Transfusion of intra-operative autologous whole blood: influence on complement activation and interleukin formation.

BACKGROUND AND OBJECTIVES: Transfusion of autologous whole blood is one available method to reduce the need for allogenic blood transfusion. The objective of this study was to investigate the safety of transfusion of intra-operative autologous whole blood by monitoring plasma concentration of laboratory variables and adverse events after transfusion with the Sangvia(®) system. MATERIALS AND METHODS: The clinical trial was designed as an open, prospective, multi-centre study, and a total of 20 patients undergoing primary hip arthroplasty were included. Systemic blood samples were taken and analysed preoperatively, at transfusion start and end and at 3, 6, 24 and 48 h after the transfusion. RESULTS: Elevated values of complement activation and pro-inflammatory cytokines were seen in the intra-operatively collected blood but the impact on systemic levels were limited with low peak levels, systemic elevations before transfusion and normalization during the study period. Elevated levels of free haemoglobin and potassium were also detected in the intra-operatively collected blood, but systemic values were within reference values after the transfusion. No clinically relevant adverse event occurred during the study. CONCLUSION: Inflammatory mediators and plasma haemoglobin were increased in intra-operatively salvaged and filtered blood compared to circulatory levels. Intra-operative retransfusion of autologous whole blood caused a transient systemic increase that normalized in the early postoperative period. There were no significant adverse events reported in the study. These data suggest that the Sangvia(®) system can be used for intra-operative collection and retransfusion of salvaged blood.

A new look at the shoulder anterior capsuloligamentous complex complementing the insertion of the subscapularis tendon-Anatomical, histological and ultrasound studies of the lesser tuberosity enthesis.

PURPOSE: The aim of this study was to examine the relation between the anterior capsuloligamentous complex (ACLC - recognized as a single structure composed of the anterior capsule and its ligaments: medial glenohumeral ligament and anterior bundle of inferior glenohumeral ligament) and the subscapularis tendon with their footprints on the lesser tuberosity. METHODS: In this study, 19 fresh cadaveric shoulder specimens were examined: 13 in morphometric measurements and 6 were examined in a histological study. The subscapularis tendon and the ACLC were dissected until their insertion onto lesser tuberosity. Measurements of both dissected structures and their footprints on the lesser tuberosity were taken with a standard caliper. Six shoulders for histological examination were dissected without separation of the subscapularis tendon from the ACLC and longitudinal and transverse section samples were taken. Additionally, two of these six shoulders underwent ultrasound assessment before final sample preparation. RESULTS: Two well-isolated structures were clearly identifiable: muscle with its tendinous chords and the ACLC, forming together the anterior wall of the joint. The ACLC insertion complemented the tendon insertion - superiorly the thickest part of the tendon stayed in contact with the thinnest part of the ACLC and inferiorly the relation was opposite - the ACLC insertion reached its maximum transverse length. This reciprocal relation was similar to superior and posterior rotator cuff tendon-capsule complex. The footprint on the lesser tuberosity, being purely fibrocartilage enthesis, was composed in 45% of the ACLC insertion. Also the fibers run of the tendon and the ACLC were different: histologic assessment confirmed the tight fusion of the tendon and the ACLC, though those two layers were easily identified as their fibers never mixed. CLINICAL RELEVANCE: Better understanding of the anterior shoulder compartment anatomy simplifies an understanding of some arthroscopic procedures. The shape of the footprint, an importance of a broad superior part of the subscapularis tendon and its relation to the ACLC could be an anatomic proof and explanation for already existing surgical activities: subscapularis release and repair and soft tissue or bony procedures (Latarjet) in anterior shoulder instability. We declare that the experiments comply with the current law of the country in which they were performed (i.e. Polish law).

Partial posteromedial olecranon resection: a kinematic study.

