Functional Arc Of Motion Research Articles

Flexor Tendon Reconstruction

Chronic injury to the flexor tendon system of the hand remains a challenging problem for the hand surgeon to treat. Both single- and two-stage techniques remain important in the reconstruction of the flexor tendon deficient digit. Modern advances include the use of allograft composites that aim to reduce the time and donor-site morbidity compared with conventional autograft techniques. Regardless of technique, restoring a gliding tendon-pulley system with a functional arc of motion is the primary goal of flexor tendon reconstruction.

Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5years.

The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft. A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor. A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients. LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.

Improved mediolateral load distribution without adverse laxity pattern in robot-assisted knee arthroplasty compared to a standard manual measured resection technique

PurposeRobot-assisted total knee arthroplasty (rTKA) remains in its infancy, is expensive but offers the promise of improved kinematic performance through precise bone cuts, with minimal soft tissue disruption, based on pre-resection soft tissue behaviour. This cadaveric study examined load transfer, soft tissue performance and radiographic indices for conventional (sTKA) versus rTKA. The null hypothesis was there would be no difference between the two modes of implantation.MethodsWhole (ten) cadaveric limbs were randomised to receive either robotic (rTKA, N = 5) or conventional measured resection (sTKA, N = 5) knee arthroplasty. Laxity patterns were established using validated fixed sensors (Verasense) with manual maximum displacement for six degrees of freedom. Tibiofemoral load and contact points were determined dynamically using remote sensor technology for medial and lateral compartments through a functional arc of motion (0–110 degrees of motion). Final component position was assessed using pre- and post-implantation CT.ResultsNo significant intergroup differences for laxity were found (n.s.). The rTKA group exhibited consistently balanced mediolateral load throughout the full arc with significantly reduced overall total load across the joint (for distinct points of measurement, p < 0.05). Despite using flexion–extension and mediolateral gap balancing with measured resection, the sTKA group failed to achieve balance in at least three points of the flexion arc. Post-operative CT confirmed satisfactory component alignment with no significant differences for positioning between the two groups.ConclusionThis work found improved load sharing for rTKA when compared to conventional surgery for same donor knees. Laxity and CT determined final component positioning was not significantly different. The work supports the contention that robot-assisted TKA delivers improved tibiofemoral load sharing in time zero studies under defined conditions but such offers the promise of improved clinical performance and reduced implant wear.

Team Approach: Elbow Contracture Due to Heterotopic Ossification

➢ The elbow is prone to the formation of heterotopic ossification after trauma. Elbow contracture due to heterotopic ossification leads to compromised range of motion and disabilities in performing daily activities.➢ The treatment of elbow contracture is challenging and requires a multidisciplinary assessment.➢ Nonoperative treatment is appropriate for patients within 6 months after the injury to counter the progressive loss of motion during the maturation of heterotopic bone.➢ Operative intervention is indicated if the functional arc of motion cannot be maintained.➢ Open arthrolysis combined with heterotopic excision, ulnar nerve decompression and transposition, and application of a hinged external fixator are effective interventions for improving elbow function.➢ A prolonged and rigorous rehabilitation protocol after elbow release is important for preserving the arc of motion achieved during surgery.

