Complex open elbow fracture Gustilo-Anderson type IIIB treated with the primary elbow arthroplasty: A case report.

Total elbow arthroplasty as a treatment option for open elbow fracture is relatively rare described. We reported a 39 years old polytrauma patient with complex open elbow fracture (Gustilo-Anderson type IIIB). The patient presented with large soft tissues defect on dorsal part of the left elbow, ulnar palsy due to the irreparable loss of the ulnar nerve, distal triceps loss due to the complete loss of the olecranon, loss of both humeral condyles with collateral ligaments and complex elbow instability. Only few similar cases have been published. Reconstructive surgery included repetitive radical debridement, irrigation, vacuum assisted closure system therapy, external fixation, coverage of the soft tissue defect with fascia-cutaneous flap from the forearm. Four months after the injury, total elbow arthroplasty with autologous bone graft (from the proximal radius) inserted in the ulnar component, was performed. At 3 years postoperatively, the patient is able to perform an active flexion from 0° to 110° with full prono-supination. Only passive extension is allowed. The ulnar neuropathy is persistent. Patient has no signs of infection or loosening of the prosthesis.

Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability.

HYPOTHESIS: This study compared the kinematic parameters and activity pattern of muscles around the glenohumeral joint in multidirectional instability (MDI) treated by only physiotherapy and by capsular shift and physiotherapy, before and after treatment, to test the hypothesis that the surgery group would demonstrate better kinematic and muscle activity than the physiotherapy group. MATERIALS AND METHODS: The study comprised 32 patients with MDI treated with only physiotherapy, 19 patients with MDI treated by capsular shift and physiotherapy, and 50 healthy shoulders as the control group. The investigated kinematic parameters were the range of humeral elevation in the scapular plane, the scapulothoracic and glenohumeral angle, the scapulothoracic and glenohumeral rhythms, and relative displacement between the rotational centers of the humerus and the scapula. The muscle activity was modeled by the on-off pattern of muscles around the shoulder. RESULTS: Before treatment, increased relative displacement between the rotational centers of the scapula and the humerus and different regression lines were observed in MDI patients. The physiotherapy strengthened the muscles, but regression lines remained monolinear. Capsular shift and physiotherapy resulted in bilinear regression lines and normal relative displacement between the rotation center of scapula and humerus was restored. After surgery and physiotherapy the activity pattern of muscles was almost normal. CONCLUSION: The significant alterations in kinematic parameters in MDI patients cannot be completely normalized by physiotherapy only. After the capsular shift and postoperative physiotherapy, the bilinear regression lines (angulation at 60 degrees ), the normal relative displacement between the rotational centers of scapula and humerus, and the normal muscular activity pattern were restored to normal ranges and maintained for at least 4 years.

Physiotherapy vs. capsular shift and physiotherapy in multidirectional shoulder joint instability.

PURPOSE: The aim of the study was to compare the kinematic parameters and the on-off pattern of the muscles of patients with multidirectional instability (MDI) treated by physiotherapy or by capsular shift and postoperative physiotherapy before and after treatment during elevation in the scapular plane. SCOPE: The study was carried out on 32 patients with MDI of the shoulder treated with physiotherapy, 19 patients with MDI of the shoulder treated by capsular shift and postoperative physiotherapy, and 25 healthy subjects. The motion of skeletal elements was modeled by the range of humeral elevation, scapulothoracic angle and glenohumeral angle, scapulothoracic (ST) and glenohumeral (GH) rhythms, and relative displacement between the rotation centers of the humerus and scapula. The muscle pattern was modeled by the on-off pattern of muscles around the shoulder, which summarizes the activity duration of the investigated muscles. RESULTS: The different ST and GH rhythms and the increased relative displacement between the rotation centers of the scapula and the humerus were observed in MDI patients. The physiotherapy strengthened the rotator cuff, biceps brachii, triceps brachii, deltoid muscles, and increase the neuromuscular control of the shoulder joints. Capsular shift and physiotherapy enabled bilinear ST and GH rhythms and the normal relative displacement between the rotation centers of the scapula and humerus to be restored. After surgery and physiotherapy, the duration of muscular activity was almost normal. CONCLUSION: The significant alteration in shoulder kinematics observed in MDI patients cannot be restored by physiotherapy only. After the capsular shift and postoperative physiotherapy angulation at 60 degrees of ST and GH rhythms, the relative displacement between the rotation centers of the scapula and humerus and the duration of muscular activity were restored.

