游离肘外侧皮瓣修复手部皮肤缺损

目的 探讨以桡侧副动脉后支供血的游离肘外侧皮瓣的设计和应用技术。方法 以肱骨外上髁后缘与三角肌止点后缘连线为轴,在肘外侧部设计包含前臂后皮神经的皮瓣,以桡侧副动静脉为蒂,蒂长可达５～８ｃｍ。临床应用游离肘外侧皮瓣修复手部皮肤缺损７例。结果７例皮瓣均完全存活,效果良好,结论 肘外侧皮瓣血管蒂较长,皮瓣薄且质地佳,手术操作较方便,适合修复中等面积手部皮肤缺损。     

Wound healing after total elbow replacement in rheumatoid arthritis Wound complications in 50 cases and laser-Doppler imaging of skin microcirculation

Wound healing complications, predisposing to deep infection, are common following prosthetic surgery of the elbow. 50 capitellocondylar elbow prostheses were inserted, using a lateral approach, in 42 patients with rheumatoid arthritis. The first 5 elbows were immobilized postoperatively for 5 days and the following 45 elbows for 12 days, because of delayed wound healing in 2 of the first 5 elbows. No wound healing complications were recorded in elbows immobilized for 12 days and elbow motion was not compromised. 5 elbows were investigated with laser-Doppler imaging (LDI) technique, both pre- and postoperatively. Postoperative LOI values were considerably higher than preoperative ones, indicating no impairment of local skin microcirculation. The authors conclude that the lateral approach is safe to use in prosthetic surgery on the elbow. Early mobilization can delay wound healing, but this can be prevented by 2 weeks of postoperative immobilization.     

游离上臂外侧皮瓣在头颈肿瘤术后缺损修复的临床应用

目的 探讨以桡侧副动脉后支供血的游离上臂外侧皮瓣的设计和应用技术.方法 临床应用游离上臂外侧皮瓣修复头颈肿瘤术后缺损9例.结果 9例皮瓣均完全存活,效果良好.结论 上臂外侧皮瓣血管蒂恒定,皮瓣薄且质地佳,手术操作方便,供区隐蔽,适合修复头颈肿瘤尤其口腔术后缺损.     

Avulsion of the distal triceps tendon with fracture of the radial head

We present a rare case of associated distal triceps tendon avulsion with radial head fracture; the lateral and medial collateral ligaments of the elbow were also ruptured. The patient underwent surgical procedure for the reinsertion of the triceps tendon using metallic anchors, radial head prosthetic replacement, and repair of the lateral collateral ligament. We believe this combined injury pattern of radial head fracture with triceps tendon rupture or avulsion should be considered according to the concept of the spectrum of elbow instability.     

Die Behandlung der Radiusk?pfchentrümmerfraktur —Resektion oder Prothese?

Comminuted fractures of the radial head (Mason 3) are rare injuries. A successful osteosynthetic reconstruction is not possible. The common treatment of this fracture is the resection of the radial head, with instability or valgus deformity of the elbow joint, or a prosthetic replacement. Both methods are discussed controversially in literature. From 1986 until 1998 42 patients with comminuted radius head fractures were treated surgically (34 silastic prostheses, 8 resections). We controlled 31 patients clinically and radiologically at an average of 5 years after operative treatment. Using a modified score of Radin and Riseborough, we got in 84% good or fair results after prosthetic replacement. In one case the removement of the prosthesis was necessary because of displacement. By using the silastic prosthesis compared to the resection we saw a much better primary stability with resultant early functional movement of the elbow joint.      