Outcomes of Primary Reverse Shoulder Arthroplasty for Dislocation Arthropathy

Background Proper soft tissue balance is paramount to maintaining stability and a functional arc of motion in shoulder arthroplasty but is impaired in patients with prior glenohumeral (GH) dislocations. The purpose of this study was to determine the clinical outcomes, revisions, and complications of reverse shoulder arthroplasty (RSA) in patients with a history of glenohumeral dislocation. Methods Twenty-four patients with a history of GH dislocations that developed arthropathy underwent primary RSA from 2007 to 2013 were retrospectively reviewed. Mean follow-up was 3.3 years (2–7 years). Mean age was 70 years. Eight patients (33%) and 7 patients (29%) had complete or partial subscapularis deficiency, respectively. Results Twenty-two patients (92%) had little to no pain at final follow-up. Mean shoulder elevation improved from 48° to 120° ( P &lt; .001) and mean external rotation increased from 13.2° to 48° ( P &lt; .001). There were trends toward less complete pain relief and poorer motion in those with complete subscapularis deficiency. None of the patients experienced a postoperative dislocation or evidence of glenoid loosening at final radiographic follow-up, but 1 patient (4.2%) underwent early revision to a hemiarthroplasty for glenoid loosening. Conclusion RSA provides patients with prior glenohumeral dislocations a stable, pain-free arc of motion. Postoperative instability was not identified as a major failure mode at short-term follow-up. Complete subscapularis deficiency is a risk factor for poorer clinical outcome.

Long-term functional outcomes and knee alignment of computer-assisted navigated total knee arthroplasty.

This retrospective study examined the relationship between the mechanical axis throughout a functional arc of motion and functional outcome scores in patients undergoing computer-assisted navigation-based total knee arthroplasty (CAN-TKA) at 6-year follow-up. The Stryker eNact Precision Knee Navigation System was utilized to obtain pre- and postoperative alignment measurements throughout the functional arc of motion. Patients were contacted via telephone and asked to complete the Short Form-12 and Western Ontario and McMaster Universities, which have been demonstrated to be reliable, valid, and sensitive assessment tools in this patient population. Statistical analysis was performed to determine the correlation between arc alignment and patient-reported functional outcome measures. A total of 47 patients at a mean of 76.1 (±6.3)-month follow-up and mean age of 65.9 (±7.9) years were surveyed. No correlation was found between the postoperative alignment or degree of intraoperative correction and the functional outcome scores. In a planned subgroup analysis of patients with a mean functional arc alignment greater than 3° from neutral, mean intraoperative degree of correction correlated with decreasing physical function (Spearman's ρ=0.772, p=0.04) and mean postoperative arc alignment positively correlated with increasing stiffness (ρ=0.798, p=0.03). This study suggests that patients undergoing CAN-TKA with mean functional arc range of motion greater than 3° may be at increased risk for suboptimal patient-reported functional outcomes. This study also illustrates the ability of CAN-TKA to measure the varus or valgus alignment of the knee throughout the entire range of motion.

Tibiofemoral forces for the native and post-arthroplasty knee: relationship to maximal laxity through a functional arc of motion

Accurate soft tissue balance must be achieved to improve functional outcome after total knee arthroplasty (TKA). Sensor-integrated tibial trials have been introduced that allow real-time measurement of tibiofemoral kinematics during TKA. This study examined the interplay between tibiofemoral force and laxity, under defined intraoperative conditions, so as to quantify the kinematic behaviour of the CR femoral single-radius knee. TKA was undertaken in eight loaded cadaveric specimens. Computer navigation in combination with sensor data defined laxity and tibiofemoral contact force, respectively, during manual laxity testing. Fixed-effect linear modelling allowed quantification of the effect for flexion angle, direction of movement and TKA implantation upon the knee. An inverse relationship between laxity and contact force was demonstrated. With flexion, laxity increased as contact force decreased under manual stress. Change in laxity was significant beyond 30° for coronal plane laxity and beyond 60° for rotatory laxity (p<0.01). Rotational stress in mid-flexion demonstrated the greatest mismatch in inter-compartmental forces. Contact point position over the tibial sensor demonstrated paradoxical roll-forward with knee flexion. Traditional balancing techniques may not reliably equate to uniform laxity or contact forces across the tibiofemoral joint through a range of flexion and argue for the role of per-operative sensor use to aid final balancing of the knee.

