Treatment of Radial Head Fractures with a Modular Metallic Radial Head Replacement.

INTRODUCTION: Radial head arthroplasty with a smooth-stemmed metallic modular implant is a reliable treatment option for patients with acute unreconstructible radial head fractures, and good clinical outcomes may be expected beyond 5 years of follow-up (Video 1). STEP 1 PREOPERATIVE PLANNING: Obtain a careful history and perform a physical examination along with appropriate imaging to facilitate appropriate treatment decisions. STEP 2 OPERATING ROOM SETUP AND PATIENT POSITIONING: Perform proper operating room setup and patient positioning, as they are required to gain access to all affected structures around the elbow in a safe and efficient manner. STEP 3 APPROACH: Make a midline posterior skin incision with development of a full-thickness lateral fasciocutaneous flap or use a direct lateral incision; the deep interval is determined on the basis of the integrity of the LCL. STEP 4 RADIAL HEAD EXCISION: Remove and preserve all fragments of the radial head for implant sizing. STEP 5 IMPLANT SIZING: Implant a prosthesis that closely replicates the dimensions of the native radial head, which is the primary goal of the procedure. STEP 6 STEM BROACHING: Sequentially broach the canal until good cortical contact is achieved and undersize the definitive stem by 1 mm to allow implant movement within the canal and appropriate articulation with the capitellum. STEP 7 INSERTION OF TRIAL COMPONENTS AND FINAL RADIAL HEAD IMPLANT: With the selected trial in place, assess the radial head diameter, height, and articular congruency. STEP 8 CLOSURE AND REPAIR OF THE LCL: Ensure proper repair of the LCL as it is essential to maintaining or restoring elbow stability. STEP 9 POSTOPERATIVE PROTOCOL: Postoperative rehabilitation depends on the status of the collateral ligaments. RESULTS: In a review of the cases of 55 patients at a mean follow-up of 8 years after radial head arthroplasty with a smooth-stemmed modular metallic prosthesis, Marsh et al.9.

Radial Head Fractures Treated with Modular Metallic Radial Head Replacement: Outcomes at a Mean Follow-up of Eight Years.

BACKGROUND: Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures. METHODS: The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively. RESULTS: At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p < 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eight-year follow-up (p = 0.012), with no loss of motion or strength (p > 0.05). CONCLUSIONS: The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Propionibacterium acnes in primary shoulder arthroplasty: rates of colonization, patient risk factors, and efficacy of perioperative prophylaxis.

BACKGROUND: Recent literature has shown that Propionibacterium acnes can be cultured from superficial and deep layers of the shoulder. Our aims were to assess the rate of P. acnes colonization in patients undergoing primary shoulder arthroplasty, to identify patient-related risk factors, and to evaluate the efficacy of our perioperative antisepsis protocol. METHODS: Thirty consecutive patients undergoing primary shoulder arthroplasty were included in our study. Swabs were taken perioperatively (4 superficial and 2 deep wound swabs) and analyzed quantitatively for P. acnes. Cefazolin minimum inhibitory concentration was determined for P. acnes isolates from positive deep cultures. RESULTS: Twenty-two patients (73%) had positive cultures for P. acnes. Male gender (P = .024) and presence of hair (P = .005) had significantly higher rates of P. acnes superficial cultures. Subjects with positive superficial P. acnes cultures (P = .076) and presence of hair with a history of steroid injection (P = .092) were more likely to have deep P. acnes-positive cultures, but this was not statistically significant. Local topical antisepsis measures did not eradicate P. acnes (P = .12). Mean cefazolin minimum inhibitory concentration for P. acnes was 0.32 µg/mL. CONCLUSION: P. acnes is commonly isolated from the skin and deep surgical wounds of patients undergoing primary total shoulder arthroplasty who have not had previous shoulder surgery. Male gender and presence of hair were significant risk factors for P. acnes colonization. Perioperative local topical antisepsis and cefazolin administration were not effective in eliminating P. acnes colonization.

Unlinked total elbow arthroplasty.

