Arthroplasty with a metal radial head for unreconstructible fractures of the radial head.

BACKGROUND: Treatment of unreconstructible comminuted fractures of the radial head remains controversial. There is limited information on the outcome of management of these injuries with arthroplasty with a metal radial head implant. METHODS: The functional outcomes of arthroplasties with a metal radial head implant for the treatment of twenty-five displaced, unreconstructible fractures of the radial head in twenty-four consecutive patients (mean age, fifty-four years) were evaluated at a mean of thirty-nine months (minimum, two years). There were ten Mason type-III and fifteen Mason-Johnston type-IV injuries. Two of these injuries were isolated, and twenty-three were associated with other elbow fractures and/or ligamentous injuries. RESULTS: At the time of follow-up, Short Form-36 (SF-36) summary scores suggested that overall health-related quality of life was within the normal range (physical component = 47 +/- 10, and mental component = 49 +/- 13). Other outcome scales indicated mild disability of the upper extremity (Disabilities of the Arm, Shoulder and Hand score = 17 +/- 19), wrist (Patient-Rated Wrist Evaluation score = 17 +/- 21 and Wrist Outcome Score = 60 +/- 10), and elbow (Mayo Elbow Performance Index = 80 +/- 16). According to the Mayo Elbow Performance Index, three results were graded as poor; five, as fair; and seventeen, as good or excellent. The poor and fair outcomes were associated with concomitant injury in two patients, a history of a psychiatric disorder in three, comorbidity in two, a Workers' Compensation claim in two, and litigation in one. Subjective patient satisfaction averaged 9.2 on a scale of 1 to 10. Elbow flexion of the injured extremity averaged 140 degrees +/- 9 degrees; extension, -8 degrees +/- 7 degrees; pronation, 78 degrees +/- 9 degrees; and supination, 68 degrees +/- 10 degrees. A significant loss of elbow flexion and extension and of forearm supination occurred in the affected extremity, which also had significantly less strength of isometric forearm pronation (17%) and supination (18%) as well as significantly less grip strength (p < 0.05). Asymptomatic bone lucencies surrounded the stem of the implant in seventeen of the twenty-five elbows. Valgus stability was restored, and proximal radial migration did not occur. Complications, all of which resolved, included one complex regional pain syndrome, one ulnar neuropathy, one posterior interosseous nerve palsy, one episode of elbow stiffness, and one wound infection. CONCLUSIONS: Patients treated with a metal radial head implant for a severely comminuted radial head fracture will have mild-to-moderate impairment of the physical capability of the elbow and wrist. At the time of short-term follow-up, arthroplasty with a metal radial head implant was found to have been a safe and effective treatment option for patients with an unreconstructible radial head fracture; however, long-term follow-up is still needed.

Total elbow arthroplasty in the treatment of posttraumatic conditions of the elbow.

Posttraumatic arthritis, arthritis secondary to instability, and nonunion or malunion about the elbow may be treated by various methods. Recommended first-line treatment in the younger, more active patient population is nonprosthetic techniques. Total elbow arthroplasty should be considered primarily as a salvage procedure for these patients. Careful patient selection will determine whether total elbow arthroplasty is an acceptable choice, despite its inherent risks and complications. Prosthetic replacement is more applicable for patients with low physical demands who are older than 60 years of age with pain, stiffness, and/or instability of the elbow who will more likely be able to comply with postoperative rehabilitation and strict activity restrictions. Previous incisions, gross instability, periarticular fibrosis with ulnar nerve encasement, loss of bone and/or soft tissue, and previous infections represent obstacles for prosthetic reconstruction in these patients. The use of unlinked total elbow designs require good bone stock with little deformity and stable capsuloligamentous support, which uncommonly is found in elbows after trauma. Linked semiconstrained prostheses have been used most frequently with good short-term results reported in the literature. Reported failure rates after longer followup have led to a search for improvements in prosthetic design, cementing techniques, and better patient selection.

The value of facet joint blocks in patient selection for lumbar fusion.

The purpose of this study was to ascertain the correlation between diagnostic facet blocks and treatment outcome, both surgical and nonsurgical. One hundred twenty-six patients who had previously undergone diagnostic facet injections were reviewed. Eighty-two had subsequently undergone lumbar arthrodesis. The rest were treated with a variety of nonoperative modalities. Statistical analysis of accumulated data failed to show any significant correlation between the results of facet blocks and outcome of operative arthrodesis. In addition, statistical analysis failed to show any significant correlation between the facet block results and the outcome of nonoperative treatment. The authors concluded that lumbar facet joint injections cannot be used to determine appropriate patient treatment because they are not predictive of either surgical of nonsurgical success.

Intraosseous vertebral body pressures.

In an effort to determine the relationship between low-back pain and intraosseous hypertension, in vivo vertebral pressure measurements were performed on 19 patients. A cannulated screw was placed percutaneously into the middle of the vertebral body by a transpedicular route. Pressure measurements were recorded with the patient in various positions. Pressures were greatest in the sitting position, lowest in the prone position, and intermediate in the standing position. A correlation was found between intravertebral body pressure and patient position. Pressures were highest in the positions most commonly associated with low-back pain.