30), respectively. Si and Ci were 70° and 72°, respectively. A strong correlation (r = 0.78) was found between RS and RT and between adjacent levels of Sd and Cd. AxSO and axCO yielded a strong inverse correlation. Male patients showed higher values than female ones in all variables (p < 0.03). The intra-class correlation coefficient (ICC) was always > 0.9. CONCLUSION: The dimensions of the LCMC decrease disto-proximally, with the coronal diameters being greater than the sagittal diameters, resembling a portion of an elliptic torus with an antero-medial concavity. The articular surface of the humeral capitellum is non-spherical, with two strongly correlated radii of curvature. The results of this study may be relevant to the stem design of radiocapitellar arthroplasty.

Primary complex total knee arthroplasty with severe varus deformity and large bone defects: mid-term results of a consecutive series treated with primary implants.

INTRODUCTION: In recent years, the use of constrained implants in complex primary TKA has gained popularity since these implants may better and more easily address severe instability present in complex primary cases (CPC). However, the need for a constrained TKA in CPC is controversial. We hypothesized that a standard TKA may be successful in most of CPC and that an intraoperative switching to a constrained device is rarely need even in the presence of severe instability and bone loss. MATERIALS AND METHODS: A consecutive series of 24 CPC (28 knees) were analysed retrospectively. Inclusion criteria were a femoro-tibial angle > 12° and bone defect of grade 2-3 (group 1). Forty-eight patients (52 knees) were analysed as controls (group 2). Patients were followed up clinically and radiographically up to a minimum of 5 years. RESULTS: In group 1, a PS was used in 24 knees and a CR in 4. In no patient, a CCK or RHK was implanted. Bone defect was treated with bone cement plus cortical screws in 15 knees (53.5%), a medial wedge in 8 (28.5%), a medial wedge plus bone grafting with cancellous screws in 5 (17.8%). Metaphyseal sleeve or cone was not used. At the last follow-up, no significant difference was found in the clinical scores between the 2 groups. CONCLUSION: In CPC with marked varus deformity, instability and bone loss, the use of primary TKA is associated with a clinical outcome comparable to standard cases. Ligamentous balancing may be addressed using primary implants and simple cost-effective techniques may be used to manage an extensive bone loss. In most CPC, an intraoperative switching to a constrained device is not necessary.

Plain films are not accurate in planning internal fixation in vancouver type B1 periprosthetic femoral fractures and in distinguishing between subtypes B1 And B2.

BACKGROUND: While few studies analysed the diagnostic validity of preoperative radiographs in distinguishing between Vancouver type B1 and B2 periprosthetic femoral fractures (PFFs), no investigation has been conducted to assess the degree of diagnostic validity of preoperative radiographs in identifying the fracture course and planning the most appropriate treatment. We analysed the diagnostic validity of radiographs in detecting the fracture course and stem stability in Vancouver type B PFFs. METHODS: Vancouver type B PFFs with different fracture courses were randomly performed in 36 dried cadaveric femurs in which a femoral broach had previously been implanted. Radiographic images, taken in the coronal and sagittal views, were analysed by 5 orthopaedic surgeons and 2 radiologists who were asked to reproduce the fracture course and to evaluate stem stability. A scoring system was used to determine the injured femoral cortex correctly identified by the examiners. RESULTS: The identification of the fracture course was scored as poor in 52.4% and 56.%, fair in 23% and 23.4% and good in 24.6% and 19.8%, The identification of the fracture course in the coronal and axial vies radiographs was scored in coronal and axial view radiographs respectively. There was no significant difference in the average score obtained by senior and young examiners. In the coronal plane, the fracture course was poorly identified by all examiners in 11 (30.5%) femurs and by 5 or more examiners in 17 (47%). The fracture course was correctly identified by 5 or more examiners in 8 femurs (22%). A vertical fracture involving an emidiaphysis was found in 8 of the 11 femurs in which the PFF was poorly diagnosed by all examiners. Stem instability was correctly diagnosed in 45% of cases. CONCLUSIONS: In type B PFFs preoperative radiographs show a reduced diagnostic validity in identifying the fracture course and, hence, in planning a correct treatment. Potentially unstable vertical fractures involving an emidiaphysis are likely to be poorly diagnosed since most of the fracture course is hidden by the femoral stem. In cementless stems the diagnostic validity of radiographs in diagnosing between Vancouver type B1 and B2 seems to be lower than that reported for cemented stems.

