Anteromedial fracture of the coronoid process of the ulna.
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Accidental Falls↗
Biomedical subjects
Joaquin Sanchez-Sotelo
Publications and source records attributed to Joaquin Sanchez-Sotelo.
Proximal humerus fractures.
Proximal humerus fractures are common injuries. Knowledge of local anatomy is paramount in the evaluation and treatment of these injuries. Information regarding humeral head vascularity, fracture patterns, bone quality, and overall geometry have direct implications for nonoperative treatment, internal fixation, and hemiarthroplasty. The ascending branch of the anterior circumflex artery perfuses most of the humeral head. When fractured, the greater tuberosity tends to displace posterosuperiorly, the lesser tuberosity and the shaft displace medially, and the head may be pulled by the attached tuberosity, impacted into valgus, or in more severe cases dislocated, impacted, or divided. Internal fixation of two-part, three-part, and selected four-part fractures may be compromised by local osteopenia; knowledge of the location of the strongest bone in the proximal humerus combined with the use of fixed-angle devices and occasionally bone graft or substitutes has improved the outcome of osteosynthesis. When the humeral head cannot be preserved, successful hemiarthroplasty requires tuberosity union and anatomic restoration of the overall geometry of the proximal humerus in terms of height, retroversion, and head-tuberosity relationships.
Fracture Fixation, Internal↗
Hospital cost of dislocation after primary total hip arthroplasty.
BACKGROUND: The treatment of dislocation following primary total hip arthroplasty usually requires the use of expensive hospital resources and sometimes requires revision surgery. The hospital costs associated with treating this complication have not been previously analyzed, to our knowledge. The purpose of this study was to assess the financial impact of treating dislocations at our institution. METHODS: Between 1997 and 2001, 3671 patients underwent a total of 4054 consecutive primary total hip arthroplasties at our institution. The patients were prospectively followed at regular intervals, and their follow-up data were recorded in an institutional total joint registry. Ninety-nine hips (2.4%) in ninety-nine patients dislocated. The costs to our institution to treat these dislocations were evaluated by determining the cost of each treatment episode required to reestablish hip stability and were expressed as the percent increase in cost compared with that of an uncomplicated primary total hip replacement. RESULTS: Of the ninety-nine hips that dislocated, sixty-two (63%) remained stable after one or more closed reductions and thirty-seven (37%) ultimately required revision surgery. The hospital cost of each closed reduction episode represented 19% of the hospital cost of an uncomplicated total hip replacement. When revision surgery was eventually needed, the average hospital costs of one or more closed reductions and the subsequent revisions represented 148% of the hospital cost of an uncomplicated primary total hip replacement. CONCLUSIONS: Dislocation after primary hip replacement continues to be a prevalent and costly complication that diminishes the cost-effectiveness of an otherwise very successful surgical procedure.
Adult↗
Total knee arthroplasty in patients with Paget's disease of bone at the knee.
The purpose of this study was to identify the technical difficulties, complications, and long-term outcome of total knee arthroplasty in patients with Paget's disease. Twenty consecutive patients (21 knees) with Paget's disease at the knee who underwent primary total knee arthroplasty were retrospectively reviewed. All arthroplasties employed cemented condylar implants. Two patients died at less than 2 years and one was lost to follow-up; the remaining 17 (18 knees) were followed for an average of 9 years. Mean Knee Society scores for pain and function improved from 41 and 36 points preoperatively to 87 and 67 points, respectively, postoperatively. One patient underwent femoral revision for aseptic loosening at 10 years. None developed substantial heterotopic ossifications or deep infection. Total knee arthroplasty in patients with Paget's disease can provide good clinical results with low revision rate and good implant durability, despite technical challenges.
Aged↗
Primary hip arthroplasty through a limited posterior trochanteric osteotomy.
