Radial head arthroplasty using a metatarsal osteochondral autograft

Purpose

Treatment of comminuted fractures of the radial head is controversial, and considerable effort has been made to restore optimal function of the elbows, either by surgical reconstruction or prosthetic replacement. This report presents our experiences in treatment of unreconstructable radial head or neck fractures using osteochondral autografts harvested from the base of the second metatarsal bones.

Methods

Five patients with radial head and one with a radial neck fracture underwent treatment with osteochondral autografts. After excision of the unreconstructable radial head, the second metatarsal base was harvested and transplanted to the radius using the intramedullary nailing technique.

Results

The reconstructed elbows were examined clinically and radiographically for a mean period of 44.8 months (range, 24–72 months). At the last follow-up, in flexion-extension, the mean elbow mobility was 130°/10°. In supination-pronation, the mean elbow mobility was 73.3°/66.7°, with a mean loss of supination of 19.2° and loss of pronation of 12.5°. Grip strength was 91%, compared with the contralateral limb. The mean Mayo Elbow Performance Score was 94.2. The mean score of AOFAS rating system to the lesser toe was 93.7 points.

Conclusion

Radial head arthroplasty with an osteochondral autograft from the second metatarsal base appears to be an effective alternative for treatment of unreconstructable radial head fractures. A larger group of patients and a longer follow-up period will be required in order to ease concerns regarding the donor site; however, none of the patients who underwent this procedure showed any complications during follow-up.     

Capitellum Fracture Fragment Excision: a Case Series

Background

Fractures of the capitellum are rare injuries, and few studies have reported the results of fragment excision.

Questions/Purposes

The purpose of this study was to determine range of motion and short-term clinical outcomes for patients treated with capitellum excision.

Methods

A retrospective review was performed to identify all patients with an isolated capitellum fracture who underwent excision as definitive treatment at our institutions. Mechanism of injury, associated elbow injuries, type of capitellum fracture, complications, and postoperative outcomes including final elbow range of motion (ROM), elbow instability, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded.

Results

Four patients met the inclusion and exclusion criteria of this study. All patients were female with an average age of 69 years (range 42–85). Based on the Bryan and Morrey classification system, three (75%) fractures were classified as type I and one (25%) fracture as type III. The average clinical follow-up was 11 months. Final examination demonstrated a mean elbow range of motion from 14° (range 0–30) of extension to 143° (range 130–160) of flexion. All patients had full forearm rotation, and there was no clinical evidence of elbow instability. The average DASH score was 18.3 (12.5–24.2) at final follow-up.

Conclusion

Excision of the capitellum, much like excision of the radial head, results in acceptable short-term outcome scores and elbow range of motion in patients with fractures that are not amenable to open reduction and internal fixation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9452-x) contains supplementary material, which is available to authorized users.     

Prosthetic radial head stem pull-out as a mode of failure: a biomechanical study

Purpose

Press-fit cementless radial head implant longevity relies on adequate bone ingrowth. Failed implant osseointegration remains a clinical concern and has been shown to lead to prosthetic failure. The purpose of this study was to test the hypothesis that implants with sufficient initial press-fit stability would be less likely to fail due to implant pull-out, as demonstrated by an increasing amount of energy required to remove the prosthesis from the canal.

Methods

Ten cadaveric radii were implanted with five sizes (6–10 mm in 1-mm increments) of grit-blasted, cementless radial head stems. A customised slap hammer was used to measure the energy required to remove each stem. Stem-bone micromotion was also measured.

Results

The suboptimally sized stem (Max − 1) (i.e. 1 mm undersized) required less energy (0.5 ± 0 J) to pull out than the optimally sized stem (Max) (1.7 ± 0.3 J) (p = 0.008). The optimally sized stem demonstrated greater initial stability (45 ± 7 μm) than the suboptimally sized stem (79 ± 12 μm) (p = 0.004).

Conclusions

This investigation demonstrates the importance of obtaining adequate press-fit stability for the prevention of radial head stem pull-out failure. These data add to the relatively scant knowledge in the literature regarding radial head biomechanics. The energy required to remove a prosthetic radial head ingrowth stem decreases in conjunction with diameter. The use of an inadequately sized stem increases the stem’s micromotion as well as the risk of prosthetic loosening due to pull-out.     