BACKGROUND: The posteromedial aspect of the olecranon process is a site of impingement and subsequent osteophyte development in throwing athletes. Treatment with débridement, with resection of osteophytes and varying amounts of normal olecranon bone, is common. We found no reports in the literature concerning the effects of resecting different amounts of normal bone from the posteromedial aspect of the olecranon. We hypothesized that excessive resection would increasingly alter elbow kinematics and that an optimum amount of olecranon resection could be identified. METHODS: We investigated the kinematic effects of increasing valgus and varus torques and posteromedial olecranon resections, in twelve cadaveric elbows, with use of an electromagnetic tracking device. Two valgus and two varus torques were applied, and three sequential resections were performed in 3-mm steps from 0 mm to 9 mm. Statistical analyses included paired t tests, 95% confidence intervals, a one-factor analysis of variance with repeated measures, and a post hoc test when significance was established. RESULTS: Sequential partial resection of the posteromedial aspect of the olecranon resulted in stepwise increases in valgus angulation with valgus torque. Clear differences were seen at each level of resection. A pattern of increased valgus angulation also was seen in association with increased valgus torque. Increased valgus torque resulted in a trend toward increased axial internal rotation of the ulna, whereas increased osseous resection resulted in a decrease in the absolute degree of internal rotation or, in some specimens, increased external rotation. CONCLUSIONS: Although no single critical amount of olecranon resection was identified, valgus angulation of the elbow increased in association with all resections, with a marked increase occurring in association with a 9-mm resection. Our findings challenge the rationale of removing any amount of normal olecranon bone in throwing athletes as doing so may increase strain on the medial collateral ligament. The implications for the professional throwing athlete are important, and we recommend that bone removal from the olecranon be limited to osteophytes, without the removal of normal bone.

Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow.

BACKGROUND: The purpose of this study was to evaluate the stabilizing effect of radial head replacement in cadaver elbows with a deficient medial collateral ligament. METHODS: Passive elbow flexion with the forearm in neutral rotation and in 80 degrees of pronation and supination was performed under valgus and varus loads (1) in intact elbows, (2) after a surgical approach (lateral epicondylar osteotomy of the distal part of the humerus), (3) after release of the anterior bundle of the medial collateral ligament, (4) after release of the anterior bundle of the medial collateral ligament and resection of the radial head, and (5) after subsequent replacement of the radial head with each of three different types of radial head prostheses (a Wright monoblock titanium implant, a KPS bipolar Vitallium [cobalt-chromium]-polyethylene implant, and a Judet bipolar Vitallium-polyethylene-Vitallium implant) in the same cadaver elbow. Total valgus elbow laxity was quantified with use of an electromagnetic tracking device. RESULTS: The mean valgus laxity changed significantly (p < 0.001) as a factor of constraint alteration. The greatest laxity was observed after release of the medial collateral ligament together with resection of the radial head (11.1 degrees +/- 5.6 degrees). Less laxity was seen following release of the medial collateral ligament alone (6.8 degrees +/- 3.4 degrees), and the least laxity was seen in the intact state (3.4 degrees +/- 1.6 degrees). Forearm rotation had a significant effect (p = 0.003) on valgus laxity throughout the range of flexion. The laxity was always greater in pronation than it was in neutral rotation or in supination. The mean valgus laxity values for the elbows with a deficient medial collateral ligament and an implant were significantly greater than those for the medial collateral ligament-deficient elbows before radial head resection (p < 0.05). The implants all performed similarly except in neutral forearm rotation, in which the elbow laxity associated with the Judet implant was significantly greater than that associated with the other two implants. CONCLUSIONS AND CLINICAL RELEVANCE: This study showed that a bipolar radial head prosthesis can be as effective as a solid monoblock prosthesis in restoring valgus stability in a medial collateral ligament-deficient elbow. However, none of the prostheses functioned as well as the native radial head, suggesting that open reduction and internal fixation to restore radial head anatomy is preferable to replacement when possible.

The anatomic features of the radial head and their implication for prosthesis design.

OBJECTIVE: To establish the anatomical features of the radial head of an average normal human being and to verify the hypothesis that no significant difference exists between the geometry of the left and right normal radial heads. DESIGN: 17 proximal ends of the radius from the left and right forearms of fresh male (average age 50 and range 40-70) cadavers were measured. BACKGROUND: A reconstruction of anatomical features of the normal bone is important for prosthesis design. METHODS: A morphologic study of the radial head was performed using a co-ordinate measuring machine integrated with a computer aided design system. For comparative purposes, a statistical analysis including linear regression and correlation was performed. RESULTS: The maximum diameter (mean 23.36 mm (SD, 1.14 mm)) and height (mean 10.14 mm (SD, 1.38 mm)) of the radial head as well as the depth (mean 1.92 mm (SD, 0.32 mm)) and maximum radius (mean 20.27 mm (SD, 4.61 mm)) of the concave articulate surface are the most important anatomical features, which should be implicated in prosthesis design. The inclinations mean 2.50 degrees (SD, 0.41 degrees ) and mean 9.50 degrees (SD, 0.52 degrees ) and shift (mean 1.71 mm (SD, 0.35 mm)) of the radial head relative to its neck should also be taken into account in prosthetic design. CONCLUSIONS: The results of the study showed that "left is equal to right" (no significant differences between sides were obtained, for probability value P>0.05). RELEVANCE: This paper describes a morphological study of the proximal radius. The results can be used to reconstruct the geometry of the injured radial head based on the obtained geometric features of the contra-lateral side. These results can be also used to design radial head prosthesis.