Outcomes after surgical stabilization of chronic traumatic elbow dislocations

Background: Several surgical protocols have been described for reduction and stabilization of chronic, posttraumatic elbow dislocations. These are supported by small case series only, and treatment recommendations remain inconclusive. Our purpose was to evaluate the outcomes of surgical treatment in a series of chronic, posttraumatic elbow dislocations at our institution. Methods: We retrospectively reviewed the charts of all patients with chronic elbow dislocations treated with a stabilization procedure. We identified 10 patients (average dislocation duration 39.6 wk) with an average follow-up at our institution of 26 mo (4 to 55 mo). Results: Five women and five men with prior elbow dislocations (two simple, eight complex; five terrible triad, three Monteggia, two Essex-Lopresti) were included. Six patients had undergone one or more unsuccessful stabilization procedures at an outside hospital. At our institution, the patients were treated with a surgical stabilization protocol tailored to their injury. At final follow-up, eight patients had a stable, concentrically reduced elbow and regained a painless, functional arc of motion. Two patients with type III coronoid fractures that could not be reconstructed had recurrent dislocations. Six patients required medial collateral ligament reconstruction to maintain stability, suggesting that medial collateral ligament injury contributed to persistent elbow instability. Conclusions: In our series, a stable and painless elbow with a functional arc of motion was restored in eight of 10 patients with chronic elbow dislocations. The presence of a type III coronoid fracture increased the risk of failure. Level of Evidence: Level IV, Case Series.

Long-Term Results of Radial Head Resection Following Isolated Radial Head Fractures in Patients Younger Than Forty Years Old

In the past, radial head resection was the surgical treatment of choice for radial head fractures that could not be internally fixed. More recently, radial head implant arthroplasty has gained popularity for the treatment of isolated radial head fractures. The purpose of the present study was to review the long-term results of radial head resection after radial head fractures not associated with elbow instability in patients younger than forty years of age. Twenty-six patients younger than forty years of age who had sustained an isolated fracture of the radial head (including six patients who had sustained a Mason type-II fracture and twenty who had sustained a Mason type-III fracture) that had been treated with primary radial head resection were reviewed retrospectively at a minimum of fifteen years (mean, twenty-five years). Outcomes were evaluated according to the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand score. Radiographic assessment of osteoarthritic changes and the carrying angle was also performed. Twenty-one patients (81%) had no elbow pain, three had mild pain, and two had moderate pain. The mean arc of motion was from 9 degrees to 139 degrees of flexion. All but one patient had a functional arc of motion. The mean pronation was 84 degrees, and the mean supination was 85 degrees. Nineteen elbows had normal strength in comparison with the unaffected side. The mean Mayo Elbow Performance Score was 95 points; the score was classified as good or excellent for twenty-four elbows (92%) and as fair for two. The mean Disabilities of the Arm, Shoulder and Hand score was 6 points. Three patients complained of wrist pain, which was mild in two patients and moderate in one. In four patients, some degree of elbow instability could be detected on physical examination. The mean carrying angle of the involved elbow was significantly greater than that of the uninjured elbow (21 degrees compared with 10 degrees). Radiographic changes of arthritis were considered mild in seventeen elbows and moderate in nine. We could not detect significant differences in functional outcome on the basis of the degree of radiographic change. Radial head resection in young patients with isolated fractures without instability yields long-term satisfactory results in >90% of cases. Osteoarthritic changes are uniformly present but typically are not associated with functional impairment.

Joint Preservation of the Osteoarthritic Ankle Using Distraction Arthroplasty

In recent years ankle distraction arthroplasty has gained popularity in the treatment of ankle arthritis as a means of both maintaining range of motion and avoiding fusion. We present a retrospective review of 25 patients who have undergone ankle distraction from 1999 to 2006. The mean age was 43 years; 16 were male, and 7 were female. Followup was 30 months after frame removal (range, 12 to 60 months). We were able to obtain followup on 23 of 25 patients. Adjuvant procedures were performed in some cases including Achilles tendon lengthening (5), ankle arthroscopy (4), open arthrotomy (1), and supramalleolar tibial and distal fibular osteotomy to correct distal tibial deformity (6). Twenty-one patients (91%) reported improved pain with those furthest post-op experiencing the best results. The average preoperative AOFAS score was 55 (range, 29 to 82), and the average postoperative score was 74 (range, 47 to 96). The difference between pre- and postoperative scores was significant (p = 0.005). SF-36 scores showed modest improvement in all components. Only two of the patients in the study underwent fusion after ankle distraction. Total ankle motion was maintained in all patients with improvement in the functional arc of motion in five patients who started with mild equinus contractures. We feel that ankle distraction offers a promising solution for many people with ankle arthritis.

