Radial head prosthesis in complex elbow dislocations: effect of oversizing and comparison with ORIF

Purpose

Elbow dislocations with complex elbow instability (CEI) and unstable radial head fractures require reconstruction by open reduction and internal fixation (ORIF) if possible or alternatively by a radial head prosthesis. The aim of this study was to determine the differential outcome of both strategies and to investigate the contribution of prosthesis-related radiographic factors such as oversizing on clinical outcome.

Methods

A total of 53 patients underwent ligament and coronoid refixation, and radial head reconstruction by ORIF (n?=?18; group 1) or by monopolar modular prosthesis (n?=?35; group 2). Patients were followed by the Mayo Elbow Performance Score (MEPS) and a radiological score including prosthesis oversizing, joint subluxation, ossifications, capitellar erosions, implant loosening and ulno-humeral osteoarthritis. To investigate the effect of oversizing, group 2 was subdivided by prosthesis overlenghtening?≥?2 mm.

Results

A total of 42 patients (79.2 %) could be followed for 3.0?±?1.3 years with an average MEPS of 76.8?±?17.2. Patients with ORIF had slightly better MEPS (82.1?±?9.9) as compared with group 2 (74.7?±?19.1) though three ORIF patients required an early conversion to prosthesis. In group 2, oversizing occurred frequently and 50 % showed an overlenghtening?≥?2 mm. Oversizing significantly decreased MEPS (63.2?±?21.3 vs 84.7?±?9.0; p?=?0.001) and elbow range of motion and increased the occurrence of other radiological abnormalities and the risk for surgical revisions. The radiological score and prosthesis overlenghtening but not prosthesis diameter showed an inverse correlation with MEPS.

Conclusions

In CEI a radial head reconstruction with a prosthesis demonstrates similarly good clinical results as compared to ORIF in anatomically sized prosthesis, but prosthesis oversizing could induce other radiographic abnormalities with then deteriorated outcome.     

Strukturierte,prioritätenorientierte Schwerverletztenversorgung nach ATLS®-Kriterien

Advanced trauma life support

Advanced trauma life support (ATLS) has been one of the most successful standardized course formats in the treatment of complex injuries for several decades worldwide. It teaches a structured, priority oriented concept of treatment.

Problem of multiple trauma patients

For admission and treatment of multiple trauma patients a well organized infrastructure is required. These corresponding structural requirements are part of the certification procedure of existing and developing trauma networks. One of the most important procedures is the preparation for the treatment of severely injured patients (be prepared). Furthermore, all actors in the trauma bay must communicate in the same language and must therefore be trained in a standardized treatment concept.

Standardized concepts

In order to achieve this, concepts, such as prehospital trauma life support (PHTLS®, pre hospital), ATLS® (trauma room doctors) and advanced trauma care for nurses (ATCN®) have been established. The patient should be handed over at the interfaces according to the approved ABCDE scheme (primary survey) which stands for A airway, B breathing, C circulation, D disability and E environment. Not only therapy is carried out in a priority oriented procedure (treat first what kills first) but also the team leader supervises treatment, organizes further logistics and performs trauma room team time out (TRTO®) at certain times. Depending on the patient’s situation a multi-slice computed tomography (MSCT), operative treatment according to the damage control principle or, in cases of a stable patient, an exact examination from head to foot (secondary survey) are performed.

Objectives

This article demonstrates the structured, interdisciplinary and interprofessional treatment of severely injured patients exemplified by the procedure at the BG Trauma Clinic Ludwigshafen.     

Effect of acute exercise on amino acid incorporation into the rat myocardium

Summary To determine the effect of acute exercise and recovery on amino acid incorporation into myocardial protein, female Wistar rats (220–240 g) were exercised to exhaustion by swimming. Animals were sacrificed at exhaustion, or 0.5, 1, 2, 4, or 16 h after exercise. Hearts were removed and perfused for 30 min with a Krebs-Henseleit bicarbonate buffer containing; 15 mM glucose, normal plasma levels of amino acids and 0.1 Ci [³H] phenylalanine per ml of buffer. Immediately following the exhaustive exercise, amino acid incorporation into extramitochondrial, mitochondrial and whole heart protein was decreased by 50, 55, and 43% respectively. Following 2 h of recovery, incorporation of [³H]-phenylalanine returned to normal in all three protein fractions. No stimulation in protein synthesis was observed in any of the cell fractions. In an attempt to estimate the intracellular availability of [³H]-phenylalanine, the TCA soluble radioactivity was determined. No change from rest was observed at exhaustion or throughout recovery suggesting that the amino acid pool size was not altered. These data indicate that exhaustive exercise temporarily reduces myocardial protein synthesis which quickly returns to normal during recovery.