肘关节三联征的治疗进展

肘关节三联征这类损伤因为其周围解剖的复杂性,生物力学研究有限,治疗相当困难,预后较差,选择治疗方案仍存在争议,本文通过检索大量参考文献对肘关节周围解剖、损伤机制、手术治疗方法及预后情况进行归纳总结。目前肘关节三联征的手术治疗方案多样,但由于个体差异的存在,临床疗效大多不确切。肘关节三联征的治疗,多数骨科医生仍然选择外侧手术入路,固定冠状突骨折,桡骨头修复或者置换,常规修复外侧副韧带,大多数学者不建议修复内侧副韧带,故仍有待商榷。     

Fractures of the elbow's lateral column radial head and capitellum

Fractures of the lateral column of the elbow involve radial head fractures or capitellum fractures. As the biomechanics of the elbow have become better understood, the importance of the radiocapitellar joint in stabilizing the elbow has been emphasized. Preservation of the radial head has gained importance. For nondisplaced radial head fractures, good results are generally obtained with a short period of immobilization followed by early range of motion. In managing displaced radial head fractures, improved techniques and more versatile instrumentation have helped make preservation more feasible. Excellent results can be achieved with ORIF. In cases in which ORIF is impossible, prosthetic replacement of the radial head is a sound alternative. Successful results have been obtained with arthroplasty, and with second-generation modular systems, the facility of performing this procedure should increase. Treatment of capitellar fractures has also benefited from improved fixation systems. If the fragment is large enough, reduction and fixation with small screws or Kirschner wires have had good success. Excision works well in patients with fragments that are too small or not amenable to fixation, especially if the other structures of the medial elbow and forearm axis are competent.     

Management of the infected total joint arthroplasty

Infection is the most severe complication of total joint arthroplasty. Prompt recognition and correct management, as well as prophylaxis against infection, are essential to minimize morbidity and maximize function. In this article, the etiology and diagnosis of prosthetic infection and the management of infected total arthroplasties of the hip, knee, ankle, shoulder, elbow, and wrist are discussed.     

Micromotion of the Souter-Strathclyde total elbow prosthesis in patients with rheumatoid arthritis 21 elbows followed for 2 years

21 elbows in 18 patients with rheumatoid arthritis were treated with a Souter-Strathclyde total elbow prosthesis. 18 elbows were included in a radiostereometry (RSA) study. The aim of this clinical RSA study was to assess the three-dimensional micromotion pattern of the Souter-Strathclyde prosthesis, and thereby gain insight in the aseptic loosening process of this prosthesis. Implants were defined as at risk of aseptic loosening when the translation rate during the second postoperative year was more than 0.4 mm along one or more coordinate axes and/or the rate of rotation was more than 1 degrees about one or more coordinate axes. Clinical examination revealed an increase in the range of motion and a marked reduction in pain. The RSA showed that 8 of 18 humeral components were at risk of aseptic loosening, although no signs of such loosening-defined as a complete radiolucent line of 2 mm or more-were found on the plain radiographs. In 7 humeral components, an anterior tilt about the transverse axis was seen that resulted in an anterior translation of the proximal tip and a posterior translation of the component's trochlea. Long-term studies of the Souter-Strathclyde prosthesis, have shown that this rotation is a specific pattern of failure in some implants. None of the ulnar components was at risk for aseptic loosening. Improvements in fixation of the Souter-Strathclyde total elbow arthroplasty should focus on the humeral component. At present, the lateral flange of the implant is enlarged to improve rotational stability about the transverse and longitudinal axes. The effect of this change in design on micromotion of the Souter-Strathclyde total elbow prosthesis will be studied in a randomized RSA study comparing the new design to the existing one.     

Ligamentous reconstruction for posterolateral rotatory instability of the elbow.

Eleven consecutively seen patients who had posterolateral rotatory instability of the elbow joint were managed operatively. The radial collateral-ligament complex was advanced and imbricated in three of them. In seven patients, the ulnar band of the radial collateral ligament (the lateral ulnar collateral ligament) was reconstructed with the palmaris longus tendon and in two of the seven, the reconstruction was augmented with a prosthetic ligament. The ligament was reconstructed with the lateral one-third of the triceps fascia in the remaining patient. Stability was obtained in ten patients, and seven patients had an excellent functional result. There was one failure in one of the patients in whom the ulnar band of the radial collateral ligament had been reconstructed with the palmaris longus tendon and augmented with a prosthetic ligament.     

