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In traumatic proximal forearm amputation where replantation is not possible, "spare parts" from the amputated segment can be used to maintain adequate length for successful use of a below-elbow prosthesis. Two patients with long-term follow-up are presented in whom forearm length was preserved with the use of a sensate palmar skin free flap.
Of 4 Paget's sarcoma patients (age range, 55-68 years) underwent limb salvage surgery by custom mega prosthesis, 3 had lesions in the upper extremity and one in the proximal femur. Three of the patients were at stage IIB of the disease, according to Enneking's system of staging musculoskeletal tumours. All 4 patients underwent wide resection with a mean length of 152.5 mm. The defects were reconstructed with custom-made prostheses: proximal humeral prostheses in 2 of the patients, total elbow prosthesis in one, and total hip prosthesis in one. During a mean postoperative follow-up period of 40 months, one died of disseminated disease 14 months after surgery; one remained disease-free; 2 had local recurrence and required amputation, of whom one died of disseminated disease one year after amputation, the other had no further evidence of the disease. We report the functional outcomes of the 2 patients who were alive at the latest follow-up. The 2-year patient survival rate was 50%.
BACKGROUND: Under certain conditions it is standard practice to excise ununited humeral condyles during insertion of a semiconstrained total elbow prosthesis. Since the osseous origins of the common extensors and flexor-pronator muscles are lost, it has been postulated that this excision has a negative effect on strength. We are not aware of any previous study in which this issue has been investigated with use of standardized, objective testing of muscle strength. METHODS: We used objective testing to determine the effect of condylar resection on the muscle strength of the elbow, forearm, wrist, and hand in thirty-two patients who had undergone total elbow arthroplasty. To eliminate bias, the normal, contralateral limb served as the control, and all strength values are given as a percentage of the normal side. The humeral condyles were intact in sixteen patients and had been resected in the other sixteen. Patient demographics were similar in the two groups. RESULTS: There were no significant differences between the two groups with regard to strength of pronation (103% of the normal side in the group with intact condyles compared with 89% in the group with resection of the condyles; p = 0.40), supination (68% compared with 89%; p = 0.49), wrist flexion (66% compared with 56%; p = 0.46), wrist extension (75% compared with 65%; p = 0.40), or grip strength (83% compared with 72%; p = 0.40). There was also no difference between the two groups with regard to the Mayo Elbow Performance Score (79 points in the group with intact condyles compared with 77 points in the group with resection of the condyles; p = 0.67). CONCLUSIONS: Condylar resection has a minimal, clinically irrelevant effect on forearm, wrist, and hand strength and no effect on the Mayo Elbow Performance Score following total elbow arthroplasty. Thus, the findings of our study support the practice of condylar resection, which simplifies total elbow arthroplasty for many conditions.
The elective free microvascular cross-hand transfer of the right hand to the left distal carpus was successfully performed in a 35-year old professional photographer. Traumatic loss of the left hand with preservation of a useful thumb and concomitant right upper extremity injury leaving the right hand with an amputated thumb, but paralyzed and insensate from a brachial plexus palsy 5 years before transfer, set the stage for such a reconstruction. Multiple immediate tendon transfers and primary nerve grafting provided for finger flexion and extension plus functional sensibility in this first reported case of an elective cross-hand microvascular transfer. Five years follow-up demonstrates useful and powerful flexion, and functional extension of digits in the reconstructed left hand and right upper extremity function has been improved with a below-elbow prosthesis.
The Bunnell Traveling Fellowship was established in 1982 with the purpose of sponsoring a young hand surgeon in the development of national and international relationships that contribute to his/her pursuit of higher learning and that foster the principles of scholarship of the American Society for Surgery of the Hand. I was fortunate to be selected as the 24th Sterling Bunnell Fellow, and I had the opportunity to follow in the footsteps of the 23 former fellows. In Bunnell's Surgery of the Hand, Fourth Edition (Boyes JH, ed. Philadelphia, Lippincott; 1964:561-567), a man with a brachial plexus injury was described. The recommended treatment was shoulder arthrodesis and transhumeral amputation, followed by fitting of an above-elbow prosthesis. Sterling Bunnell has been quoted as saying, "To someone who has nothing, a little is a lot." Nowhere in the field of hand surgery is this more true than in patients with brachial plexus injuries. The theme and purpose of my traveling fellowship was to evaluate the status and advances of adult brachial plexus surgery throughout the world, to determine the utility of the contralateral C7 nerve transfer, to evaluate the optimal reconstruction of grasp, and finally to determine the philosophies of experts around the world regarding the treatment of these patients.