Revisiting the tibial crest as reference for the mechanical alignment of the tibial component in total knee arthroplasty: a cadaveric study on Caucasian tibiae.

PURPOSE: The accuracy of the tibial crest (TC) in guiding the mechanical alignment of the tibial component in total knee arthroplasty (TKA) has been investigated in a few studies on Asian patients. No study analyzed the anatomical variants of the TC. We analyzed the morphological types of the TC in cadaveric tibiae of Caucasian subjects and assessed whether the TC may be considered an accurate guide for the mechanical alignment of the tibial component in TKA. METHODS: The TC and mechanical axis (MA) were identified in 86 dried cadaveric tibiae by placing metal landmarks along the TC course and a guidewire overlapping the MA. Coronal view radiographs were taken in different positions of tibial axial rotation, and the relationships between the TC and MA were analyzed. RESULTS: The TC showed three different patterns, comprising a curved, mixed and straight course in 47 (54.6%), 21 (24.4%) and 18 (20.9%) tibiae, respectively. When a curved course was found, the TC intersected the MA at proximal and distal points located, on average 22.4% and 63.3% along the tibial length, respectively. When a straight course was found, the mean angle between the TC and MA was 2.9°. In 35% of the cases, the two axes differed by more than 3°. CONCLUSION: The TC of Caucasian subjects exhibits a marked variability in its course and relationship with the MA. Unlike the TC in Asian subjects, the TC of Caucasians cannot be considered an accurate anatomical reference to guide the coronal alignment of the tibial component in TKA.

Chronic complex persistent elbow instability: a consecutive and prospective case series and review of recent literature.

BACKGROUND: Chronic complex persistent elbow instability (CCPEI) is a condition that even expert elbow surgeons find challenging to treat. The results of the few studies that have dealt with the treatment of this condition are conflicting. We describe the surgical results of a consecutive prospective series of patients with CCPEI and provide a review of the recent literature. METHODS: We assessed 21 patients with previous failed surgical or conservative treatment, with a terrible-triad injury in 13, Monteggia-like lesion in 6, humeral shear fracture-dislocation in 1, and radial head fracture-dislocation in 1. Overall, 21 open débridement procedures, 15 ulnar nerve transpositions, 6 ulnar in situ neurolysis procedures, 7 total elbow arthroplasties, 8 radial head arthroplasties, 1 radial head resection with humeroradial anconeus interpositional arthroplasty, 4 coronoid graft reconstructions, 14 ligament retensioning procedures, 3 ulnar nonunion treatments, and 2 ulnar osteotomies were performed. Two dynamic external fixators were applied. The Mayo Elbow Performance Score, quick Disabilities of the Arm, Shoulder and Hand score, and modified American Shoulder and Elbow Surgeons score were used preoperatively and postoperatively. RESULTS: The mean follow-up period was 29.4 months. A significant improvement was found between preoperative and postoperative clinical scores and range-of-motion values. The reintervention and major complication rates were 19% and 23%, respectively. Arthritic evolution was observed in 71% of the cases. CONCLUSIONS: CCPEI is a challenging condition with an uncertain prognosis. The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. The time interval between the initial trauma and index surgical procedure significantly affects the feasibility of reconstructive procedures.

Post-traumatic proximal radioulnar synostosis: results of surgical treatment and review of the literature.