This study evaluates primary hip replacement performed using a modified posterior approach through a limited posterior trochanteric osteotomy bone block that includes the insertions of the posterior capsule and short external rotators--as this may enhance secure reattachment of the posterior soft-tissue envelope and protect against postoperative instability. Sixty-eight consecutive primary hip replacements performed through a posterior trochanteric osteotomy were prospectively followed. Two were lost to follow-up before a minimum of 2 years after the arthroplasty; the remaining 66 hips were followed for a mean of 10 years (range: 2 to 15). The median Harris hip score improved from 43 to 84 points (p < 0.0001). Radiographic union of the osteotomy was confirmed in 64 hips (94%). Two episodes of early dislocation occurred 5 days and 8 months postoperatively; both were successfully managed nonoperatively without continuing instability. There were no cases of late instability. Posterior approach to the hip joint through a posterior trochanteric osteotomy is associated with high union rates and a low rate of late instability after hip replacement.
Adult↗
Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia.
Fifty-four consecutive acute Achilles tendon ruptures were treated with end-to-end suture augmented with gastrocnemius fascial flaps. Surgery was performed within 24 h. Mean patient age was 35 (23-57) years, and 46 were men. Mean follow-up time was 4.8 (2-8) years. At follow-up, the mean visual analogue scale for pain was 0.49, and the mean AOFAS ankle-hindfoot score was 95 (74-100) points. Fifty-three patients were able to stand on their tiptoes for 30 s and perform repeated toe raises, and 50 patients were able to perform single-limb hopping. Complications included rerupture in one case, deep infection in three cases, delayed wound healing in eight cases, and deep venous thrombosis in one case. Reconstruction of acute ruptures of the Achilles tendon augmented with gastrocnemius-soleus fascial flaps provided a good outcome but was associated with a high complication rate.
Achilles Tendon↗
Comparison of wear and osteolysis in hip replacement using two different coatings of the femoral stem.
We compared the clinical and radiographic results of two matched series of total hip arthroplasties, one with hydroxyapatite-coated femoral stems, the other with a similar but porous-coated femoral stem. The prevalence of radiographic osteolysis was 16% in hips with hydroxyapatite-coated stems and 43% in hips with porous-coated femoral stems. In hips with hydroxyapatite-coated stems, osteolysis was always limited to Gruen zones 1 and 7. In contrast, distal osteolysis was present around 26% of the porous-coated stems. At 7 years, the survival-free rate of distal osteolysis was 100% in hips with hydroxyapatite-coated stems but 90% in hips with porous-coated stems (p=0.04). Circumferential hydroxyapatite coating of the femoral component reduced the occurrence of osteolysis and eliminated distal osteolysis at 5-10 years of follow-up. In addition, hydroxyapatite coating did not alter the wear rate.
Adult↗
Instability after shoulder arthroplasty: results of surgical treatment.
BACKGROUND: Currently, there is little available information regarding the surgical treatment of instability following shoulder arthroplasty. The purpose of the present study was to review the results of revision surgery performed for the treatment of instability after shoulder arthroplasty to better define the causes of instability and the risk factors for an unsatisfactory outcome. METHODS: Between 1985 and 1999, thirty-three shoulders (seven of which had had a hemiarthroplasty and twenty-six of which had had a total shoulder arthroplasty) were treated surgically at our institution for anterior instability (nineteen shoulders) or posterior instability (fourteen shoulders). The primary arthroplasty had been performed for the treatment of degenerative arthritis in sixteen shoulders, arthritis of dislocation in six, acute fracture in four, rheumatoid arthritis in three, and other conditions in four. RESULTS: The instability was attributed to abnormal capsular tension and/or rotator cuff dysfunction in twenty-one shoulders, component malpositioning in one shoulder, and a combination of both in eleven shoulders. One shoulder was treated with removal of the components. In the remaining thirty-two shoulders, each of the elements that was contributing to the instability was specifically addressed at the time of surgery. Revision surgery restored stability in nine of the thirty-two shoulders. Anterior instability was associated with a higher failure rate than posterior instability was (p = 0.04). Although eleven shoulders had additional surgery for the treatment of recurrent instability, only fourteen of the thirty-three shoulders were stable at the time of the final follow-up. According to the Neer rating system, there were four excellent, six satisfactory, and twenty-three unsatisfactory results. CONCLUSIONS: Soft-tissue imbalance is present in most cases of instability following shoulder arthroplasty, and component malpositioning plays an additional role in some cases. More than one-half of the shoulders in the present study remained unstable despite attempts at revision. Surgical treatment of instability following arthroplasty is associated with only a modest success rate.