Kapandji pinning and tuberosities fixation of three- and four-part fractures of the proximal humerus

Purpose

The Kapandji pinning was initially described for the treatment of surgical neck fractures of the humerus in young patients. The aim of our study was to evaluate functional and radiological outcomes of the Kapandji modified technique in displaced complex three- and four-part fractures.

Methods

From 2005 to 2009, 32 patients (23 three-part and nine four-part fractures) were included retrospectively. The mean age was 63 years old (range, 22–86), and the dominant shoulder was involved in 40 % of the cases.

Results

At a mean follow up of 25 months (12–72), the mean absolute Constant score achieved 68 points (35–98) and adjusted score 80 % (47–100). Patients had an average forward elevation of the shoulder of 132° (80°–180°), an average external rotation of 36° (0°–90°), and an average internal rotation to the level of L1 (sacrum to the level of T6). The older the patients were the worst was the active anterior elevation recovery (r = −0.3; p = 0.01). Reduction and fixation of initial varus-displaced fractures was not as reliable as in valgus. In eight cases (25 %), K-wire migrations were observed and were correlated with age over 70 years old (p = 0.001). Two partial osteolysis of the greater tuberosity and two avascular necrosis of the humeral head (one was associated with a non-union) were identified. Moreover, three patients developed adhesive capsulitis.

Conclusion

The Kapandji technique with fixation of tuberosities provides satisfactory results for the treatment of complex proximal fractures of the humerus. However, we do not recommend this technique for patients older than 70 years and in cases of varus displaced fractures.     

Correlating preoperative imaging with intraoperative fluoroscopy in iliosacral screw placement

Background

Percutaneous iliosacral screw placement can successfully stabilize unstable posterior pelvic ring injuries. Intraoperative fluoroscopic imaging is a vital component needed in safely placing iliosacral screws. Obtaining and appropriately interpreting fluoroscopic views can be challenging in certain clinical scenarios. We report on a series of patients to demonstrate how preoperative computed tomography (CT) imaging can be used to anticipate the appropriate intraoperative inlet and outlet fluoroscopic views.

Materials and methods

24 patients were retrospectively identified with unstable pelvic ring injuries requiring operative fixation using percutaneous iliosacral screws. Utilizing the sagittal reconstructions of the preoperative CT scans, anticipated inlet and outlet angle measurements were calculated. The operative reports were reviewed to determine the angles used intraoperatively. Postoperative CT scans were reviewed for repeat measurements and to determine the location and safety of each screw.

Results

Preoperative CT scans showed an average inlet of 20.5° (7°–37°) and an average outlet of 42.8° (30°–59°). Intraoperative views showed an average inlet of 24.9° (12°–38°) and an average outlet of 42.4° (29°–52°). Postoperative CT scans showed an average inlet of 19.4° (8°–31°) and an average outlet of 43.2° (31°–56°). The average difference from preoperative to intraoperative was 4.4° (−21° to 5°) for the inlet and 0.45° (−9° to 7°) for the outlet. The average difference between the preoperative and postoperative CT was 2.04° (0°–6°) for the inlet and 2.54° (0°–7°) for the outlet.

Conclusion

There is significant anatomic variation of the posterior pelvic ring. The preoperative CT sagittal reconstruction images allow for appropriate preoperative planning for anticipated intraoperative fluoroscopic inlet and outlet views within 5°. Having knowledge of the desired intraoperative views preoperatively prepares the surgeon, aids in efficiently obtaining correct intraoperative views, and ultimately assists in safe iliosacral screw placement.

Level of evidence

IV, Retrospective case series.     

Ulnar variance as a predictor of persistent instability following Galeazzi fracture-dislocations

Background

We investigated the radiographic parameters that may predict distal radial ulnar joint (DRUJ) instability in surgically treated radial shaft fractures. In our clinical experience, there are no previously reported radiographic parameters that are universally predictive of DRUJ instability following radial shaft fracture.