BACKGROUND: Post-traumatic proximal radioulnar synostosis is a very rare and disabling condition whose surgical treatment has traditionally been viewed with pessimism. The results of the few case series in the literature are conflicting. Our aims were (1) to describe the clinical results of a case series treated surgically by a single elbow surgeon and (2) to review the literature. METHODS: Twelve patients were evaluated. Preoperative radiographs and computed tomography scans were performed. According to the Viola and Hastings classification, there was 1 case of type IC synostosis; 3, type IIA; 2, type IIIA; and 8, type IIIB. Two patients had a double synostosis. The synostosis was excised in 10 cases; in addition, radial head excision, radial head arthroplasty, and proximal radial diaphyseal resection were performed in 1, 3, and 2 cases, respectively. The Mayo Elbow Performance Score, modified American Shoulder and Elbow Surgeons score, and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were used for the preoperative and postoperative evaluation. The nonparametric Wilcoxon signed rank test was used for the statistical analysis. RESULTS: The mean follow-up period was 20.5 months. The final mean extension-flexion and pronation-supination arcs were 116° and 123°, respectively. Significant improvements were found in the Mayo Elbow Performance Score (P = .005), modified American Shoulder and Elbow Surgeons score (P = .012), and QuickDASH score (P = .002), with mean values of 24, 28, and 17, respectively. One synostosis recurrence and one late disassembly of the radial head arthroplasty were observed. CONCLUSIONS: Post-traumatic proximal radioulnar synostosis surgery is effective, but careful preoperative planning based on the pathoanatomic characteristics of each type of synostosis and associated lesions is mandatory. Synostosis excision is performed in most cases, whereas additional surgical procedures should be considered in selected cases.

Midterm results of radiocapitellar arthroplasty of the elbow: a multicentre prospective study on two different implants.

AIMS: The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up. PATIENTS AND METHODS: A total of 31 patients with a mean age of 54 years (27 to 73) were analyzed; nine had primary osteoarthritis (OA) and 17 had post-traumatic OA, three had capitellar osteonecrosis, and two had a fracture. Overall, 17 Lateral Resurfacing Elbow (LRE) and 14 Uni-Elbow Radio-Capitellum Implant (UNI-E) arthroplasties were performed. Pre- and postoperative assessment involved the Mayo Elbow Performance Score (MEPS), the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the modified American Shoulder Elbow Surgeons (m-ASES) score. RESULTS: The mean follow-up was 6.8 years (3.8 to 11.5). The mean MEPS, m-ASES, and Q-DASH scores improved significantly by 50 (p < 0.001), 55 (p < 0.001), and 54 points (p < 0.001), respectively, with no differences being detected between the implants. Preoperative pronation and supination were worse in patients in whom the UNI-E was used. Two patients with the UNI-E implant had asymptomatic evidence of gross loosening. CONCLUSION: Radiocapitellar arthroplasty yielded a significant improvement in elbow function at a mean follow-up of 6.8 years, with a high implant survival rate when the LRE was used in patients with primary or post-traumatic OA, without radial head deformity, and when the UNI-E was used in patients in whom radial head excision was indicated. Cite this article: Bone Joint J 2019;101-B:1362-1369.

The native coronal orientation of tibial plateaus may limit the indications to perform a kinematic aligned total knee arthroplasty.