Lateral collateral ligament instability of the elbow

Lateral elbow support is provided by a combination of bony anatomy and the ligaments and tendons that originate at the lateral epicondyle. Instability is typically posttraumatic in nature. In the acute setting of elbow fracture-dislocation, restoration of lateral soft tissue support can be typically accomplished by a direct repair of the lateral ligament and extensor tendon origins to the humeral epicondyle. In chronic settings, a reconstruction is most commonly necessary using a free tendon graft. Indications and surgical techniques are discussed.     

Geometric analysis of selected press fit prosthetic systems for proximal humeral replacement.

The ability of a prosthetic system to replicate a wide range of normal anatomy appears dependent in part to its capacity to produce variable prosthetic geometries. Several modern designs have recently been developed in order to provide multiple prosthetic options. The purpose of this study was to compare the geometry of select press fit prosthetic systems in terms of their ability to match normal three-dimensional geometry of the proximal humerus. The anatomy of 60 humeral specimens from 30 cadavers known from CT data and computer-aided design (CAD) analysis was compared to a 1996 database of four conventional shoulder prosthetic systems (fixed inclination angle, one medial-lateral offset position per head) and one so-called anatomic system (variable inclination angles, multiple head offset positions). The prosthetic system with greatest geometric options allowed for a significantly better replication of the anatomy. Average displacement of the center of rotation was 2.1 mm compared to 9.7 mm for the other systems combined. Reduction in surface arc was 12 degrees compared to 32 degrees. The most problematic feature of conventional prosthetic systems in terms of replicating normal humeral anatomy is the gap created by the prosthetic collar and Morse taper.     

Fracture of the radial head with associated elbow dislocation: results of treatment using a floating radial head prosthesis

OBJECTIVES: To assess elbow function, complications, and problems of radial head fractures associated with elbow dislocation receiving surgical treatment with a floating prosthesis. DESIGN: Prospective clinical study. SETTING: University Hospital, Orthopaedic Department, Sart Tilman, Liège, Belgium. PATIENTS: Eleven consecutive adult patients were treated with a floating prosthesis for acute radial head fractures associated with elbow dislocation from January 1994 to September 1996. INTERVENTION: The floating radial head prosthesis (Tornier SA, Saint-Ismier, France) was used in all our patients. The implant is in two parts: a radial head made of high-density polyethylene enclosed in a cobalt-chrome cup, which articulates in a semiconstrained manner with the spherical end of a cemented intramedullary stem. The implants were inserted within the first week following the injury (range 2 to 7 days). Three cases also required internal fixation of the coronoid process of the ulna; in one case plate fixation of an olecranon fracture was also performed. MAIN OUTCOME MEASUREMENTS: Patients were assessed by physical examination, a functional rating index (Morrey et al.), and radiographs. The parameters evaluated were motion, stability, pain, and grip strength. Potential complications such as infection, prosthetic failure, or dislocation were investigated. RESULTS: The minimum follow-up time was two years (mean 32 months, range 24 to 56 months). Four patients were considered to have excellent results, four patients were considered to have good results, two patients had fair results, and one patient had a poor result. There were no cases of infection, prosthetic failure, or dislocation. No patient required prosthetic revision. CONCLUSION: The basic principle of maintaining anatomic and physiologic relationships applies when deciding on treatment for radial head fractures with associated elbow dislocation. The loss of lateral osseous support will render the elbow grossly unstable. We believe that a floating prosthesis may be indicated in Mason Type III radial head fractures associated with elbow dislocation, especially in the presence of associated destabilizing fractures. Well-controlled comparative randomized studies will be needed to delineate the optimal treatment for a given situation.     

