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Results of total elbow arthroplasty following radial head excision and synovectomy in rheumatoid arthritis
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J. Shoulder Elbow Surg. March~April 1996
Abstracts
A COMPARISON OF DISTAL HUMERUS FRACTURE FIXATION: A BIOMECHANICAL STUDY. S.R. Jacobson, R.R. Glisson and J.R. Urbaniak. Duke University Medical Center, Durham, NC. A study was performed to compare bending and torsional stiffness of five multiple-plate constructs for distal humerus fracture fixation. The sagittal and frontal plane bending stiffness was determined in 22 fresh frozen, intact human humeri using a servo-hydraulic materials testing device. A transverse osteotomy was made 4 cm proximal to the distal extent of the trochlea. Fixation was achieved by combinations of 3.5 mm pelvic reconstruction plates (PRP), 3.5 mm dynamic compression plates (DCP), or 3.5 mm one-third tubular plates (TTP). Depending on position, 3.5 n',m cortical or 4.0 mm cancellous screws were used. Plates were applied in three positions: medially, along the medial supracondylar column; laterally, along the lateral supracondylar column; or posterolaterally, extending distally to the capitellum. Each specimen was randomly assigned to one of five construct groups: Construct I: PRP (medial), DCP (posterolateral); Construct II: PRP (medial), PRP (lateral); Construct III: PRP (medial), PRP (posterolateral); Construct IV: TTP (medial), DCP (posterolateral); Construct V: PRP (medial), PRP (lateral), PRP (posterolateral). The frontal and sagittal plane bending stiffness relative to the intact specimen and the absolute torsional stiffness were determined for each plated specimen. The bending stiffness of intact specimens was significantly greater than plated specimens, regardless of the construct applied (p < .0001). All plated specimens were stiffer in the frontal plane as compared to the sagittal ptane (p < .000t) and, when compared to intact specimens, demonstrated a disproportionale decrease in sagittal plane stiffness (p < .00l). Constructs I and V had significantly greater relative bending stiffness in the sagittal plane than Constructs iII and IV (p < .0083). Construct IV had the lowest relative bending stiffness in the frontal plane. This reached statistical significance when compared to Constructs lI and V (p ~ .0077). There was no significant difference in the torsional stiffness of the five constructs. It is concluded that the multiple plate constructs offered significantly less bending stiffness than the intact specimens, with a particular deficiency in the sagittal plane. The triple plated construct (Construct V) did not confer greater stiffness and was technically difficult to implant. The medial pelvic reconstruction plate combined with the posterolateral DCP (Construct I) provided the greatest sagittal plane stiffness, in addition to comparable frontal plane and torsional stiffness. We recommend its use in the treatment of fractures of the distal humerus.
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RESULTS OF TOTAL ELBOW ARTHROPLASTY FOLLOWING RADIAL HEAD EXCISION AND SYNOVECTOMY tN RHEUMATOID ARTHRITIS. E.H. Schemitsch, MD FRCS(C) 1, F.C. Ewald, MD 2, T.S. Thornhill, MD z, St. Michael's Hospital, University of Toronto, Toronto, Canada ~, The Brigham and Women's Hospital, Harvard Medical School, Boston, Ma z. Purpose: to determine the results of total elbow arthroplasty following radial head excision and synovectomy in rheumatoid arthritis. Methods: The cases of twenty-three consecutive patients who had a capitelloeondylar total elbow arthroplasty after a failed radial head excision and synoveetomy were compared with those of a non-consecutive group of twenty-three patients who had a primary capitellocondylar total elbow arthroplasty, The two groups were matched for age, sex, length of follow-up, side, type of prosthesis and surgical approach. Results: At an average followup of four years, use of a 100 point rating score demonstrated an improvement from an average preoperative score of 21 points to an average postoperative score of 87 points in the failed radial head excision and synoveetomy group, and an improvement from an average preoperative score of 22 points to an average postoperative score of 94 points in the primary arthroplasty group. Greater improvement occurred in terms of relief of pain (19<0.05), functional
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cont.
status (p<0.01), and elbow score (p<0.03) in the primary arthroplasty group. Four patients in the failed synovectomy group and none in the primary arthroplasty group required additional surgery (p<0.04). Elbow instability was seen in six patients in the failed synovectomy group and none in the primary arthroplasty group (p<0.009). Conclusions: While radial head excision and synovectomy is a conservative and effective method of treating the painful rheumatoid elbow, conversion to capitellocondylar total elbow arthroplasty is more difficult and the results at minimum two year follow-up are inferior to a primary capitellocondylar total elbow arthroplasty.
Total Elbow Arthroplasty for Flail and Unstable Elbows. A.E. Inglis MD*, A.E. lnglis Jr. MD, MP. Figgie MD, & L. Asnis BS, Hospital for Special Surgery & Beth Israel Medical Center, New York 24 patients with flail or unstable elbows underwent elbow arthroplasty between 1975 and 1992. A flail elbow was defined as one in which the foream was dependent wherever the upper arm was positioned. An unstable elbow was defined as one in which there was 45 ~ of mediaNateral instability. The indications for surgery were pain and poor hand function. A semiconstrained prosthesis was used in all cases, 14 required a customized implant. Follow-up averaged 5.9 years. Good or excellent results were achieved in 20 of 24 patients. Fair results were achieved in two due to triceps weakness and two failed, one due to deep infection, the other due to humeral component loosening. The average flexion was 130~ extension -17 ~ and arc of motion 102~ 60-135~ Five patients required reoperation. The surgery required detailed preoperative planning and is highly demanding of the surgeon's experience, especially in cases with multiple prior operative procedures or with significant anatomical deficiencies. Implant arthroplasty is a therapeutic option in patients with flail and unstable elbows.