PURPOSE: To investigate the coronal alignment of tibial plateaus in normal and osteoarthritic knees and to simulate the effects of a tibial cut performed in total knee arthroplasty (TKA) using a kinematic alignment technique with standard instrumentation. METHODS: The coronal alignment of tibial plateaus was measured in three groups including group 1 (reference group), 50 cadaveric tibiae showing no evidence of degenerative changes of tibial plateaus; group 2, 49 patients who underwent MR of the knee, showing no or mild degenerative changes of the knee joint and, group 3, 54 patients with knee osteoarthritis who underwent computer-assisted total knee arthroplasty. RESULTS: The coronal alignment of tibial plateaus averaged 2.4° with no significant differences between groups. The mean coronal orientation of tibial plateaus was 3° ± 2° in men and 1.6° ± 2° in women (p = 0.03). A coronal alignment of tibial plateaus of 3° or more was found in 69 cases (45%) and 5° or more in 23 (14.7%). The simulation of a tibial cut performed with an error of 3° in varus in 15% of the subjects showing a native coronal orientation of tibial plateaus of 3° or more, led to a final tibial cut greater 6° in 13.7% of cases. CONCLUSIONS: A coronal alignment of tibial plateaus of 3° or more in varus was found in near half of normal subjects and osteoarthritic patients. A preoperative measurement of the coronal alignment of tibial plateaus is advisable in any patients scheduled for kinematic aligned TKA. As errors in the alignment of the tibial component of 3° or more may occur using standard instrumentations, the results of this study raise questions on performing a kinematic aligned TKA with standard instrumentations. LEVEL OF EVIDENCE: IV.

Lumbar Interspinous Process Fixation and Fusion with Stand-Alone Interlaminar Lumbar Instrumented Fusion Implant in Patients with Degenerative Spondylolisthesis Undergoing Decompression for Spinal Stenosis.

STUDY DESIGN: Prospective cohort study. PURPOSE: To assess the ability of a stand-alone lumbar interspinous implant (interspinous/interlaminar lumbar instrumented fusion, ILIF) associated with bone grafting to promote posterior spine fusion in degenerative spondylolisthesis (DS) with vertebral instability. OVERVIEW OF LITERATURE: A few studies, using bilateral laminotomy (BL) or bilateral decompression by unilateral laminotomy (BDUL), found satisfactory results in stenotic patients with decompression alone, but others reported increased olisthesis, or subsequent need for fusion in DS with or without dynamic instability. METHODS: Twenty-five patients with Grade I DS, leg pain and chronic low back pain underwent BL or BDUL and ILIF implant. Olisthesis was 13% to 21%. Follow-up evaluations were performed at 4 to 12 months up to 25 to 44 months (mean, 34.4). Outcome measures were numerical rating scale (NRS) for back and leg pain, Oswestry disability index (ODI) and short-form 36 health survey (SF-36) of body pain and function. RESULTS: Fusion occurred in 21 patients (84%). None had increased olisthesis or instability postoperatively. Four types of fusion were identified. In Type I, the posterior part of the spinous processes were fused. In Type II, fusion extended to the base of the processes. In Type III, bone was present also around the polyetheretherketone plate of ILIF. In Type IV, even the facet joints were fused. The mean NRS score for back and leg pain decreased by 64% and 80%, respectively. The mean ODI score was decreased by 52%. SF-36 bodily pain and physical function mean scores increased by 53% and 58%, respectively. Computed tomography revealed failed fusion in four patients, all of whom still had vertebral instability postoperatively. CONCLUSIONS: Stand-alone ILIF with interspinous bone grafting promotes vertebral fusion in most patients with lumbar stenosis and unstable Grade I DS undergoing BL or BDUL.

Contribution of cartilage to size and shape of radial head circumference: magnetic resonance imaging analysis of 78 elbows.

BACKGROUND: The aims of our study were to quantify cartilage thickness at the minimum and maximum diameters of the radial head circumference and to investigate its influence on the size and shape of the proximal radius. METHODS: We analyzed high-definition magnetic resonance imaging scans of 78 healthy elbows in 19 men and 20 women, with a mean age of 28 (21-32) years. All measurements were estimated in the axial plane just distal to the fovea radialis. Maximum and minimum bone diameters, maximum and minimum total diameters (including cartilage thickness), and cartilage thickness were calculated. Cartilage thickness was measured at 4 different points: (1) at the articular side of the maximum diameter (point A), (2) at the nonarticular side of the maximum diameter (point B), (3) at the medial side of the minimum diameter (point C), and (4) at the lateral side of the minimum diameter (point D). Pearson correlation and t test were used for the statistical analysis. RESULTS: Mean maximum and minimum bone diameters and maximum and minimum total diameters were 22.2, 21.5, 24.0, and 23.2 mm, respectively. All differences between diameters were statistically significant. Mean cartilage thickness at points A, C, and D was 1.7, 0.8, and 0.8 mm, respectively. No measurable cartilage thickness was found at point B. No significant correlation was found between bone diameters and cartilage thickness. CONCLUSIONS: Cartilage surface significantly increases and modifies the size and shape of the radial head. The observation that cartilage thickness varies between subjects and does not correlate with bone parameters suggests that the diameters of the radial head cannot be inferred from indirect measurements of dry bones or radiographs.