Micromotion of the Souter-Strathclyde total elbow prosthesis in patients with rheumatoid arthritis

21 elbows in 18 patients with rheumatoid arthritis were treated with a Souter-Strathclyde total elbow prosthesis. 18 elbows were included in a radiostereometry (RSA) study. The aim of this clinical RSA study was to assess the three-dimensional micromotion pattern of the Souter-Strathclyde prosthesis, and thereby gain insight in the aseptic loosening process of this prosthesis. Implants were defined as at risk of aseptic loosening when the translation rate during the second postoperative year was more than 0.4 mm along one or more coordinate axes and/or the rate of rotation was more than 1° about one or more coordinate axes. Clinical examination revealed an increase in the range of motion and a marked reduction in pain. The RSA showed that 8 of 18 humeral components were at risk of aseptic loosening, although no signs of such loosening - defined as a complete radiolucent line of 2 mm or more - were found on the plain radiographs. In 7 humeral components, an anterior tilt about the transverse axis was seen that resulted in an anterior translation of the proximal tip and a posterior translation of the component's trochlea. Long-term studies of the Souter-Strathclyde prosthesis, have shown that this rotation is a specific pattern of failure in some implants. None of the ulnar components was at risk for aseptic loosening. Improvements in fixation of the Souter-Strathclyde total elbow arthroplasty should focus on the humeral component. At present, the lateral flange of the implant is enlarged to improve rotational stability about the transverse and longitudinal axes. The effect of this change in design on micromotion of the Souter-Strathclyde total elbow prosthesis will be studied in a randomized RSA study comparing the new design to the existing one.     

Radial head,radiocapitellar and total elbow arthroplasties: A review of recent literature

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.     

Course of the innervation supply of medial head of triceps muscle and anconeus muscle at the posterior aspect of humerus (anatomical study)

Introduction In elbow surgery; posterior side of joint has been described as the front door for accessing the elbow pathologies. Triceps splitting, triceps reflection, posterolateral Kocher, posteromedial Bryan-Morrey, modified MacAusland transolecranon approaches are the well known posterior surgical approaches. In the English literature, release and transposition of ulnar nerve on the medial side was fully described in posterior approaches. We believe that there was a need to identify the structures at the lateral aspect of the elbow while an iatrogenic injury may inversely effect an excellent radiological result. Therefore, we exposed the detailed innervation supply to the anconeus muscle and medial head of triceps muscle and tried to show possible denervation sites of these two structures during posterior approaches.Materials and methods This study was performed on 14 elbows in formalin-preserved 7 cadavers. We exposed the course of the innervation supply to the medial head of triceps muscle and anconeus muscle and tried to show possible denervation sites of these two structures during posterior approaches. The branching pattern of radial nerve innervating anconeus muscle and its deriving level from radial nerve was identified. Distance from a vertical line which is passing through lateral epicondyle to branching point was measured.Results The mean distance of the branching point of the nerve to medial head of triceps muscle and anconeus was 168.3 mm (range 130.36–185.4). The nerve to anconeus muscle ran along the posterior aspect of the humerus from the horizontal line passing through lateral epicondyle at a distance of 142.20 mm (range 153.72–136.41) medial to olecranon and at a distance of 47.45 mm (range 77.13–30.14) lateral to olecranon.Conclusion Although splitting the fibers of triceps proximaly increases the exposure of the posterior humerus, innervation of the lateral portion of the medial head of triceps muscle and anconeus muscle may be jeoparadized. Therefore, surgeons who have interest in elbow surgery; (1) should revise the course of the nerve to medial head of triceps and anconeus muscle, (2) be aware of possible iatrogenic injury of the extensor muscles of the elbow via transtricipital approaches, (3) try to choose a more conservative posterior surgical approach.     

Geometric analysis of commonly used prosthetic systems for proximal humeral replacement.