The effect of forearm rotation on laxity and stability of the elbow.

OBJECTIVE: The purpose of this study was to quantify the relationship between forearm rotation and valgus/varus laxity of the elbow joint over the range of elbow flexion. BACKGROUND: There is little known about the influence of forearm rotation on the laxity and stability of the elbow joint. The general opinion exists that forearm rotation does not significantly influence the laxity and stability of the elbow joint. METHODS: Nine fresh-frozen cadaver elbows were used. Passive elbow flexion with the forearm in neutral rotation and in 40 degrees and 80 degrees of pronation and supination was performed under valgus/varus loads: (1) in intact elbows; (2) after a lateral surgical approach (lateral epicondylar osteotomy of the distal humerus); (3) after release of the anterior bundle of the medial collateral ligament; and (4) after release of the anterior bundle of the medial collateral ligament plus radial head resection. Valgus/varus elbow laxity was quantified using an electromagnetic tracking device. RESULTS: There was a statistically significant effect (P < 0.05) of forearm rotation on valgus/varus laxity throughout the range of flexion. The laxity was always greater in pronation than in supination, regardless of the surgical approach or the integrity of the anterior bundle of the medial collateral ligament or radial head. CONCLUSIONS: Valgus/varus laxity of the elbow is forearm rotation-dependent. The potential role of this effect should be considered and controlled for in the design of studies examining laxity and stability of the elbow joint. RELEVANCE: The observation that forearm pronation increases valgus/varus laxity, particularly in medial collateral ligament deficient elbows, implies a possible additional factor in throwing kinematics that might put professional baseball pitchers at risk of medial collateral ligament injury due to chronic valgus overload. Our data indicate that forearm rotation should be considered during the clinical examination of elbow instability.

[Endoprosthetic replacement as an alternative treatment for radial head resection in comminuted fractures]. / Endoprotezoplastyka jako alternatywa resekcji glowy kosci promieniowej w zlamaniach wieloodlamowych.

Indications for radial head endoprosthetic replacement (Link) and early results in 2 patients 52 and 20 years of age are presented. Excellent results were achieved according to Mayo Elbow Performance Index criteria. The authors introduce own dismantable endoprosthesis with moving head.

[Elbow contracture: causes, management]. / Przykurcz stawu lokciowego--przyczyny, sposoby leczenia.

Early results after conservative or operative treatment of 15 patients (6 females, 9 males) for contracture of the elbow are presented. The correction achieved has been evaluated by Mayo Elbow Performance Index and by range of flexion and extension movement. Immobilization of the injured elbow should be as short as possible, fixed deformity is an indication for surgery. Resulting contracture of the elbow depends not only on injury severity but on the type of treatment also. One case has been discussed.

[Use of connected Zespol plate fixators in clinical practice]. / Zastosowanie polaczonych plytkowych stabilizatorów ZESPOL w praktyce klinicznej.

A concise introduction of ZESPOL method is followed by the delineation of the author's original improvements concerning ZESPOL plates connection and use of aligning rods illustrated with photographs. Fixation technique and final results in 5 patients operated on with connected ZESPOL plates have presented. It is concluded that connecting of ZESPOL plates broadens indications for use of this method and pragmatic suggestions of the authors aid to its better understanding.

[Treatment outcome for fracture of the radial head]. / Wyniki leczenia zlaman glowy kosci promieniowej.

Clinical, radiological and dynamometric assessment served to evaluate results of treatment for the radial head fracture in 51 patients out of 89 managed between 1983 and 1993. Comminuted fractures, especially if complicated by ligament-capsular injury of the elbow have bad prognosis. Results of treatment are poor in this type of injury regardless the mode of management.