Electromyographic analysis during pull, forward punch, elevation and overhead throw after conservative treatment or capsular shift at patient with multidirectional shoulder joint instability.

PURPOSE: The aim of this study was to compare the muscle activity of patients with multidirectional instability treated in a conservative or complex manner (capsular shift with postoperative rehabilitation) and the muscle activity of stable shoulder joints before and after treatment during pull, push, and elevation of upper extremities and during overhead throw. SCOPE: The study was carried out on 34 patients with multidirectional shoulder instability treated non-operatively, on 31 patients with multidirectional shoulder instability treated operatively, and on 50 healthy subjects. Signals were recorded by surface EMG from eight different muscles. The mean and standard deviation of the maximum amplitude of normalized voluntary electrical activity for the different movement types and time broadness values during overhead throw were determined for each muscle in all groups and compared with each other. CONCLUSION: The centralization of the glenohumeral joint and the reduction of instability is attempted to be ensured by the organism through increasing the role of rotator cuff muscles (p=0.009) and decreasing the role of the deltoid, biceps brachii, and pectoralis maior muscles (p=0.007). At patients after short-term and long-term conservative treatment, the maximum amplitude of normalized voluntary electrical activity of stabilizer muscles is significantly higher (p=0.006), and that of accelerator muscles is significantly lower (p=0.005) and the time broadness is significantly longer (p=0.01) than that of the control group. At patients after complex treatment (open capsular shift with postoperative conservative rehabilitation) the characteristic of the muscle pattern is similar (p=0.19) to the control group. The complex treatment resolves the labral ligamentous abnormalities by operative treatment and restores the impaired muscular control by postoperative rehabilitation, whereas the conservative treatment restores only the muscular control.

Functional results and quality of life after shoulder girdle resections in musculoskeletal tumors.

From 1981 to 2001, 91 shoulder resections were performed to treat shoulder girdle tumors (64 primary and 27 metastatic) in 90 patients (53 male and 37 female patients). The mean age was 34 years in patients with a primary tumor and 61 years in those with metastases. There were 7 partial scapulectomies, 13 total scapulectomies, 56 proximal humeral resections, 5 diaphyseal resections, 5 total shoulder girdle resections (Tikhoff-Linberg procedure), and 5 other procedures performed. Prosthesis implantation was carried out in 41 cases, autologous fibular transposition was done in 19, and massive homologous bone grafting was done in 4. Of the patients, 37 were clinically reviewed with a mean follow-up of 4.7 years (range, 1-20 years) by use of the recommendations of the Musculoskeletal Tumor Society for pain, function, position of hand, lifting ability, manual dexterity, and satisfaction. Nine patients were reviewed via a questionnaire and telephone interview. Twenty-six had died, and eighteen were lost to follow-up. The best results were achieved after partial scapulectomy and after humeral resection reconstructed with fibular transposition, when the function of the rotator cuff was preserved. After total scapulectomy and after humeral resection with the implantation of a tumor endoprosthesis, the function of the shoulder remained moderate because the rotator cuff was damaged. The overall satisfaction was generally good after all types of shoulder resections as a result of pain relief, preserved hand function, and improvement of psychological status. Patients can compensate extremely well by using the preserved joints and the contralateral upper limb; therefore, patient satisfaction does not rely on shoulder function alone.