The ulnar greater sigmoid notch "coverage angle": bone and cartilage contribution. Magnetic resonance imaging anatomic study on 78 elbows.

BACKGROUND: To study the degree of coverage provided by the greater sigmoid notch (GSN) to the humeral trochlea, as well as the contribution of the olecranon and coronoid process cartilage tips to this angle, and its variations. METHODS: We recruited 39 healthy volunteers, comprising 19 women and 20 men, with a mean age of 28 years (range, 21-32 years). High-definition magnetic resonance images were obtained for the right and left elbows. Four angles were measured on the sagittal plane passing through the coronoid and olecranon tips: angle A, identified by 2 lines from the trochlea center to the olecranon bone-cartilage junction and olecranon cartilage tip; angle B, identified by 2 lines from the trochlea center to the olecranon and coronoid bone-cartilage junction; angle C, identified by 2 lines from the trochlea center to the coronoid bone-cartilage junction and coronoid cartilage tip; and GSN coverage angle (GSN-ca), defined as the sum of angles A, B, and C. Pearson correlation tests, t tests, and intraclass correlation coefficients were used for statistical analyses. RESULTS: The mean angle A, angle B, and angle C values were 6° (range, 2°-12°), 182° (range, 153°-204°), and 9° (range, 2°-16°), respectively. No correlations were found between these 3 angles. The mean GSN-ca was 198° (range, 167°-222°), and the GSN-ca was less than 180° in 8% of the cases. No significant differences emerged for side or gender or for total length of the ulna. CONCLUSION: The GSN showed significantly different shapes on the sagittal plane that we defined as closed type when the GSN-ca was greater than 180° (92%) and as open type when the GSA-ca was less than 180° (8%). The cartilage tip contribution varied and was not correlated with that of bone.

The risk of sacrificing the PCL in cruciate retaining total knee arthroplasty and the relationship to the sagittal inclination of the tibial plateau.

BACKGROUND: In cruciate retaining total knee arthroplasty (TKA), a partial avulsion of PCL may occur when en-bloc tibial osteotomy is performed. We evaluated the effects of a tibial cut performed with different degrees of posterior slope on PCL insertion and whether the results are affected by the sagittal inclination of the patient's tibial plateau. METHODS: We selected 83 MRIs of knees showing mild or no degenerative changes. The effects of a simulated tibial cut performed with a posterior slope of 0°, 3°, 5° and parallel to the patient's tibial plateau inclination on PCL insertion in the proximal tibia were investigated. The results were correlated with the degree of posterior inclination of the tibial plateau. RESULTS: Every angle we used for the tibial cut caused a PCL avulsion greater than 50%. The percentage of PCL avulsion significantly increased with increasing the posterior slope of the tibial cut. Patients with sagittal tibial plateau inclination <5° showed greater PCL avulsion than those with sagittal inclination >8°. CONCLUSIONS: Most of the PCL insertion is likely to be sacrificed when resection of the proximal tibia is performed en-block. The risk of PCL avulsion is reduced in patients showing a marked posterior inclination of the tibial plateau, but even in this group of patients a surgical technique aimed at sparing most of the PCL insertion is necessary.

Discovery elbow system: 2- to 5-year results in distal humerus fractures and posttraumatic conditions: a prospective study on 24 patients.