For more than 60 years, total elbow arthroplasty (TEA) has been successfully used to treat a variety of elbow conditions. Although first designed to treat older patients with rheumatoid arthritis, the indications have expanded to include younger, higher-demand patients with a broad range of elbow pathology. Two groups of TEA currently exist. The first group includes linked or semiconstrained elbows with a mechanical connection between the humeral and ulnar components that prevents disassociation. These implants do not rely on muscular or ligamentous tissues for stability. The second group includes unlinked implants that have no physical connection between the humeral and ulnar components. They rely on bearing surface architecture as well as soft-tissue integrity for elbow stability. Critical to the success of unlinked implants is a thorough preoperative evaluation of elbow stability, including bone stock, collateral ligament integrity, and periarticular muscle function. Unlinked implants should apply less strain to the bone-cement-implant interfaces, which may theoretically decrease rates of bearing wear and aseptic loosening. For this reason, some surgeons prefer unlinked implants for younger, higher-demand patients. To date, unlinked implants have not been clinically shown to improve survivorship compared with linked devices. No prospective randomized trials comparing linked and unlinked TEAs are currently available. Historically, unlinked implants have had higher revision rates, mostly caused by instability and early design flaws. More recent series have shown no significant differences in outcomes compared with linked devices. Unlinked TEA provides reliable pain relief and improved range of motion for patients with a variety of elbow disorders. Diligent patient selection and careful surgical technique are of utmost importance when considering an unlinked TEA as a treatment option. The recent development of convertible implants now allows surgeons to make intraoperative decisions regarding elbow stability and convert to a linked implant without revising the stems.

Does bony increased-offset reverse shoulder arthroplasty decrease scapular notching?

BACKGROUND: The purpose of this cohort study was to compare scapular notching rates, range of motion, and functional outcomes between patients who underwent a standard Grammont-style reverse shoulder arthroplasty (RSA) and patients who underwent bony increased-offset reverse shoulder arthroplasty (BIO-RSA) at a minimum of 2 years' follow-up. We hypothesized that the BIO-RSA cohort would have lower notching rates and improved rotational range of motion; however, validated outcome scores between cohorts would be no different. METHODS: A comparative cohort study was designed after a sample size calculation. A total of 40 patients were studied with 20 in each cohort (RSA vs BIO-RSA). All patients underwent an interview and physical examination. Outcomes included range of motion; shoulder strength; Disabilities of the Arm, Shoulder and Hand (DASH) score; American Shoulder and Elbow Surgeons score; Simple Shoulder Test score; Constant score; and Global Rating of Change scale score. Radiographs were obtained for all patients and examined for scapular notching. RESULTS: When we compared demographic characteristics between the standard RSA and BIO-RSA cohorts, including age, sex, and follow-up duration, there were no significant differences between groups (P > .05). In addition, there were no significant differences between cohorts when we compared forward elevation (P = .418); external rotation (P = .999); internal rotation (P = .071); strength (P > .376); Disabilities of the Arm, Shoulder and Hand score (P = .229); American Shoulder and Elbow Surgeons score (P = .579); Simple Shoulder Test score (P = .522); Constant score (P = .917); or Global Rating of Change scale score (P = .167). The frequency of scapular notching, however, was significantly higher (P = .022) in the RSA cohort than in the BIO-RSA cohort: 75% versus 40%. CONCLUSIONS: Although the scapular notching rate was significantly higher in the standard RSA group, no other outcome measures were statistically different, including range of motion, strength, and validated outcome scores.

Noise levels in adult and pediatric orthopedic cast clinics.

Prolonged exposure to high-intensity noise has been associated with noise-induced hearing loss, hypertension, psychological stress, and irritability. The National Institute of Occupational Safety and Health considers levels above 85 decibels (dB) as harmful. In the study reported here, we sought to determine whether noise levels in orthopedic cast clinics were within safe limits. A calibrated noise dosimeter was worn by cast technologists during 7 adult and 7 pediatric cast clinics, and noise levels were recorded. Mean equivalent continuous noise levels were 77.8 dB (adult clinics) and 76.5 dB (pediatric clinics), mean noise levels adjusted for an 8-hour day were 76.6 dB (adult) and 75.9 dB (pediatric), and mean peak noise levels were 140.0 dB (adult) and 140.7 dB (pediatric). Mean noise levels in cast clinics were within safe limits and there was no statistical difference in noise levels between adult and pediatric clinics. However, peak noise levels in all clinics exceeded recommended limits, and even brief exposure to noise of this intensity may be hazardous.

