To show the role and effectiveness of semi-constrained total elbow arthroplasty in restoring elbow function in severe, irreversible post-traumatic osseous and chondral injuries. Eighteen patients, aged 19–80, 11 male and 7 female, suffering from serious, irreversible anatomical and functional lesions of the elbow joint due to previous severe untreated or inadequately treated fractures (T-type transcondylar, trochlear-condylar, open fxs with large bony defects, severe osteochondral, heterotopic ossification in ICU fracture patients). Postop follow up was 9–57 months. All patients were treated with modular, cemented, semi-constrained linked total elbow arthroplasty. A functional brace was used post-operatively, and motion was permitted on the 3rd post-op day. The patients were allowed a full range of motion at 1 week post-op and they were subjected to vigorous physiotherapy. Post-op results were evaluated by using Mayo, DASH, quick-DASH scores and measuring grip strength and range of motion. Our results ranged from satisfactory to excellent in 16 patiens, with good strength and wide motion arc (with up to 15o extension-flexion deficit). One old female patient suffered a severe cerebral stroke with a bad outcome. In another young male patient the motion arc reached only 40% of the normal (spasticity, ICU patient with brain injury). Semi-constrained linked total elbow arthroplasty proves to be an effective method of treatment in severe, irreversible, intraarticular post-traumatic elbow injuries with chondral destruction and grave functional deficit, provided the proper technique is employed and a vigorous rehabilitation program is followed.
We prove the importance of the complete osteoligamentary elbow reconstruction and the usefulness of the liga-mentoplasty by palmaris longus combined with other procedures in complex elbow unstable injuries. 17 patients aged between 17 and 72 suffered elbow luxation or subluxation with rupture of the medial collateral ligament, associated with:
Fracture of the radius head, fracture of the coronoidal process(terrible triade),1) olecranon fractures. In 3 compaound injuries we had open fractures with Brahial artery lesion, Ulnar nerve pulsy, radial nerve laceration, Brahial plexus injury. The lesions happened between 2 hours and 2 yrs pre-operatively, caused to work accidents or to traffic accidents with a follow up between 8–62 months. 10 of the injuries were operated almost in emergency by ligamen-toplasty with palmaris longus, coronoidal process fixation with screw or ancor, radial head osteosynthesis or prosthesis. The vascular injuries urgently operated while the nerve lesions left for secondary repair. A functional splint was applied postoperatively, initially fixated between 110–85 degrees. The splint removed 2 months postoperatively, while full rang of motion obtained. We performed both Mayo clinic, DAS scores and grasp strength force and Range of Motion measurement evaluation procedures Satisfactory to excellent results have been obtained in 11 cases with stable joints and range of motion with 20 degrees extension-flexion deficit while in I case the instability persited, in another one arrived 50% of the normal range of motion. The complex elbow injuries with ligamentary instability are effectively treated if except fractures we always repair The medial-anterior ligaments lesion with liga-mentoplasty and ancors.
All patients were operated by ligamentoplasty with palmaris longus by medial incision, fenestration of the medial epicondyl and olecranon and transoseus pivoting of the palmaris longus which was enforced by 2 anchor sutures. An elbow flexion-extension functional splint was applied postoperatively, initially fixated between 110–85 degrees. The splint was removed 2 months postoperatively, while full rang of motion has been obtained.
All traumatic cases happened almost 2 weeks before operation except three which caused between 2 and 6 months earlier. In the 2 diabetic cases the lesion appeared between 3 and 5 month ago. We have performed: 9 sural flaps, 5 perforator-posterior tibial artery flap, 1 medial plantar, 4 based on distal perforators of the peroneal artery, 1 Saphenous, 2 muscular flaps. All patients were between 17 and 81 years all and the follow up between 8 month and 2 years. Everywhere before the flap we performed surgical debridement. As supplementary combined reconstructive technique we performed: 1. Mega papineau technique, 2. Bone filling, 3. Distraction osteogennesis, with spatial Taylor frame.
These flaps are better tolerated by the patient than the traditional techniques and safer, less demanding and faster to perform than the free tissue transfers.
The axillary nerve injuries most commonly are observed after trauma such as contusion-stretch, gunshot wound, laceration and iatrogenic injuries. Two of the most commons causes seem to be the glenohumeral dislocation and the proximal humerus fractures. The axillary nerve may sustain a simple contusion, or its terminal elements may be avulsed from the deltoid muscle. Compressive neuropathy in the quadrilateral space also has been reported (quadrilateral space syndrome, Calhill and Palmer, 1983). The axillary nerve injuries incidence represents less than 1% of all nerve injuries.
Patients were operated between 3 to 6 months after trauma and an anterior deltopectoral approach was usually followed during surgery. The follow up period ranged from 1 to 8 years.
The purpose of this study was to evaluate the results of the surgical treatment of the thoracic outlet syndrome. Between 1990–2002, 46 patients, 15 male and 31 female aged ranging from 23 to 49 years old (mean age 34 years) underwent decompressive surgery of the thoracic outlet syndrome. Some 9 patients required bilateral operations. Symptoms due to compression of neural elements were present in 23 patients, of vascular elements in 12 patients and of both elements in 11 patients. The duration of symptoms was less than 2 years in 25 patients and 2 to 6 years in 21 patients. Operations consisted of scalenectomy in 47 cases with brachial plexus neurolysis for neurogenic indication, release of the pectoralis minor muscle insertion in 5 cases and cervical rib resection in 3 cases. The follow up period ranged from 1 to 12 years (mean 5 years). The results were classified as excellent with symptoms elimination in 27 cases, good with symptoms significant improvement in 19 cases and poor with symptoms persistent or aggravation in 9 cases. First rib resection in 4 patients with poor results and release of the pectoralis minor muscle insertion in 1 patient leaded to significant improvement of their symptoms. Some 90% of patient with symptoms less than 2 years had a successful result compared with only 76% in those with symptoms longer than 2 years. Complications included pneumothorax in one case and temporary phrenic nerve palsy in another case. A selective surgical decompression of the thoracic outlet syndrome yields satisfactory results in appropriately selected patients.