PURPOSE: To prospectively evaluate preliminary results of the Discovery Elbow System (DES) used for acute distal humerus fractures and posttraumatic conditions. METHODS: We analyzed 24 patients (9 men and 15 women), with a mean age of 69 years (range, 45-89 y). Ten had comminuted distal humerus fractures (group I), and 14 had severe post-traumatic arthritis, chronic instability, or nonunion (group II). Clinical and radiographic evaluations were performed. The preoperative (group II) and postoperative (both groups) evaluations were assessed with the Mayo Elbow Performance Score and Mayo Elbow Performance Index, the Quick Disabilities of the Arm, Shoulder, and Hand score, and the modified American Shoulder and Elbow Surgeons score. Patient satisfaction was evaluated on a 4-point scale. RESULTS: Mean follow-up was 41 months (range, 29-63 mo). At the last evaluation, average flexion, extension, pronation, and supination were 136°, 17°, 80°, and 83°, respectively. The average Mayo Elbow Performance Score, Quick Disabilities of the Arm, Shoulder, and Hand score, and the modified American Shoulder and Elbow Surgeons score were 96, 20, and 84, respectively, and without significant intergroup differences. According to the Mayo Elbow Performance Index, there were 20 excellent, 3 good, and 1 fair result. Twenty patients were very satisfied or satisfied with the outcome. A significant increase in the functional scores was observed in group II compared with preoperative results. Radiological evaluation showed 1 patient with progressive radiolucency and 1 with a nonprogressive radiolucency at the final follow-up. No mechanical failures were observed. Two transient ulnar neuropathies, 1 wound infection, and 1 epicondyle fracture were observed. CONCLUSIONS: The DES yielded promising 2- to 5-year results in the treatment of acute fractures and posttraumatic conditions regarding pain relief, functional improvement, and patient satisfaction, achieving excellent results in most cases. The DES may represent an effective linked-implant option for total elbow replacement in such patients. However, long-term studies are needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: prospective study on 76 patients.

INTRODUCTION AND AIM: Complex elbow instability (CEI) is one of the most troublesome pathologies that orthopaedic surgeons have to face. One of the key requirements regarding the CEI surgical treatment is an early rehabilitation programme to avoid the elbow stiffness caused by a long period of immobilisation. Although this is well known, no study has ever examined how, and to what extent, the functional range of motion (ROM) is recovered during the various stages of a prompt rehabilitation. Our aims were: (1) to prospectively analyse the pattern of ROM recovery in a series of patients with CEI who underwent early rehabilitation and (2) to identify the period of time during rehabilitation in which the greatest degree of motion recovery is obtained. MATERIALS AND METHODS: A total of 76 patients (78 elbows) with CEI were followed up for 2 years. All the patients underwent anatomical and stable ostheosynthesis of all the fractures, radial head replacement in Mason III fractures, ligament injuries reconstruction and early rehabilitation that started 2 days after surgery. Two surgeons evaluated the ROM with a hand-held goniometer every 3 weeks for the first 3 months, then at 6, 12 and 24 months after surgery. RESULTS: At the 3-week follow-up, the mean flexion (F), extension (E), pronation (P) and supination (S) were 113°, 29°, 60° and 62°, respectively. At the 6-week and 9-week follow-up, F, E, P and S were 119°, 23°, 70° and 69° and 123°, 24°, 72° and 71°, respectively. At the 3-month follow-up, these values were 131°, 18°, 76° and 72°, while at the 6-month follow-up they were 136°, 15°, 79° and 77°, respectively. Thereafter, the ROM improvement was not significant. DISCUSSION: This study shows that the first 6 months represent the critical rehabilitation period to obtain a functional elbow; indeed, 70% of the patients recovered functional ROM between the third and sixth month, though the recovery of flexion proved to be slower than that of the other elbow movements. Thereafter, improvement continued, though at a lower rate, until the end of the first year, when approximately 80% of the patients had recovered the functional ROM. CONCLUSIONS: Following CEI surgical treatment, a rehabilitation programme needs to be started promptly and continued for at least 6 months because a significant improvement of ROM occurs prevalently in this period, which should be considered the critical time period to obtain a functional elbow in a majority of patients.