Adult↗
Management of the smashed distal humerus.
The purpose of this article is to present a principle-based approach to treating the smashed distal humerus. These injuries are challenging to even the most experienced surgeons. The four goals, in order of priority, are soft tissue healing without infection, restoration of diaphyseal bone stock, union between the distal fragments and the shaft, and a stable and mobile articulation.
Bone Plates↗
Surgical techniques for reconstruction of chronic insufficiency of the triceps. Rotation flap using anconeus and tendo achillis allograft.
Seven patients with chronic insufficiency of the triceps were treated by either a rotation flap using anconeus (4) or an allograft of tendo Achillis (3). The latter procedure was selected for patients with a large defect in whom the anconeus muscle had been devitalised. Five disruptions were in patients who had previously undergone an elbow replacement. The patients were assessed for subjective satisfaction, pain, range of movement and strength, and the results were graded using the Mayo Elbow Performance Score (MEPS). The mean follow-up was for 33 months (9 to 63). One rotation flap failed six months after operation. At the most recent follow-up, the remaining six patients had no or slight pain, restoration of a functional arc of movement and normal or slightly decreased power of extension. All six were satisfied with the outcome and were able to resume their daily activities with no limitations other than those imposed by the previous elbow replacement. The final MEPS was 100 points in five patients and 75 in one.
Achilles Tendon↗
Reconstruction of chronic ruptures of the distal biceps tendon with use of an achilles tendon allograft.
BACKGROUND: Chronic ruptures of the distal biceps tendon are uncommon and are complicated by the retraction and poor quality of the muscle and tendon. Surgical procedures that have been described for the treatment of this injury are limited by the quality and availability of the structures used for augmentation. The purpose of the present study was to describe the surgical technique for reconstruction of the tendon with an Achilles tendon allograft and to report our preliminary experience with this procedure. METHODS: An Achilles tendon allograft was used to reconstruct a chronic rupture of the distal biceps tendon in four patients. The patients were evaluated with regard to subjective satisfaction, pain, range of motion, and strength in flexion and supination. The results were graded with use of the Mayo elbow performance score. RESULTS: After an average duration of follow-up of 2.8 years (range, 2.0 to 3.7 years), all four patients had a satisfactory subjective result, a full range of motion, and an excellent Mayo elbow performance score. The strength of flexion and supination was comparable with that on the contralateral side in two patients and was slightly decreased in the other two. CONCLUSIONS: Reconstruction of chronic disruptions of the distal biceps tendon with an Achilles tendon allograft appears to offer a satisfactory technical solution for this challenging problem and has provided satisfactory clinical results to date.
Achilles Tendon↗
Long-term results of use of a collared matte-finished femoral component fixed with second-generation cementing techniques. A fifteen-year-median follow-up study.
BACKGROUND: So-called second-generation cementing techniques in total hip arthroplasty have been shown to provide better survival of the femoral component than first-generation methods do; however, surface finish and other features of the component design also influence the durability of the reconstruction. The purpose of this study was to determine the results of primary total hip replacement with use of a collared femoral component with a matte-finished surface fixed with second-generation cementing techniques and followed for ten to twenty years. METHODS: The study group consisted of 256 consecutive hips in 236 patients who had had a primary total hip arthroplasty with fixation of a Harris Design-2 femoral component with second-generation cementing techniques (use of an intramedullary plug and a cement gun). The mean age of the patients at the time of the operation was sixty-six years. One hundred and twelve patients were male, and 124 were female. Seven patients were lost to follow-up less than ten years after the operation. The median duration of follow-up of the living patients who had not had a revision was 15.4 years. RESULTS: At the time of the most recent follow-up, nineteen femoral components (7%) had been revised because of aseptic loosening, five (2%) had been removed because of deep infection, and one (0.4%) had been revised because of recurrent dislocation. The mean Harris hip score for the surviving patients who had not had a revision improved from 51 points preoperatively to 91 points at the most recent evaluation. At fifteen years, the estimated survival rate of the femoral components was 92.2% with revision due to aseptic loosening as the end point and 90.1% with mechanical failure (radiographic loosening or revision due to aseptic loosening) as the end point. Patients who were younger than fifty years old at the time of the operation had a lower fifteen-year rate of survival of the femoral implant, in terms of both revision due to aseptic loosening (72.3% compared with 95.7%, p = 0.0001) and mechanical failure (72.3% compared with 93.1%, p = 0.005), than did patients who were fifty years or older. CONCLUSIONS: Fixation of this collared matte-finished femoral component with use of second-generation cementing techniques for primary total hip replacement provided satisfactory results at ten to twenty years in older patients but less satisfactory results in younger patients.
