Purpose: Loosening remains a problem with semi-constrained total elbow prostheses. The trend in recent years has been to improve prosthesis design to achieve stability of the humeral implant. We report a small series of nine Coonrad-Morrey total elbow prostheses where three early loosenings were observed in the ulnar implant. We attempt to analyse the causes and present a review of the recent literature.

Material and methods: Nine patients, mean age 60 years, age range 57–63 years, underwent total elbow arthroplasty with a Coonrad-Morrey prosthesis for rheumatoid disease (n=5), stiff degenerative joints after trauma (n=3, flexion-extension 20°), floating joint after trauma (n=1). The posterolateral approach described by Bryan and Morrey was used for eight elbows and the posterior approach for one. Clinical and radiological results were assessed with the performance index and the Mayo clinic score respectively.

Results: Mean follow-up was 3.6 years (1.5–4.7). Outcome was very good or good for seven elbows (score > 75 and > 50), fair for one (< 50) and poor for one (< 25). Three elbows were pain free, two presented pain during movement against force. Flexion was greater than 120° in four elbows (all four rheumatoid polyarthritis). Radiologically, we observed three cases of ulnar implant loosening with two type IV lucent lines, and one type III line. There was one humeral implant with a lucent line which did not change over time (type I). The two cases of type IV lines were associated with radial and anterior translation migration of the prosthetic stem with effraction or lysis of the ulnar cortical. The three ulnar loosenings appeared between the second and third postoperative year on two post-trauma stiff degenerative elbows (flexion-extension < 20°) and one rheumatoid elbow. At last follow-up, there was one poor result requiring revision surgery, one fair result, and one very good result (totally asymptomatic type 4 lucent line).

Discussion: The causes of these loosenings were studied: difficult cementing technique in a tight canal, mediocre primary stability of the ulnar implant opposing the excellent fit of the humeral implant with an encased graft under the anterior wing, excessive constraint. Our results are similar to those reported by Hilebrand who had 30% evolving ulnar lucent lines and suggest that we should reserve this prosthesis for unstable elbows.

Purpose : Compartment syndrome is a serious complication common to all trauma victims and may be life-threatening after fracture of the femur or require amputation after fracture of the lower leg. We report our experience with six cases and attempt to identify clinical signs suggestive of this severe complication.

Material and methods: This series included four fractures of the leg and two fractures of the femur. The leg fracture victims constituted a heterogeneous group. Their mean age was 39.5 years, range 24 – 54 years. These four women had one transverse fracture, one short oblique fracture, one isolated fracture of the tibia, and one comminutive fracture. Two of the fractures were open (grade 1 and 2). There were three low-energy fractures and one high-energy fracture. The femur fracture victims exhibited more similarity. These two young patients (18 and 20 years) both had a closed, high-energy, comminutive fracture.

Results: For the leg fractures, the diagnosis of compartment syndrome was suggested in three patients by postoperative pain refractory to medical treatment. Tension in the compartment was the inaugural sign in the other patient. Diagnosis was confirmed by pressure measurements which exceeded 45 mmHg in all cases and reached 60 mmHg in one. The anterior compartment was involved alone in three patients and all three compartments in one. Time to diagnosis ranged from 1 to 12 hr. Two patients underwent surgery within six hours and cured without sequelae. Anterior tibia palsy developed despite aponeurotomy before six hours in the patient with a peak pressure of 60 mmHg. The fourth patient developed severe sequelae with anaesthesia of the foot, anterior and posterior tibial palsy, and infected non-union of the leg bones.

For the femur fractures, diagnosis was suggested by high tension in the anterior compartment confirmed at pressure measurement: 60 and 70 mmHg. Rapid reduction in pressure was followed by signs of muscle necrosis in one patient. Aponeurotomy performed rapidly in the other patient did not prevent motor deficit involving the popliteal branches.

Discussion: Pressure monitoring should be performed systematically in patients with leg fractures, irrespective of the type of fracture or the causal mechanism. Pressure monitoring should also be a routine practice in patients with high-energy fracture of the femur. Outcome depends on two important factors: the level of the pressure peak and the duration of high pressure.