Is systematic 1-stage exchange a valid attitude in chronic infection of total elbow arthroplasty?

INTRODUCTION: Surgical treatment for chronic infection of total elbow arthroplasty (TEA) generally involves 2-stage exchange. In the lower limb, 1-stage strategies are increasingly implemented, but few cases have been reported for the elbow. We present results in a preliminary series, with the aim of: (1) assessing control of infection in systematic 1-stage exchange for chronic TEA infection, (2) detailing clinical and radiological results, and (3) analyzing intra- and post-operative complications. HYPOTHESIS: Systematic 1-stage exchange for chronic TEA prosthetic joint infection provides satisfactory control of infection. MATERIAL AND METHODS: Seven non-selected patients were operated on by 1-stage exchange for chronic infection of TEA during the study period. Two died before the minimum 2 years' follow-up, from causes unrelated to the infection. Thus 5 patients (4 women, 1 man; mean age at surgery, 61 years [range: 48-69 years]) were included for analysis. At a minimum 2 years' follow-up, all underwent clinical examination and elbow X-ray. Infection was monomicrobial in 4 cases and polymicrobial in 1. Isolates comprised Staphylococcus aureus in 40% of cases (2/5), Staphylococcus epidermidis in 60% (3/5) and Staphylococcus Warneri in 20% (1/5). Three patients showed fistula. Three were under immunosuppression/immunomodulation treatment. RESULTS: At a mean 40 months' follow-up (range: 24-60 months), 4 patients (80%) were free of infection and 1 showed signs of persistent infection. Mean range of flexion-extension was 81° (range: 60-95°) and pronation-supination 128° (range: 80-160°). Mean Mayo Elbow Performance Score was 75 points (range: 65-90). There were 2 intraoperative fractures and 1 neurologic deficit with partial regression. CONCLUSION: One-stage exchange provided control of infection in 80% of cases, despite cutaneous fistulae or immunosuppression treatment. Clinical results and complications rate were similar to those reported for 2-stage exchange. LEVEL OF EVIDENCE: IV; retrospective study without control group.

Combined median and ulnar nerve palsy complicating distal radius fractures.

BACKGROUND: Fractures of the distal radius only rarely give rise to complications in the immediate postoperative period. Combined median and ulnar nerve palsy is a complication that can be missed by the surgeon. MATERIALS AND METHODS: Three cases diagnosed early after surgery are reported here. The patients were 15, 16, and 30 years of age, respectively. None had preoperative neurological deficits. The youngest patient was injured during sports and the other 2 patients during traffic accidents. All 3 patients had a displaced fracture of the distal radius combined with a fracture of the distal fourth of the ulna or ulnar styloid process and were treated by anterior plate fixation. Operative times were 47, 62, and 120minutes, respectively. Compartment syndrome was ruled out based on low pain intensity and absence of forearm tightness to palpation. RESULTS: The electrophysiological study performed 1 month post-injury in all 3 patients showed severe impairments of both median and ulnar nerve function. Median and ulnar nerve release surgery was performed in the 15-year-old 6 weeks post-injury. No nerve damage or fibrosis was seen during the procedure. All patients recovered fully within 3 months and had normal findings from follow-up electrophysiology testing after 6 months. DISCUSSION: Combined median and ulnar nerve palsy has rarely been reported and is among the rare complications of distal radial fractures that can develop in the event of a high-energy trauma and/or major displacement. Both previously published data and our experience indicate that surgical nerve release is unnecessary. Clinical recovery within 3 months is the rule. LEVEL OF EVIDENCE: IV, case-reports.

Evaluation of thirty eight cemented pegged glenoid components with variable backside curvature: two-year minimum follow-up.

BACKGROUND: The PERFORM™ pegged glenoid system has been used for shoulder arthroplasty since 2012. This system offers multiple backside curvatures per size to better match variable patient anatomy. As a result, less reaming is required and subchondral bone is preserved-a critical factor in preventing glenoid migration and loosening, thus enhancing implant longevity. PURPOSE: The purpose of this study was to analyze all radiographic modifications around this new glenoid implant. METHOD: Thirty-eight shoulders which received the PERFORM™ pegged glenoid component between June 2012 and January 2014 for primary or secondary osteoarthritis were reviewed at two-years minimum follow-up. There were 13 men and 22 women with an average age of 67 years. Humeral components were an uncemented short stem implant in nine (23%) and a resurfacing implant in 29 (77%). RESULTS: At 27-months average follow-up (24-41), Constant score improved from 30 to 65 points. Range of motion improved significantly at follow-up from 100° to 142° for the anterior elevation, and from 15 to 40° for the external rotation. Radiographic lucent lines (RLL) were observed post-operatively in eight cases (21%), and in 16 cases (42%) at the last follow-up with an increase of the RLL score from 0.36 ± 0.8 to 1.3 ± 2 (p < 0.001) without signs of loosening (RLL > 12). One revision has been performed after anterior shoulder dislocation, rotator cuff tear and glenoid component migration. RLL score was not correlated with dominant side, sex, age, or Constant score. DISCUSSION-CONCLUSION: The cemented pegged glenoid component with multiple backside curvatures gave satisfactory results at two-years minimum follow-up for up to three years with a low RLL score. Long-term studies are mandatory to confirm these results.

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

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