Adolescent↗
Shoulder arthroplasty for arthritis after instability surgery.
BACKGROUND: We are not aware of any large published studies regarding the intermediate to long-term results of shoulder arthroplasty performed for the treatment of osteoarthritis after instability surgery. Therefore, we reviewed the results of this procedure, the risk factors for an unsatisfactory outcome, and the rates of failure in our patients. METHODS: Between January 1, 1978, and December 31, 1997, thirty-three patients (thirty-three shoulders) with glenohumeral arthritis after instability surgery were treated with a shoulder arthroplasty at our institution. Two patients were excluded from the study: one died less than two years postoperatively, and one had not been managed by the senior surgeon. The remaining thirty-one patients, including twenty-one patients who had had a total shoulder arthroplasty and ten who had had a hemiarthroplasty, were followed for a minimum of two years (mean, seven years) or until the time of revision surgery. The mean age at the time of the shoulder arthroplasty was forty-six years. RESULTS: Shoulder arthroplasty was associated with significant pain relief (p < 0.001) as well as significant improvement in external rotation (from 4 degrees to 43 degrees; p < 0.001) and active abduction (from 94 degrees to 141 degrees; p < 0.001). There was not a significant difference between the hemiarthroplasty group and the total shoulder arthroplasty group with regard to postoperative external rotation, active abduction, or pain. According to a modification of the rating system of Neer et al., there were four excellent, two satisfactory, and four unsatisfactory results in the hemiarthroplasty group and three excellent, five satisfactory, and thirteen unsatisfactory results in the total shoulder arthroplasty group. Three patients in the hemiarthroplasty group and eight patients in the total shoulder arthroplasty group underwent revision surgery. The estimated survival of the components (and 95% confidence interval) was 97% (91% to 100%) at two years, 86% (74% to 99%) at five years, and 61% (42% to 86%) at ten years. CONCLUSIONS: The data from the present study suggest that shoulder arthroplasty for the treatment of osteoarthritis of the glenohumeral joint following instability surgery in this relatively young group of patients provides pain relief and improved motion but is associated with high rates of revision surgery and unsatisfactory results due to component failure, instability, and pain due to glenoid arthritis.
Adult↗
Periprosthetic humeral fractures after total elbow arthroplasty: treatment with implant revision and strut allograft augmentation.
BACKGROUND: Periprosthetic fractures are among the most challenging complications of elbow arthroplasty, and published information about the outcome of treatment is limited. The purpose of the present study was to determine the results of implant revision and strut allograft augmentation for the treatment of humeral periprosthetic fractures that occur around a loose humeral component. METHODS: Between 1991 and 1999, eleven periprosthetic fractures that occurred around a loose humeral component were treated with cortical strut allograft augmentation and revision arthroplasty with use of a Coonrad-Morrey semiconstrained implant. Six fractures occurred after a primary arthroplasty, and five occurred after a revision arthroplasty. Two parallel strut grafts were used for fracture fixation in most cases. Patients were followed for an average of three years (range, nine months to 7.8 years) and were evaluated clinically and radiographically. RESULTS: Clinical and radiographic fracture union was obtained in ten of the eleven patients. One patient required revision surgery because of aseptic loosening of the humeral component seven years and nine months after fracture union; there were no other implant failures. Complications included one additional nondisplaced humeral periprosthetic fracture after surgery that failed to heal with closed treatment, one olecranon fracture, one permanent ulnar nerve injury, and one case of triceps insufficiency. At the time of the most recent follow-up, seven of the eight patients with an intact reconstruction had a functional arc of motion and no or slight pain and one had limited motion and moderate pain. CONCLUSIONS: Periprosthetic humeral fractures that are associated with a loose humeral component can be effectively treated with revision elbow arthroplasty and strut allograft augmentation. The technique is associated with a high rate of fracture union, implant survival, and satisfactory clinical results. However, the complication rate is substantial.