Materials and methods

Fifty consecutive patients, ages 20–79 years, with unilateral radial shaft fractures and possible associated DRUJ injury were retrospectively identified over a 5-year period. Distance from radial carpal joint (RCJ) to fracture proportional to radial shaft length, ulnar variance, and ulnar styloid fractures were correlated with DRUJ instability after surgical treatment.

Results

Twenty patients had persistent DRUJ incongruence/instability following fracture fixation. As a proportion of radial length, the distance from the RCJ to the fracture line did not significantly differ between those with persistent DRUJ instability and those without (p = 0.34). The average initial ulnar variance was 5.5 mm (range 2–12 mm, SD = 3.2) in patients with DRUJ instability and 3.8 mm (range 0–11 mm, SD = 3.5) in patients without. Only 4/20 patients (20 %) with DRUJ instability had normal ulnar variance (−2 to +2 mm) versus 15/30 (50 %) patients without (p = 0.041).

Conclusion

In the setting of a radial shaft fracture, ulnar variance greater or less than 2 mm was associated with a greater likelihood of DRUJ incongruence/instability following fracture fixation.     

Retrograde dynamic locked nailing for valgus knee correction: a revised technique

Purpose

Traditionally, valgus knee deformity is predominately corrected by stabilisation with a plate inserted via the medial approach to the supracondylar region of the femur. However, this technique is unfavourable from both a biomechanical and a biological point of view. A revised retrograde dynamic locked nailing was developed to improve correction of this defect.

Method

Forty-one knees with valgus deformity (average tibiofemoral angle, 22°; range, 16–29°) in 25 adult patients were treated by oblique femoral supracondylar varus osteotomy and stabilised with retrograde dynamic locked nails. Postoperatively, early ambulation with protected weight bearing and range of motion knee exercises were encouraged.

Result

Thirty-five knees of 21 patients were followed-up for an average of 2.6 years (range, 1.1–4.5 years). All osteotomy sites healed with an average union period of 3.4 months (range, 2.5–5.0 months). There were no significant complications. At the latest follow-up, the average tibiofemoral angle was 7.1° valgus (range, 4–10° valgus). For all of the knees, the outcomes were satisfactory (p < 0.001).

Conclusion

The technique described here may be a feasible alternative for correction of valgus knee deformity. The advantages of this technique include the use of a biomechanically more appropriate method, a minimal complication rate and a high rate of satisfactory outcomes.     

Monobloc radial head prostheses in complex elbow injuries: results after primary and secondary implantation

Purpose

Dislocations of components, loosening of the stem, overstuffing and removal in up to 24 % of common radial head prostheses (RHP) after implantation in complex elbow injuries signal the need for improvement. The latest biomechanical evidence shows advantages for monopolar designs. Clinical results after primary and secondary implantation of the newly designed press-fit monobloc monopolar RHP in cases of complex elbow injury are evaluated.

Methods

Twenty-nine patients [median age 60 years (29–86)] were followed up retrospectively for a median of 25 months (7–54) post-operatively. Subjective parameters, the Mayo Elbow Performance Score (MEPS), the Broberg and Morrey score (BMS), latest radiographs and complications were evaluated.

Results

MEPS and BMS averaged 87.2 ± 12.9 and 81.1 ± 11.9 points, respectively. No case of implant loosening was observed; the RHP had to be removed in one case (3 %). The overall complication and revision rate was higher after secondary (53 %) than after primary (19 %) implantation.

Conclusions

Satisfactory clinical results and low short-term removal rates emphasise the practicality of monobloc monopolar RHP. Differentiated treatment of complex elbow fracture-dislocations is compulsory to avoid the need for secondary RHP implantation which carries a higher complication rate.     

The acromial index is not predictive for failed rotator cuff repair

Background

The main objective of this study was to evaluate the association between the acromial index (AI) and the incidence of recurrent tears of the rotator cuff (RC) in a cohort of patients with full thickness tears who underwent arthroscopic primary repair.

Methods

A prognostic study of a prospective case series of 103 patients with full thickness RC tears was undertaken. The average age was 59.5 years (39–74) and follow-up was 30.81 months (12–72). True anterior–posterior X-rays were obtained during the pre-operative evaluation. Pre and post-operative magnetic resonance imaging (MRI) were recorded.