Fracture and nonunion of the olecranon in total elbow arthroplasty

While fracture and nonunion of the olecranon have been reported in patients undergoing total elbow arthroplasty, little information exists about the management and outcome of these cases. Twenty-four patients (twenty-five elbows) were studied; fifteen (sixteen elbows) with rheumatoid arthritis and nine with post-traumatic elbow disorders. Twenty-three of the twenty-five elbows presented with an olecranon fracture or nonunion prior to the reported arthroplasty. During arthroplasty the olecranon fragment was initially treated by tension band in sixteen elbows, excision in four, suture fixation in two and three with stable fibrous union were left alone. At an average follow-up of 66 months (range, 18 to 242), there were twelve excellent, nine good, three fair and one poor results. The mean pre-operative Mayo Elbow Performance Score improved from 42 (range, 20 to 62) points pre-operatively to 86 (range, 50 to 100) points post-operatively (p < 0.001). Of the eighteen patients undergoing an attempt at union, nine (50%) obtained osseous union, eight (45%) developed a stable fibrous union and one patient underwent subsequent excision of the fragment due a superficial infection (5%). Fifteen of twenty-one could extend the hand above the head against gravity. A functional arc of motion and satisfactory clinical outcome can be achieved with osseous or a stable fibrous nonunion.

Minimally Constrained Elbow Implant Arthroplasty: The Discovery Elbow System

The Discovery Elbow System (Biomet Orthopedics, Warsaw, Ind) is the latest generation of elbow replacement systems. Its minimally constrained design provides more closely matching articular surfaces, avoids use of a true hinge, and anatomically reproduces the axis of elbow motion. Improved instruments facilitate its implantation. The anatomic positioning of the humeral condyles allows for preservation of the ulnar collateral ligament to help share in implant loading. Elbow replacement reliably restores a painless functional arc of motion in almost all patients. Historically, elbow implant survivorship has been better in low-demand patients who have been functionally compromised by diffuse disease than in posttraumatic or osteoarthritic patients who otherwise are active and have no significant disabilities other than their elbows. The decision to proceed with elbow replacement should be made considering both age and activity level.

Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft

Purpose: This retrospective study was designed to evaluate the clinical and radiographic results of a hemi-hamate autograft for the treatment of comminuted dorsal proximal interphalangeal (PIP) joint fracture/dislocations. Methods: Thirteen consecutive patients underwent hemi-hamate autograft for the treatment of an unstable dorsal PIP fracture dislocation. The fractured middle phalangeal base was debrided and the defect was replaced using a size-matched portion of the dorsal/distal hamate osteoarticular surface and was secured with miniscrews. The average middle phalangeal volar lip involvement on initial radiographs was 60% (range, 40% to 80%). The average time to surgery was 45 days (range, 2–175 d). Range of motion, stability, and grip strength were measured at a mean follow-up evaluation of 16 months. Radiographs were evaluated for union, graft incorporation, and/or collapse. Subjective data, satisfaction, and return to work were obtained on 12 of the 13 patients at a mean follow-up evaluation of 17 months. Results: The average arc of motion at the PIP joint was 85° (range, 65° to 100°). The distal interphalangeal (DIP) joint average arc of motion was 60° (range, 35° to 80°). Average grip strength was 80% of the uninjured side. Bony union was achieved in all patients. One graft showed ulnar collapse but graft resorption was not noted. Except for 2 patients with recurrent dorsal subluxation there were no complications. The average pain level was 1.3 (as rated on a visual analog scale of 0–10). Eleven of 12 patients were very satisfied with their function and one was somewhat satisfied; one patient was lost to follow-up. Conclusions: When greater than 50% of the volar base of the middle phalanx is fractured in a PIP fracture/dislocation or the joint remains unstable despite a lesser degree of involvement, a hemi-hamate autograft should be considered. This procedure reconstructs the cup-shaped contour of the middle phalangeal articular surface and facilitates a stable, functional arc of motion at the PIP joint. Additionally, in our experience the procedure renders minimal disability and has a low complication rate.

