Nieuwsbrief 2009 - 001 : Extremiteiten

Comparison of perioperative complications in patients with and without rheumatoid arthritis who receive total elbow replacement

Health status as an important outcome factor after hemiarthroplasty

Total shoulder arthroplasty in patients with Parkinson's disease

The effect of the long head of the biceps on glenohumeral kinematics

Cross-linked glenoid prosthesis: A wear comparison to conventional glenoid prosthesis with wear particulate analysis

The anatomy of the deltoid insertion

Comparison of perioperative complications in patients with and without rheumatoid arthritis who receive total elbow replacement

JSES , Volume 18, Issue 1, Pages 21-26 (January 2009)

Koroush Kabir, MDa

Summary

Total elbow replacement is a well-recognized surgical treatment for patients with advanced rheumatoid arthritis (RA) of the elbow. At present, there is minimal literature outlining the perioperative complications associated with total elbow replacement. We endeavored to identify complication rates and hospital disposition differences between patients with and without RA who received a total elbow replacement. Data from the Nationwide Inpatient Sample was used to capture 3,617 patients who received a total elbow arthroplasty between 1988-2005. Of these, 888 had a primary diagnosis of RA and were compared against patients without RA. Analyses addressed perioperative complications and hospital disposition factors, such as charges and length of stay.

Overall complication rates were very low with only 2 variables, respiratory complications (P = .01) and renal failure (P = .04) demonstrating significantly worse outcomes in patients without RA (P = .01). Patients without RA had also had longer lengths of stay (P < 0.01). There were 9 reported perioperative deaths. The findings suggest that the perioperative complications of a total elbow replacement for all patients studied are few and that outcomes in patients with RA are nearly equivalent to those in patients without RA.

Health status as an important outcome factor after hemiarthroplasty

JSES, Volume 18, Issue 1, Pages 75-82 (January 2009)

Christof Burger, MDa, Philipp Fischera, Oliver Weber, MDa, Andreas Florczyk, MDb, Hans Goost, MDa, Christoph Rangger, MD

Summary

The goal of this study was to determine functional results of hemiarthroplasty for 3- and 4-part proximal humeral fractures in elderly patients and to analyze factors affecting the outcome. Thirty-eight consecutive shoulders were treated with hemiarthroplasty after proximal humeral fracture. Two groups of patients with different health status were classified. Group I consisted of patients with 2 or less comorbidities and a maximum of 2 medications at the time of injury.

Patients in group II had 3 or more comorbidities with a minimum of 3 medications at the time of injury. The mean of the absolute Constant score in group I was 41, compared to 27 in group II (P < .05). Furthermore, compliance of the patient and regular physiotherapy proved to be important prognostic factors. If primary hemiarthroplasty is not likely to be successful with a low functional score, this surgical procedure should be reconsidered especially in patients with more than three comorbidities.

Total shoulder arthroplasty in patients with Parkinson's disease

Journal of Shoulder and Elbow Surgery, Volume 18, Issue 1, Pages 96-99 (January 2009)

Thomas J. Kryzak, MD, John W. Sperling, MD, Cathy D. Schleck, BSc, Robert H. Cofield, MD

Summary

Currently, there is little information available on the results of total shoulder arthroplasty (TSA) in patients with Parkinson's disease. The purpose of the current study was to determine the results, risk factors for an unsatisfactory outcome, and rates of failure of TSA in patients with Parkinson's disease. Between 1978 and 2005, 49 total shoulder arthroplasties were performed in patients with Parkinson's disease for osteoarthritis of the shoulder.

Forty-three shoulders (36 patients) were followed for a minimum of 2 years (mean, 8 years) or until the time of revision surgery. Total shoulder arthroplasty in patients with Parkinson's disease was associated with significant improvement in pain from 4.6 to 1.8 (P < .001), external rotation from 21° to 44° (P < .001), and active abduction from 100° to 119° (P = .0489). There was no significant improvement in internal rotation (P = .09). There was no significant difference in outcome between males and females nor was there an association with stage of Parkinson's disease and outcome (P > .05).

Eight shoulders underwent revision arthroplasty. Three of the 8 revisions were performed less than 1 year from the time of surgery due to instability. Total shoulder arthroplasty is associated with significant long-term improvement in pain, external rotation, and abduction in patients with Parkinson's disease. However, early postoperative instability appears to be higher in this patient population. The results of TSA in our patients with Parkinson's disease were marginal, with 20 (47%) achieving unsatisfactory results.