Results

Eighteen cases with recurrent tears (17.4 %) were seen on post-operative MRI. The average AI for patients with recurrent tears was 0.711 ± 0.065 and for patients without recurrent tears 0.710 ± 0.064 (p < 0.05). A positive association between age and recurrent tears of the RC was noted (average ages: recurrent tears group 63 ± 5.9 years; group without recurrent tears 58.8 ± 7.5 years) (r = −0.216; p = 0.029). We did not find an association between size of the primary tear and recurrent tears (r = −0.075; p < 0.05) or between degrees of retraction of the primary and recurrent tears of the cuff (r = −0.073; p < 0.05). We observed that 38.9 % of the recurrent tears cases presented with more than one tendon affected before the arthroscopy. At follow-up, none of these recurrent tears showed more than one tendon affected on MRI evaluation.

Conclusion

In this study, we found that the AI radiological measurement is not a predictor for recurrent tears of the RC after primary arthroscopic repair.     

Magnetic Resonance Imaging is not suitable for interpretation of meniscal status ten years after arthroscopic repair

Purpose

The purpose of this study was to assess the MRI features of the all-inside repaired meniscus in the long-term.

Methods

Among 27 consecutive all-inside arthroscopic meniscal repairs, 23 patients aged 25 ± 5 years at the time of surgery were reviewed at a median follow-up of 10 ± 1 years. Retrospective clinical examinations and imaging assessments using a 1.5-T MRI after all-inside arthroscopic meniscal repair were conducted.

Results

At follow-up, Lysholm and IKDC averaged 89 ± 11 and 95 ± 8, respectively. MRI examinations revealed no meniscal signal alteration in three patients (13 %), a vertical signal located in the previously torn area in seven (30 %), a horizontal grade 3 in nine (39 %), and a complex tear (grade 4) in four (17.5 %). There were no differences between medial and lateral menisci (p = 0.15), stable and stabilised knees (p = 0.56).

Conclusions

Several abnormal vertical and/or horizontal hypersignals are still present on MRI examination ten years after arthroscopic all-inside meniscal repair. The appearance of early signs of osteoarthritis is rare, suggesting a chondroprotective effect of the repaired meniscus.     

Computer-assisted surgery as indication of choice: total knee arthroplasty in case of retained hardware or extra-articular deformity

Purpose

The use of traditional cutting guides during knee arthroplasty in some cases could be extremely difficult, if not impossible, because of angular deformities, IM sclerosis, long-stemmed hip implants, or hardware within the femoral canal that cannot be removed. In these difficult cases navigation-assisted knee arthroplasty should be considered as an effective and appealing option.

Methods

We present 14 cases in which ideal mechanical and prosthetic alignment was achieved with different image-free, computer-assisted navigation systems, because of an extra-articular deformity (group A, nine patients) or because of a retained implant or hardware (group B, five patients).

Results

After a mean follow-up of 28 months (range 12–53 months), the average knee score increased overall from a mean of 33 points (range 12–63) to 78 points (range 63–90). The average functional score improved from a mean of 32 points (range 10–65) to 72 points (range 40–90). The postoperative mechanical axis ranged between 3° of varus and 3° of valgus. There was an implant revision in one patient who had a traumatic rupture of medial collateral ligament, which occurred 27 months after the index procedure.

Conclusions

Based on our results we think that the navigation-assisted technique provides an alternative approach to the traditional instrumentation for treating these difficult patients in an effective and less invasive manner.     

Factors associated with the success of the Rigo System Chêneau brace in treating mild to moderate adolescent idiopathic scoliosis

Background

Adolescent idiopathic scoliosis (AIS) is the most prevalent spine deformity within the pediatric population. Orthosis is the mainstay of conservative treatment for mild to moderate AIS. The Rigo System Chêneau (RSC) brace is a custom-made thoracolumbar sacral orthosis (TLSO) based on a three-dimensional correction concept. The purpose of this study was to identify factors that could predict the therapeutic success/failure of the RSC brace.