Proximal row carpectomy: Indications, surgical technique, and long-term results

Proximal row carpectomy (PRC) can be an effective procedure in the treatment of painful arthritis of the wrist. Many conditions—most commonly untreated scaphoid nonunions and chronic scapholunate dissociation—can result in scapholunate advanced collapse pattern of arthritis, whereby the radioscaphoid and midcarpal joint become degenerative. Typically, the radiolunate joint, which is the basis for motion-preserving reconstructive procedures such as proximal row carpectomy, is spared. PRC converts a complex link joint to a simple hinge joint by creating a radiocapitate articulation. The ideal candidate for PRC has radioscaphoid arthritis with preservation of the capitate articular surface and the lunate fossa of the radius. This paper describes preoperative evaluation, surgical technique of both standard PRC and PRC with capsular interposition, postoperative rehabilitation, and results. Proximal row carpectomy is effective in treating posttraumatic arthritis of the wrist, has a low failure rate, and leaves the patient with a functional arc of motion and acceptable grip strength. With long-term follow-up, many patients show radiographic evidence of progressive radiocapitate arthritis, but do not manifest a corresponding deterioration in clinical function.

PERIPROSTHETIC HUMERAL FRACTURES AFTER TOTAL ELBOW ARTHROPLASTY

Periprosthetic fractures are among the most challenging complications of elbow arthroplasty, and published information about the outcome of treatment is limited. The purpose of the present study was to determine the results of implant revision and strut allograft augmentation for the treatment of humeral periprosthetic fractures that occur around a loose humeral component. Between 1991 and 1999, eleven periprosthetic fractures that occurred around a loose humeral component were treated with cortical strut allograft augmentation and revision arthroplasty with use of a Coonrad-Morrey semiconstrained implant. Six fractures occurred after a primary arthroplasty, and five occurred after a revision arthroplasty. Two parallel strut grafts were used for fracture fixation in most cases. Patients were followed for an average of three years (range, nine months to 7.8 years) and were evaluated clinically and radiographically. Clinical and radiographic fracture union was obtained in ten of the eleven patients. One patient required revision surgery because of aseptic loosening of the humeral component seven years and nine months after fracture union; there were no other implant failures. Complications included one additional nondisplaced humeral periprosthetic fracture after surgery that failed to heal with closed treatment, one olecranon fracture, one permanent ulnar nerve injury, and one case of triceps insufficiency. At the time of the most recent follow-up, seven of the eight patients with an intact reconstruction had a functional arc of motion and no or slight pain and one had limited motion and moderate pain. Periprosthetic humeral fractures that are associated with a loose humeral component can be effectively treated with revision elbow arthroplasty and strut allograft augmentation. The technique is associated with a high rate of fracture union, implant survival, and satisfactory clinical results. However, the complication rate is substantial.