The effect of the long head of the biceps on glenohumeral kinematics

Journal of Shoulder and Elbow Surgery, Volume 18, Issue 1, Pages 122-129 (January 2009)

Neal S. ElAttrache, MDb, James E. Tibone, MDc, Michelle H. McGarry, MSd, Thay Q. Lee, PhDd

Summary

The long head of the biceps has been described as a stabilizing force in the setting of glenohumeral instability. However, data are lacking on the effect of loading the long head of the biceps on glenohumeral kinematics. Six cadaveric shoulders were tested for glenohumeral rotational range of motion and translation using a custom shoulder testing system and the Microscribe 3DLX (Immersion, San Jose, CA). The path of glenohumeral articulation (PGA) was measured by calculating the humeral head center with respect to the glenoid articular surface at maximal internal rotation, 30°, 60°, 90°, and maximal external rotation.

Significant decreases in glenohumeral rotational range of motion and translation were found with 22-N biceps loading vs the unloaded group. With respect to the PGA, the humeral rotation center was shifted posterior with biceps loading at maximal internal rotation, 30°, and 60° of external rotation. Loading the long head of the biceps significantly affects glenohumeral rotational range of motion, translations, and kinematics.

Cross-linked glenoid prosthesis: A wear comparison to conventional glenoid prosthesis with wear particulate analysis

JSE surgery, volume 18, Issue 1, pages 130-137 (January 2009)

Conrad Klotz, BS, MBAb, Daren L. Deffenbaugh, MSb, Don McNulty, MS, PEb, Laura Richards, BEngc, Joanne L. Tipper, PhDc

Summary

Wear debris has been observed in shoulder arthroplasties that use an ultrahigh–molecular weight polyethylene (UHMWPE) glenoid component, and the biologic response to this debris contributes to aseptic loosening of the implant. The objective of this study was to assess the wear and particle morphology of a cross-linked UHMWPE prosthetic glenoid. To our knowledge, this is the first time a simulator with kinematic considerations for assessing wear has been used in a shoulder model.

Shoulder wear testing was conducted on 2 groups of glenoids (n = 3 in each group) by use of an orthopaedic joint simulator to create worst-case scenario motions. One group was manufactured from conventional UHMWPE. The second was manufactured from 50-kGy cross-linked UHMWPE. The resulting wear rates for the conventional and cross-linked glenoid components were 46.7 ± 2.6 mg/million cycles and 7.0 ± 0.4 mg/million cycles, respectively. Particles isolated from the 2 groups showed similar morphologies; however, the calculated osteolytic potential of the cross-linked glenoid was significantly lower. The results of this study support the use of cross-linked UHMWPE glenoids in clinical applications.

The anatomy of the deltoid insertion

Journal of Shoulder and Elbow 2008 10.12, Volume 17

George S. Athwal, MD, John W. Sperling, MD, Robert H. Cofield, MD

summary

Deltoid muscle integrity is critical to shoulder function. The deltoid insertion, however, is often partially released during surgical approaches for internal fixation of proximal humerus fractures and shoulder arthroplasty. The purpose of this study was to evaluate the clinically relevant anatomy of the deltoid insertion. Ten fresh-frozen upper extremity cadaveric specimens were dissected to determine the insertional anatomy of the deltoid muscle. Measurements were made with micro-calipers and acetate grid sheets. The deltoid tendon and fibrous aponeurosis were in continuity with the lateral intermuscular septum posteriorly and the lateral aspect of the brachialis and deep brachial fascia anteriorly in all 10 specimens.

This interconnection remained in continuity following complete release of the deltoid insertion. The width of the insertion of the anterior head of the deltoid was a mean of 7.3 mm, the middle averaged 4.7 mm, and the posterior averaged 7.8 mm. The mean length of the anterior insertion was 70 mm, the middle was 48.4 mm, and the posterior was 63.4 mm. The mean width of the deltoid tendon and the investing fascia at the superior margin of the insertion was 21.9 mm and at the inferior margin 13.1 mm. Partial detachment without repair, as performed during surgical approaches, should not result in complete loss of continuity of the deltoid insertion. Knowledge of the insertion and interconnections of the deltoid permits a more anatomic repair following extended release during complex fracture fixation or revision surgery.