Adult↗
Medial oblique compression fracture of the coronoid process of the ulna.
The most widely recognized coronoid fractures have been described as occurring in the coronal plane according to the amount of process detached from the ulna. Over the last few years, we have recognized that the coronoid fracture is a much more complex injury than originally thought. This report calls attention to an oblique, medial compression fracture of the coronoid, a fracture so subtle as to be missed by routine assessment but sometimes associated with joint subluxation or dislocation. The currently accepted classification system based on a simple fracture pattern in the coronal plane may be too simplistic to characterize fractures of the coronoid fully.
Accidental Falls↗
Understanding proximal humerus fractures: image analysis, classification, and treatment.
Proximal humerus fractures are difficult to define because of their extreme variability and potential for complexity. We designed a study to evaluate further why this is true. Radiographs of 113 proximal humeral fractures were assessed by 3 knowledgeable observers. The observers were asked to answer independently 9 questions about the fracture, to classify the fracture according to the Neer classification, and to recommend treatment. Two months later, a learning session was held to discuss discrepancies among the observers and to develop learning points to improve analysis of the images. Two months later, the radiographs were reassessed. Developing 10 learning points enhanced the ability to interpret images at the second review and provide more consistent fracture classification with statistically significant improvements. The problem is understanding the images of complex fractures-not the classification system. To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced.
Adult↗
Tension-band wiring for olecranon fractures: analysis of risk factors for failure.
Thirty-seven consecutive olecranon fractures treated with tension-band wiring were evaluated at a mean follow-up of 4 years. There was no or mild pain in 33 cases, mean elbow extension was 7 degrees , and mean elbow flexion was 131 degrees . According to the Mayo Elbow Performance Score, the results were graded as good or excellent in 32 cases (86%). Most patients had mild residual upper extremity disability (mean Disabilities of the Arm, Shoulder and Hand score, 18 points). In 10 patients, degenerative changes developed. Arthritic changes were significantly associated with elbow instability (P = .014) and length of follow-up (P = .031) and were more common in the presence of associated radial head or coronoid fractures (P = .06). Hardware removal was required in 17 cases. Tension-band wiring provides satisfactory results in a high percentage of olecranon fractures. However, the outcome may be compromised in the presence of elbow instability and associated fractures of the radial head and coronoid.
Adult↗
Surgical treatment of developmental dysplasia of the hip in adults: I. Nonarthroplasty options.
Hip dysplasia is a developmental disorder that results in anatomic abnormalities leading to increased contact pressure in the joint and, eventually, coxarthrosis. However, many patients with hip dysplasia become symptomatic before the development of severe degenerative changes because of abnormal hip biomechanics, mild hip instability, impingement, or associated labral pathology. Several nonarthroplasty treatment options are available. Because the primary deformity is mostly acetabular, for many patients, a reconstructive osteotomy that restores more nearly normal pelvic anatomy is preferable. The Bernese periacetabular osteotomy is presently favored because it provides good correction while creating little secondary pelvic deformity or destabilizing the pelvis. Proximal femoral osteotomy is occasionally needed as a complement to pelvic osteotomy and may also be indicated as an isolated procedure when most deformity is located on the femoral side (coxa valga subluxans). Arthroscopy can be beneficial when symptoms seem to be related only to labral tears or loose bodies in the absence of severe structural abnormalities about the hip. Fusion and resection arthroplasty are rarely indicated and are reserved for occasional patients who are not candidates for total hip replacement or other procedures but who complain of refractory hip pain.
Acetabulum↗