BACKGROUND: The anatomy of the proximal part of the humerus is extremely variable. The extent to which existing prosthetic systems and operative technique allow replication of this variability has not been established. METHODS: Four commonly used press-fit prosthetic systems for shoulder arthroplasty were compared with respect to their ability to match the superior-inferior and medial-lateral dimensions of the articular surface in twenty-one cadaveric humeri. The comparisons were accomplished with a computer optimization algorithm that searched a database of prosthetic geometry and selected the best match to the original anatomy. The algorithm assumed an osteotomy of the humeral head at an angle equivalent to the stem-head angle of the prosthesis, without violation of the greater tuberosity or the metaphyseal bone. The best match was defined as the prosthetic combination (stem and head) that least displaced the center of rotation and the articular surface, with both factors weighted equally. RESULTS: None of the prosthetic systems that were evaluated allowed identical replication of the articular surface. Rather, they displaced the center of rotation a mean of 14.7 millimeters (range, 3.3 to 31.4 millimeters) from its original position. To reach this minimized displacement, the prosthetic combinations that were selected by the algorithm also resulted in a mean diminution of the arc of the articular surface (a smaller head size) of 26 degrees (range, 11 to 41 degrees). In every instance, the selected prosthesis imposed a superior and lateral shift of the center of rotation that in effect shifted a smaller prosthetic humeral head up the slope of the humeral osteotomy. CONCLUSIONS: Press-fit prosthetic systems for shoulder arthroplasty that are commonly used necessitate marked alterations of the original anatomy. To the extent that a shoulder arthroplasty is an attempt to reproduce the normal anatomy, these findings have profound implications for operative technique and future prosthetic design. CLINICAL RELEVANCE: We believe that the superior position of the prosthetic head predicted by the present study plays a role in late complications of shoulder arthroplasty, such as rotator cuff tendinopathy, superior humeral migration, and loosening of the glenoid component.     

Assessment of Instant Loss of Elbow Flexion in Children with Untreated Gartland IIA Humeral Supracondylar Fractures—A Simulation Study with Lateral Elbow Radiographs

Objective

The suitability of in situ cast fixation for treating Gartland IIA humeral supracondylar fractures has remained controversial due to concerns regarding loss of elbow flexion. This study aimed to assess the instant loss of elbow flexion after Gartland IIA humeral supracondylar fractures based on the relationship between the anterior marginal line of the humerus and capitellum in the lateral view.

Methods

This simulation study was conducted with normal radiographs using Adobe Photoshop 14.0, followed by verification using clinical cases. Standard lateral views of normal elbows of children were collected from January 2008 to February 2020. Adobe Photoshop was used to simulate Gartland IIA supracondylar fractures with different degrees of angulation in the sagittal plane. A formula was deduced to assess flexion loss, and this method was verified in three cases. The data were grouped by age, and the relationship between elbow flexion loss and age, as well as the angulation of the fracture, was analyzed using a one-way or multivariate ANOVA.

Results

There was a flexion loss of 19° (11–30°) when the anterior margin line of the humerus was tangential to the capitellum. This loss increased with age at injury (r = 0.731, P = 0.000). Moreover, the difference in angulation in the sagittal plane also influenced the extent of elbow flexion loss (r = −0.739, P = 0.000). The more horizontal the fracture line in the lateral view, the greater the loss of elbow flexion.

Conclusion

Instant elbow flexion loss after Gartland IIA humeral supracondylar fractures increases with age at the time of injury and decreases with angulation in the sagittal plane. When the anterior margin of the humerus is tangential to the capitellum, there will be an average loss of 19° in elbow flexion. These findings provide a quantitative reference for clinical decision-making in the treatment of Gartland IIA supracondylar fractures.     

Fitting of electronic elbow on an elbow disarticulated patient by means of a new surgical technique

Rehabilitation of trans-humeral amputees represents a challenge. One of the difficulties to overcome is prosthetic suspension. In the case of elbow disarticulation the presence of humeral condyles permits better suspension, but there is no room for elbow joints, particularly electronic ones, and the only available mechanisms are provided by external hinges. The purpose of this report is to present a case of a primarily elbow disarticulated patient, with indication for surgical revision due to bad skin coverage, neuroma and the wish to improve prosthetic fitting. The surgical plan outlined was to produce a shortening of the humerus, by means of an osteotomy just above the humeral condyles, preserving them for prosthetic suspension. This bone reduction was carried out with complementary shaping of bone segments with an indentation to enhance fixation. The operation was completed with neuroma resection, myodesis and removal of the skin grafted area. Preservation of the humeral condyles actually produced effective suspension. For final fitting a Utah Arm II was used, with wrist rotator, and interchangeable hand and Greifer for terminal devices. Good initial results and at nine months follow-up suggest this procedure should be considered in other elective situations.