SURGICAL CORRECTION OF EXTENSOR TENDON SUBLUXATION AND ULNAR DRIFT IN THE RHEUMATOID HAND: LONG-TERM RESULTS

Subluxation of the extensor digitorum communis tendons in the rheumatoid hand causes ulnar digital drift. If passively correctable, the digit may be realigned by soft tissue rebalancing and extensor centralization, which may preserve a more functional arc of motion than achieved with arthroplasty. A total of 71 centralization procedures were done in 15 rheumatoid patients with a mean age of 55 years and an average follow-up of 9 years. A distally based central-third strip of extensor tendon was used. Correction of ulnar drift deformity was from an average of 47° preoperatively to 7.9° postoperatively, and correction of active range of motion of the metacarpophalangeal joints was from an average of 38° to 56.2°. Reoperation and complication rates were low. This technique corrects and maintains ulnar drift in the rheumatoid hand. Range of motion at the metacarpophalangeal joint level is improved and converted to a more functional one by decreasing the extensor lag.

Arthroscopic Release of the Stiff Elbow

Arthroscopic Release of the Stiff Elbow

Technique for unstable olecranon fracture-subluxations

This article presents a reliable method for treating unstable olecranon fracture-subluxations. These fractures are not amenable to traditional AO/ASIF methods of internal fixation with tension band wiring because of comminution and/or ulnohumeral subluxation. This injury can be successfully treated using a posterior 3.5 DC plate that is bent to an 80° angle at the proximal end. In a preliminary review of six patients so treated, a functional arc of motion was achieved in five of six patients. The range ofmotion was from 15° ± 25° extension to 135° ± 10° flexion with an arc of 120° ± 35°. The results were excellent (functional arc, no or minimal pain, excellent strength) in four cases. There were three reoperations: one for plate removal, one for ulnar nerve transposition (related to an open distal humerus fracture with soft tissue loss), and one for ligament repair and ORIF of a displaced coronoid fracture. This method of plating comminuted proximal ulnar fractures with elbow subluxation has the advantages of stable fracture fixation, excellent purchase on even small proximal fragments, and buttressing against elbow subluxation—all of which permit immediate motion.

RECONSTRUCTION OF TRAUMATIC ABSENCE OF THE THUMB BY MICROVASCULAR FREE TISSUE TRANSFER FROM THE FOOT

The development of microvascular surgical techniques during the last quarter century has advanced the ability of the hand surgeon to reconstruct the traumatically amputated thumb. The use of tissue from the foot has become the mainstay of therapy for this previously exceedingly difficult reconstructive problem. Although numerous minor variations of thumb reconstruction with use of the toes from the foot are available, three main techniques--the complete great toe transfer, wraparound flap, and second toe transfer--provide a predictable outcome. With multiple donor sites available, the surgeon can choose a procedure based on the needs of the patient as well as the particular preferences of the individual surgeon involved. The uniform goal in thumb reconstruction is to provide a cosmetically acceptable, stable, mobile, and sensible thumb that can be used in opposition and pinch maneuvers. Transfer of the great toe can provide excellent reconstruction in the selected patient. This transfer may be the procedure of choice in the child who requires continued epiphyseal growth of the transferred digit. The esthetic appeal of this transfer is somewhat dependent on individual patient variation and the appearance of the toe relative to that of the contralateral uninjured thumb. In patients with a narrow great toe, the transfer can provide an ideal esthetic result. Disadvantages of this transfer are that it is less esthetic when the toe is very bulbous in appearance and that the resultant defect and morbidity in the donor foot may be significant, possibly affecting activities of daily living. The wraparound flap provides the unique ability to customize the thumb reconstruction. The final esthetic outcome of the thumb can be altered in nail size, circumference, and length. Use of the wraparound flap permits a greater portion of the great toe to be left with the foot in an attempt to preserve more normal gait and function postoperatively. This type of transfer does not permit interphalangeal joint motion and may not permit metacarpophalangeal joint motion. Therefore, the requirements of a normal carpometacarpal joint with excellent thenar musculature so that the postoperative thumb can be put through a functional arc of motion are essential. Transferring a portion of the distal phalanx in the wraparound flap permits the intercalary iliac crest graft to have viable bone on both the distal and proximal aspects, thereby reducing postoperative osteopenia of the iliac crest graft itself.(ABSTRACT TRUNCATED AT 400 WORDS)