J. Shoulder Elbow Surg. March~April 1996
Abstracts
A COMPARISON OF DISTAL HUMERUS FRACTURE FIXATION: A BIOMECHANICAL STUDY. S.R. Jacobson, R.R. Glisson and J.R. Urbaniak. Duke University Medical Center, Durham, NC. A study was performed to compare bending and torsional stiffness of five multiple-plate constructs for distal humerus fracture fixation. The sagittal and frontal plane bending stiffness was determined in 22 fresh frozen, intact human humeri using a servo-hydraulic materials testing device. A transverse osteotomy was made 4 cm proximal to the distal extent of the trochlea. Fixation was achieved by combinations of 3.5 mm pelvic reconstruction plates (PRP), 3.5 mm dynamic compression plates (DCP), or 3.5 mm one-third tubular plates (TTP). Depending on position, 3.5 n',m cortical or 4.0 mm cancellous screws were used. Plates were applied in three positions: medially, along the medial supracondylar column; laterally, along the lateral supracondylar column; or posterolaterally, extending distally to the capitellum. Each specimen was randomly assigned to one of five construct groups: Construct I: PRP (medial), DCP (posterolateral); Construct II: PRP (medial), PRP (lateral); Construct III: PRP (medial), PRP (posterolateral); Construct IV: TTP (medial), DCP (posterolateral); Construct V: PRP (medial), PRP (lateral), PRP (posterolateral). The frontal and sagittal plane bending stiffness relative to the intact specimen and the absolute torsional stiffness were determined for each plated specimen. The bending stiffness of intact specimens was significantly greater than plated specimens, regardless of the construct applied (p < .0001). All plated specimens were stiffer in the frontal plane as compared to the sagittal ptane (p < .000t) and, when compared to intact specimens, demonstrated a disproportionale decrease in sagittal plane stiffness (p < .00l). Constructs I and V had significantly greater relative bending stiffness in the sagittal plane than Constructs iII and IV (p < .0083). Construct IV had the lowest relative bending stiffness in the frontal plane. This reached statistical significance when compared to Constructs lI and V (p ~ .0077). There was no significant difference in the torsional stiffness of the five constructs. It is concluded that the multiple plate constructs offered significantly less bending stiffness than the intact specimens, with a particular deficiency in the sagittal plane. The triple plated construct (Construct V) did not confer greater stiffness and was technically difficult to implant. The medial pelvic reconstruction plate combined with the posterolateral DCP (Construct I) provided the greatest sagittal plane stiffness, in addition to comparable frontal plane and torsional stiffness. We recommend its use in the treatment of fractures of the distal humerus.
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RESULTS OF TOTAL ELBOW ARTHROPLASTY FOLLOWING RADIAL HEAD EXCISION AND SYNOVECTOMY tN RHEUMATOID ARTHRITIS. E.H. Schemitsch, MD FRCS(C) 1, F.C. Ewald, MD 2, T.S. Thornhill, MD z, St. Michael's Hospital, University of Toronto, Toronto, Canada ~, The Brigham and Women's Hospital, Harvard Medical School, Boston, Ma z. Purpose: to determine the results of total elbow arthroplasty following radial head excision and synovectomy in rheumatoid arthritis. Methods: The cases of twenty-three consecutive patients who had a capitelloeondylar total elbow arthroplasty after a failed radial head excision and synoveetomy were compared with those of a non-consecutive group of twenty-three patients who had a primary capitellocondylar total elbow arthroplasty, The two groups were matched for age, sex, length of follow-up, side, type of prosthesis and surgical approach. Results: At an average followup of four years, use of a 100 point rating score demonstrated an improvement from an average preoperative score of 21 points to an average postoperative score of 87 points in the failed radial head excision and synoveetomy group, and an improvement from an average preoperative score of 22 points to an average postoperative score of 94 points in the primary arthroplasty group. Greater improvement occurred in terms of relief of pain (19<0.05), functional
3
cont.
cont.
status (p<0.01), and elbow score (p<0.03) in the primary arthroplasty group. Four patients in the failed synovectomy group and none in the primary arthroplasty group required additional surgery (p<0.04). Elbow instability was seen in six patients in the failed synovectomy group and none in the primary arthroplasty group (p<0.009). Conclusions: While radial head excision and synovectomy is a conservative and effective method of treating the painful rheumatoid elbow, conversion to capitellocondylar total elbow arthroplasty is more difficult and the results at minimum two year follow-up are inferior to a primary capitellocondylar total elbow arthroplasty.
Total Elbow Arthroplasty for Flail and Unstable Elbows. A.E. Inglis MD*, A.E. lnglis Jr. MD, MP. Figgie MD, & L. Asnis BS, Hospital for Special Surgery & Beth Israel Medical Center, New York 24 patients with flail or unstable elbows underwent elbow arthroplasty between 1975 and 1992. A flail elbow was defined as one in which the foream was dependent wherever the upper arm was positioned. An unstable elbow was defined as one in which there was 45 ~ of mediaNateral instability. The indications for surgery were pain and poor hand function. A semiconstrained prosthesis was used in all cases, 14 required a customized implant. Follow-up averaged 5.9 years. Good or excellent results were achieved in 20 of 24 patients. Fair results were achieved in two due to triceps weakness and two failed, one due to deep infection, the other due to humeral component loosening. The average flexion was 130~ extension -17 ~ and arc of motion 102~ 60-135~ Five patients required reoperation. The surgery required detailed preoperative planning and is highly demanding of the surgeon's experience, especially in cases with multiple prior operative procedures or with significant anatomical deficiencies. Implant arthroplasty is a therapeutic option in patients with flail and unstable elbows.