Revision arthroscopic contracture release in the elbow resulting in an ulnar nerve transection: surgical technique

The Olecranon Osteotomy-Facilitated Elbow Release (OFER)

BACKGROUND

Elbow contractures can cause functional limitation, and treatment can be challenging. The purpose of this article is to describe a novel technique that releases posttraumatic elbow contractures through an olecranon osteotomy and report the outcomes.

METHODS

Thirty-five patients with refractory posttraumatic elbow contracture who underwent an olecranon osteotomy-facilitated elbow release (OFER) procedure were included in the study. The average patient age was 39.5 years (range, 18 to 63 years), and the mean duration of follow-up was 37.2 months (range, 24 to 72 months). Preoperative and postoperative data included age, sex, cause of contracture, previous surgical procedures, active elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, visual analog scale pain scores, and radiographs. Intraoperative tourniquet time and complications were recorded.

RESULTS

The mean preoperative elbow motion arc was 33° (51° to 84° of flexion). Postoperatively, the motion arc improved significantly (p < 0.001) to 110° (16° to 126° of flexion). The mean visual analog pain scale score improved from 6.3 preoperatively to 1.4 at the time of follow-up (p < 0.001). The mean DASH score improved from 57.5 preoperatively to 10.9 postoperatively (p < 0.001). The maximal improvement in the motion arc occurred at a mean of 8.7 weeks. There was 1 postoperative ulnar neurapraxia that resolved spontaneously. The intraoperative tourniquet time averaged 27 minutes (range, 18 to 45 minutes). The average time until radiographic evidence of union of the olecranon osteotomy site was 6.6 weeks (range, 5.7 to 7.7 weeks).

CONCLUSIONS

The OFER is a safe and effective means of treating posttraumatic elbow contractures, and is an alternative to traditional open or arthroscopic techniques.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Tips to avoid nerve injury in elbow arthroscopy

Elbow arthroscopy is a technical challenging surgical procedure because of close proximity of neurovascular structures and the limited articular working space. With the rising number of elbow arthroscopies being performed nowadays due to an increasing number of surgeons performing this procedure and a broader range of indications, a rise in complications is foreseen. With this editorial we hope to create awareness of possible complications of elbow arthroscopy, particularly nerve injuries, and provide a guideline to avoid complications during elbow arthroscopy.

The effect of a manufacturer recall on the threshold to revise a metal-on-metal hip

PURPOSE

Management of the unexplained, painful large diameter metal-on-metal (MOM) hip replacement is difficult. Although there are guidelines for surgeons, there is no clear documented evidence describing the overall threshold for revision surgery. The 2010 product recall of the DePuy Articular Surface Replacement (ASR) and subsequent media coverage may have increased patient and surgeon apprehension, resulting in earlier intervention, i.e. at a greater Oxford hip score (OHS) than expected. Our aim was to investigate whether the threshold for revision using known parameters was affected by the ASR recall. These parameters include poor clinical results (persistent pain or mechanical symptoms), pseudotumour or other progressive soft tissue involvement, osteolysis and high or rising metal ion levels.

METHODS

We used our national referral database of MOM hips, which were revised between 2008 and 2012. Once inclusion and exclusion criteria were applied, we identified 240 patients--71 patients in the pre-recall group and 169 patients in the post-recall group.

RESULTS

The ASR product recall did not seem to affect the threshold for revision of a MOM hip, with no significant difference between the two groups in terms of the functional (median OHS = 17 pre-recall and 20 post-recall; p = 0.2109) and radiological (median inclination angle = 50 pre-recall and 48 post-recall; p = 0.3221) markers used to guide management. We did however discover that blood metal ion levels were higher in the post-recall group.

CONCLUSION

Issue of a product recall did not change the hip function threshold for revision surgery. The decision to revise a metal-on-metal hip is complex and should follow published guidelines, encompassing metal ion measurement and cross-sectional imaging where appropriate.

The Canadian Arthroplasty Society’s experience with hip resurfacing arthroplasty

The purpose of this study was twofold: first, to determine whether the five-year results of hip resurfacing arthroplasty (HRA) in Canada justified the continued use of HRA; and second, to identify whether greater refinement of patient selection was warranted.

This was a retrospective cohort study that involved a review of 2773 HRAs performed between January 2001 and December 2008 at 11 Canadian centres. Cox’s proportional hazards models were used to analyse the predictors of failure of HRA. Kaplan–Meier survival analysis was performed to predict the cumulative survival rate at five years. The factors analysed included age, gender, body mass index, pre-operative hip pathology, surgeon’s experience, surgical approach, implant sizes and implant types. The most common modes of failure were also analysed.

The 2773 HRAs were undertaken in 2450 patients: 2127 in men and 646 in women. The mean age at operation was 50.5 years (sd 8.72; 18 to 82) and mean follow-up was 3.4 years (sd 2.1; 2.0 to 10.1). At the last follow-up a total of 101 HRAs (3.6%) required revision. Using revision for all causes of failure as the endpoint, Kaplan–Meier survival analysis showed a cumulative survival of 96.4% (95% confidence interval (CI) 96.1 to 96.9) at five years. With regard to gender, the five-year overall survival was 97.4% in men (95% CI 97.1 to 97.7) and 93.6% in women (95% CI 92.6 to 94.6). Female gender, smaller femoral components, specific implant types and a diagnosis of childhood hip problems were associated with higher rates of failure. The most common cause of failure was fracture of the femoral neck, followed by loosening of the femoral component.

The failure rates of HRA at five years justify the ongoing use of this technique in men. Female gender is an independent predictor of failure, and a higher failure rate at five years in women leads the authors to recommend this technique only in exceptional circumstances for women.

Cite this article: Bone Joint J 2013;95-B:1044–50.