Radial head, radiocapitellar and total elbow arthroplasties: a review of recent literature.

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.

Clinical usefulness of proximal ulnar and radial fracture-dislocation comprehensive classification system (PURCCS): prospective study of 39 cases.

BACKGROUND: Complex fracture-dislocations of the proximal ulna and radius represent a challenge even for expert orthopaedic surgeons. A new comprehensive classification, the proximal ulnar and radial fracture-dislocation comprehensive classification system (PURCCS), was recently proposed. The aim of this study was to analyze the clinical usefulness of this classification in a large series of patients. MATERIALS AND METHODS: We studied 38 patients (39 elbows) with a mean age of 56 years. All patients were classified with the PURCCS by use of standard radiography, computed tomography, and intraoperative fluoroscopy. Surgical treatment was performed according to the PURCCS therapeutic algorithm. Patients were followed up for a mean of 23 months. The clinical evaluation was performed with the Mayo Elbow Performance Score and Index (MEPS and MEPI); the Disabilities of the Arm, Shoulder, and Hand (DASH) score; and the modified American Shoulder and Elbow Surgeons (m-ASES) score. RESULTS: Each pattern of fracture-dislocation in our series finds its position within the PURCCS. At the last follow-up, the mean MEPS, DASH score, and m-ASES score were 91.2, 14.9, and 83.9, respectively. The mean extension, flexion, pronation, and supination were 19°, 136°, 81°, and 79°, respectively. According to the MEPI, 72%, 20%, and 8% of cases were rated excellent, good, and fair, respectively. Two patients with elbow stiffness underwent a reoperation, with final satisfactory results. CONCLUSION: The PURCCS helps identify the main lesions of each injury pattern; the associated therapeutic algorithm helps select correct surgical strategies. This study showed that the clinical results were satisfactory in the majority of cases, with few major complications and reinterventions. The PURCCS is a comprehensive classification that may contribute to the surgical management of these difficult fracture-dislocations. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Use of fine-threaded K-wires in the treatment of coronoid fractures in complex elbow instability.

The coronoid process is one of the main elbow constraints that provides ulnohumeral joint stability. Coronoid fractures may be fixed using multiple techniques, including transosseous sutures, screws, and plates. The goal of this study was to analyze the clinical and radiographic outcomes in a series of patients with complex elbow instability in whom coronoid fractures were repaired using fine-threaded K-wires. Eight men and 10 women (mean age, 47 years) were followed prospectively for a mean of 26 months. Surgical treatment consisted of open reduction and internal fixation of all fractures; radial head replacement in Mason III injuries; lateral collateral ligament repair in all patients; and, in cases of persistent instability, medial collateral ligament repair, hinged fixator application, or both. Coronoid fixation was performed using 2 or more fine-threaded K-wires, depending on the fragment size, inserted from the posterior aspect of the ulna and directed toward the coronoid fragment using a 1-step fixation technique. At last follow-up, mean extension was 15°, mean flexion was 133°, mean pronation was 78°, and mean supination was 69°; mean Disabilities of the Arm, Shoulder and Hand score was 9.7, mean American Shoulder and Elbow Surgeons score was 85, and mean Mayo Elbow Performance Score was 89. According to the Mayo Elbow Performance Index, 10 excellent, 7 good, and 1 fair result were recorded. All but 1 patient had a stable elbow. Fracture healing was observed in all but 1 patient. No secondary coronoid fragment dislocation or implant failures were reported. This study shows that using fine-threaded K-wires provides easy, minimally invasive, stable, and successful 1-step fixation that can be used to obtain osteosynthesis of coronoid fractures in patients with complex elbow instability.