In traumatic forearm amputation, if replantation is not indicated or possible, then adequate forearm length preservation is desirable to allow use of a below-elbow prosthesis. A case is presented in which forearm replantation was not done, but forearm length was preserved by use of a palmar skin free microvascular flap.
A particularly short traumatic amputated forearm finally led to a simplified under-elbow prosthesis after a long surgical program including: 1) A progressive 8 cm ulnar lengthening with a Wagner device; 2) and a secondary groin flap resurfacing the distal stump. Complications essentially concerned the ulnar lengthening particularly because of a weak osseous callus. Final aesthetic and functional results are satisfying with a 6 years follow-up.
Microsurgical transfer of a skin flap salvaged from a nonreplantable upper extremity that would otherwise be discarded may provide essential soft-tissue coverage of the amputation stump, so maintaining a functional range of motion in the elbow joint. A radial forearm free flap measuring 24 cm long by 9 cm wide was salvaged from the degloved forearm skin of a patient who sustained a proximal forearm amputation that was considered unsuitable for replantation. This allowed coverage of the proximal radius and ulna, preservation of a functional elbow joint, and successful fitting of a below-elbow prosthesis.
The history is presented of a 21-year-old woman with an osteoclastoma (giant cell tumour) which was treated with total local excision and an elbow prosthesis. A 5-year follow-up report, the problems of treatment and the different grades of malignancy, are discussed briefly, and the value of histological grading is shown.
Experiments were conducted to determine whether any observable short-term biological effects were caused by a static magnetic field created with CoSm magnets similar to those used in the elbow prosthesis described on pages 69-80. Tissue culture studies of several cell lines showed no obvious effects on cell growth rate, morphology, or the ability to grow and remain confluent; and no deleterious effects of the magnetic field were evident as a result of an in-vivo study of wound and bone healing in rats. Long-term effects, if any, have yet to be determined.
A nine year old girl with a congenital above-elbow amputation was supplied with a myoelectrically controlled arm prosthesis at the Regional Hospital, Orebro, Sweden, in May 1978. The prosthesis was equipped with an artificial hand as well as an elbow joint. The latter was designed at New York University, for switch control but adapted to myoelectric control in the Department of Clinical Neurophysiology at the Regional Hospital, Orebro. The electric signals from the biceps and triceps muscles were used for the control of hand closing and opening as well as elbow flexion and extension. Two different control methods have been applied and clinically tested. The first is a three-level method in which slight contraction of biceps/triceps gives closing/opening motions of the hand and a higher contraction level in these muscles gives flexion/extension of the elbow. The second is a contraction-rate detection method in which slow contraction of biceps/triceps gives closing/opening of the hand and faster contraction of these muscles gives flexion/extension of the elbow. Both methods have been tested on the patient in a laboratory set-up and in a clinical trial which is still going on. Small electronic control circuits have been designed and placed inside the socket of the prosthesis, which is completely self contained. From the different tests performed, the second control method seems to be the most suitable for the actual patient. She is using her prosthesis every day, continuously improving her controlling ability.
A stainless-steel or titanium prosthetic replacement for the trochlea and capitellum was developed and used in ten elbows, five with post-traumatic lesions, three with rheumatoid arthritis, and two with ankylosis secondary to hemophilia. After followups of from one to seven years, the results were found to be unpredictable or poor in the patients with inflammatory arthritis or hemophilia, while a stable, painless elbow with a functional range of motion was achieved in four of the five patients with post-traumatic lesions.
The place of the myo-electric prosthesis in below-elbow amputees has been reviewed. Forty-three patients were seen and all possessed both a myo-electric prosthesis and a standard artificial limb. Nearly half the patients used the newer device almost all the time at work and many of these wore it for the majority of their waking hours. Its use at work was mainly related to the patient's type of job and here in turn there was concern about damaging the device. It is suggested that acceptance would be further increased if greater attention were paid to the durability of the arm and its glove. Criteria for prescription and future developments are discussed.