Materials and methods

A retrospective cohort study was performed on all consecutive patients according to the Scoliosis Research Society (SRS) criteria for the success of conservative treatment. Participants had a 2-year follow-up beyond the termination of brace treatment. All patients were treated with the RSC orthotic device.

Results

Ninety-three patients met the inclusion criteria. At treatment onset, their average age was 12.9 years, average Cobb angle 31.97°, Risser score 1.07, and the mean angle of thoracic rotation (ATR) was 10.2°. The mean brace treatment period was 36 months. Treatment was successful in 83.8 % of these patients (n = 79). The average final Cobb angle was 28.97°, Risser score 4.88, and ATR 8.09°. The pre-treatment factors associated with the success of applying the RSC brace were a high Risser score [odds ratio (OR) = 2.97, 95 % confidence interval [CI] 1.18–7.44; p = 0.02), a low Cobb angle (OR = 0.92, 95 % CI 0.85–0.99; p = 0.02), and low ATR (OR = 0.86, 95 % CI 0.75–0.99; p = 0.04).

Conclusions

The treatment of mild to moderate AIS with the RSC brace provides excellent clinical results. Its added benefit is enabling a three-dimensional correction of a three-dimensional deformity. Pre-treatment high Risser score, low Cobb angles, and low ATRs are associated with treatment success.

Level of evidence

Retrospective analysis, Level III.     

Double dome osteotomy for the treatment of cubitus varus in children

Purpose

The purpose of this study was to report double dome osteotomy used to correct paediatric cubitus varus and to avoid lateral prominence after correction.

Methods

Eighteen children with cubitus varus underwent double dome osteotomy. Preoperative templating created from radiographs was used to determine the bone cuts. Double dome osteotomy created a proximal and distal cut, then varus deformity and sagittal alignment were corrected. The osteotomies were fixed with K-wires and immobilised in a long-arm cast. Radiographics and clinical histories were evaluated. Ulno-humeral angle pre and postoperative, range of motion and lateral prominent index were evaluated.

Results

The osteotomy was performed in 18 patients, with an average age of 7.5 years. All patients ended up with flexion of 130° or greater with full and symmetrical pronation and supination. The average ulno-humeral angle difference compared to the uninjured side was 3.27°. The mean of the lateral prominent index was −0.91. The mean follow up was 50.3 months (30–115 months). All of the patients had excellent clinical and radiographic alignment. No revisions were made in this series. One transient radial nerve palsy and one superficial infection occurred.

Conclusion

This series demonstrates that double dome osteotomy can provide reliable correction of varus deformity and prevent lateral prominence with a minimal complication rate.     

Arthroscopic Percutaneous Repair of Anterosuperior Rotator Cuff Tear Including Biceps Long Head: A 2-Year Follow-up

Background

To report the results of an arthroscopic percutaneous repair technique for partial-thickness tears of the anterosuperior cuff combined with a biceps lesion.

Methods

The inclusion criteria were evidence of the upper subscapularis tendon tear and an articular side partial-thickness tear of the supraspinatus tendon, degeneration of the biceps long head or degenerative superior labrum anterior-posterior, above lesions treated by arthroscopic percutaneous repair, and follow-up duration > 24 months after the operation. American Shoulder and Elbow Surgeons (ASES) score, constant score, the pain level on a visual analogue scale, ranges of motion and strength were assessed.

Results

The mean (± standard deviation) age of the 20 enrolled patients was 56.0 ± 7.7 years. The forward flexion strength increased from 26.3 ± 6.7 Nm preoperatively to 38.9 ± 5.1 Nm at final follow-up. External and internal rotation strength was also significantly increased (14.2 ± 1.7 to 19.1 ± 3.03 Nm, 12.3 ± 3.2 to 18.1 ± 2.8 Nm, respectively). Significant improvement was observed in ASES and constant scores at 3 months, 1 year and the time of final follow-up when compared with preoperative scores (p < 0.001). The mean subjective shoulder value was 86% (range, 78% to 97%).

Conclusions

The implementation of complete rotator cuff repair with concomitant tenodesis of the biceps long head using arthroscopic percutaneous repair achieved full recovery of normal rotator cuff function, maximum therapeutic efficacy, and patient satisfaction.