Acute limb ischemia following closed reduction of a hip arthroplasty dislocation.

Hip dislocation is a well-described complication of total hip arthroplasty (THA) and dislocation rates are substantially higher following revision hip arthroplasty. Vascular complications following closed reduction of hip dislocations are exceedingly rare, but a high index of suspicion is essential for patients with underlying vascular abnormalities. Popliteal artery aneurysms are the most common peripheral arterial aneurysms with a prevalence of 1% and they should be suspected in patients with prominent popliteal pulses. This article presents a case of an 84-year-old man with a revision total THA who sustained a posterior hip dislocation. The hip was reduced under conscious sedation using the Bigelow technique. The leg was distally neurovascularly intact based on the clinical exam immediately before and after the reduction. Over the next few hours, the foot became progressively ischemic and an urgent computed tomography angiogram revealed bilateral popliteal artery aneurysms with acute thrombosis of the aneurysm on the affected limb. The patient underwent emergent femoral popliteal bypass using a Dacron supported interpositional graft. The majority of the foot was salvaged but the toes eventually became necrotic. Direct compression of the aneurysm during reduction of the hip dislocation in conjunction with transiently decreased blood pressure from conscious sedation likely resulted in a low flow state within the artery leading to thrombosis of the aneurysm. To our knowledge, this is the first reported case of such an event. This case emphasizes the need for a high index of suspicion for vascular injuries following manipulation of limbs with underlying arterial aneurysms. Reduction maneuvers for hip dislocations should be modified to minimize compression of the popliteal fossa in limbs with vascular abnormalities. Serial postreduction neurovascular exams are essential for identification and prompt management of vascular complications.

Bilateral femoral neck fractures resulting from a grand mal seizure in an elderly man with Down syndrome.

Simultaneous bilateral hip fractures are exceedingly rare and usually occur following a seizure. To our knowledge, only 22 cases of such injuries have been reported in the literature during the past forty years and the majority of fractures are treated with open reduction and internal fixation. We present a case of a 66-year old man with Down syndrome and severe dementia who was diagnosed with bilateral displaced femoral neck fractures following an epileptic seizure. He was treated with single staged bilateral uncemented monopolar hemi-arthroplasties through lateral Hardinge approaches. The treatment choice was governed by fracture displacement, the lack of pre-existing osteoarthritis, length of time to diagnosis, the patient's age, ambulatory status and mental impairment, with the intention to minimize post-operative complications such as avascular necrosis, non-union and hip dislocation.

The effect of pedometer position and normal gait asymmetry on step count accuracy.

Manufacturers of pedometers recommend wearing a pedometer on the midline of the right thigh and this recommendation is used in research. However, there is conflicting evidence regarding the effect of pedometer position on accuracy. The purpose of this study was to systematically evaluate the effect of pedometer position on accuracy for 3 modes of gait. The Yamax SW200 pedometer was evaluated in 20 subjects in 5 different positions simultaneously: left mid-axillary, left mid-thigh, umbilical, right mid-thigh, and right mid-axillary. Each subject was asked to walk on a treadmill (54, 80, and 107 m.min(-1)), to walk overground (slow, preferred, and fast speeds), and to ascend and descend stairs. Pedometer steps were recorded and compared with actual steps observed. Using the same protocol, instantaneous triaxial accelerometry was used to explain position-dependent differences in accuracy. At slow speeds, the left mid-axillary position demonstrated the lowest net mean (+/-SD) error across all modes of gait (7.7% (+/-11.6%) overground;-0.6% (+/-2.2%) stairs). The right mid-thigh position had significantly (p<0.01) higher error for treadmill (18.1% (+/-17.3%)), overground (12.9% (+/-15.2%)), and stairs (2.9% (+/-3.9%)). Pedometer position dependent error was demonstrated, with the left mid-axillary position superior to the recommended position of right mid-thigh. The greater accuracy on the left side was wholly explained by gait asymmetry evident in step-induced accelerations recorded at right and left pedometer positions. A model of absolute error based on the ratio of steps at different gait speeds was generated to demonstrate the importance of this finding in pedometer-based lifestyle intervention studies.