From March 1966 to June 1985, 9 patients with humerus malignant tumor were treated by en-bloc resection and immediate reconstruction. There were 5 males and 4 females. The ages ranged from 18 to 74 with an average of 38.3 years. These 9 lesions were diagnosed by pathology as malignant giant cell tumor of the bone (2), chondrosarcoma (2), reticulum cell sarcoma (1), osteoblastoma (osteosarcomatous) (1), osteogenic sarcoma (1) and metastatic cancer (1) clear cell cancer and 1 thyroid cancer), located either in the upper or lower end of the humerus. Cutting margin was 4-7 cm from the tumor. The length of resected humerus was 10-18 cm. Simple excision without reconstruction was done only in 1 patient. The bone defect after resection was reconstructed with autogenous fibular graft in 3 patients, replantation of the limb in 2, one of whom was added with prosthesis for reconstruction of the elbow function, humerus prosthesis in 2 and elbow prosthesis in 1. All the patients were followed. Only two had died and 7 are still alive without evidence of disease. The longest survival was 20.5 years and the shortest, 18 months with an average of 10.1 years. The causes of death (1 osteoblastoma and 1 osteogenic sarcoma) were recurrence and lung metastasis. The indication, extent of excision and causes of recurrence are discussed.
The usefulness of wisely prescribed powered components in the rehabilitation of upper extremity amputees has long been recognized (Schmidl, 1973). Their value is especially evident in the prosthetic rehabilitation of high level adult and child amputees (Heger et al, 1985). In recent years, manufacturers of prosthetic hardware have provided practitioners with a wide selection of either myo-electrically or switch controlled electromechanical components and systems. As a rule, however, most commercially available components are designed to serve the adult amputee and do not lend themselves for use in the prosthetic rehabilitation of children. One current exception is the availability of child-size electric hands. The availability of the world's first child-size electric hand in 1970 at the Ontario Crippled Children's Centre later known as the Variety Village 105 hand, gave tremendous impetus to the fitting of younger children with externally powered components and myoelectric control systems. However, this trend served to benefit the young below-elbow patient only (Sorbye et al, 1972). The successful fitting of higher amputation levels in this age group stopped at the elbow level. Existing artificial elbows such as the Variety Village and Hosmer elbow with their necessary powerpacks are simply too bulky and too heavy for pre-school age children. The need for a lightweight compact electric elbow, suitable for 3-8 year old children, still has not been addressed. This single case report illustrates an innovative and successful conversion of a 6-3/4 Otto Bock hand into a small electric elbow. The idea was first proposed by Schmidl (1973).
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PURPOSE OF THE STUDY: We report a retrospective analysis of 16 patients with rheumatoid arthritis treated with a total humero-ulnar and humero-radial GUEPAR prosthesis (GIII). MATERIAL AND METHODS: The GUEPAR III elbow prosthesis is an anatomic polyethylene-metal gliding prosthesis designed to maintain physiological valgus. Right and left models are available in two sizes. On the humero-ulnar side of the prosthesis, was associated with a radial head, born on an intramedullary metallic stem, that can be fit with several sizes of mobile polyethylene cups. The 16 GIII prostheses were implanted in 1997 to 2001 in accordance with the manufacturers instructions. Mean follow-up was 2 years. RESULTS: Before surgical treatment, all patients had moderate or severe but invalidating pain. The Mayo Clinic score was 33 points. The Larsen radiographic score was grade III (7 elbows) or grade IV (9 elbows). Patients were reassessed 1 to 5 years after implantation of the GIII (mean follow-up 2 years). At last follow-up the mean Mayo Clinic score had improved from 33 to 90 points. Outcome was considered excellent for 15 elbows and fair for 1. DISCUSSION: We review the indications for total elbow arthroplasty in patients with rheumatoid arthritis. Semi-constrained prostheses are useful and necessary for the treatment of elbows exhibiting massive destruction, but the use of minimally constrained prostheses such as the GUEPAR III is becoming increasingly widespread. We use the GUEPAR III for 70% of our patients, particularly those with rheumatoid arthritis.
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