Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Bacterial Biofilms and Periprosthetic Infections -...

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Bacterial Biofilms and Periprosthetic Infections -...: Bacterial Biofilms and Periprosthetic Infections This is an important article because it emphasizes that low-virulence infections sheltere...

Bacterial Biofilms and Periprosthetic Infections - how do we know if a failure is 'aseptic'?

Bacterial Biofilms and Periprosthetic Infections

This is an important article because it emphasizes that low-virulence infections sheltered in biofilms may underlie many apparently ‘aseptic’ failures of prosthetic joint arthroplasty.

The authors point out that in nature most bacteria in nature grow as biofilms rather than as isolated or ‘planktonic’ colonies. Interestingly, the biofilm matrix has a structure and function analogous to the extracellular matrix that is the hallmark of higher-order multicellular organisms. As with the extracellular matrix, the biofilm matrix is produced by cells but, in this case, bacterial cells. The biofilm matrix offers protection as well as provides an organizing scaffold, which can facilitate the metabolic activity and even communication among the bacteria. Bacteria in biofilms are relative protected from immune system attack and are less susceptible to antibiotics. In a biofilm, bacteria can be tolerant to antibiotics at concentrations that are several hundredfold greater than that needed to kill planktonic bacteria. While in biofilms, bacteria seem to exist in a more quiescent, less virulent state; however, they can still elicit a host inflammatory response that contributes to continual adjacent tissue destruction that results ultimately in the clinical symptoms of pain and implant loosening seen in longstanding chronic periprosthetic infection.

It can be difficult to culture biofilm bacteria. Special methods may be necessary, including polymerase chain reaction methodologies and mass spectrometry. These methods have been successful in identifying organisms in culture-negative periprosthetic infection as well as in cases of revision arthroplasty thought to be due to aseptic loosening. The authors suggest that many ‘aseptic’ failures of arthroplasty components may actually involve low-grade chronic infections that simply present as chronic pain, which may be the only clinical symptom.

It can be difficult to resolve such infections. The authors suggest that any surgical treatment will ultimately fail if that treatment does not adequately remove the biofilm at the infection site.

A single-stage exchange can be successful if it adequately removes the biofilm at the infection site: that on the prosthesis as well as that in surrounding tissues.

While the authors do not discuss chronic low grade shoulder infections, it is well recognized that the commonly recovered Priopionibacterium is an excellent former of biofilms 

http://jbjs.org/article.aspx?articleid=1787550

Instructional Course Lecture   |   December 18, 2013 

Bacterial Biofilms and Periprosthetic Infections

William V. Arnold, MD, PhD1; Mark E. Shirtliff, PhD2; Paul Stoodley, PhD3 

1 The Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107. E-mail address: balec.arnold@comcast.net
2 Department of Microbiology and Immunology, School of Medicine, University of Maryland-Baltimore, Room #9209 - 650 West Baltimore Street, Baltimore, MD 21201
3 Departments of Microbial Infection and Immunity and Orthopedics, Center for Microbial Interface Biology, 716 Biomedical Research Tower, The Ohio State University, 460 West 12th Avenue, Columbus, OH 43210

View Disclosures and Other Information

J Bone Joint Surg Am, 2013 Dec 18;95(24):2223-2229

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The diagnosis and treatment of periprosthetic infection after joint arthroplasty is often frustrating for the orthopaedic surgeon. The application of certain diagnostic criteria and different treatment strategies can be better directed if these infections are placed in the context of microbial biofilms. An understanding of this biofilm mode of microbial infection can help to explain the phenomenon of culture-negative infection as well as provide an understanding of why certain treatment modalities often fail. Continued basic research into the role of biofilms in infection will likely provide improved strategies for the clinical diagnosis and treatment of periprosthetic infection.

Topics

biofilms ; prosthetic joint infection ; infection

http://www.nytimes.com/2013/12/29/business/a-second-wind-from-an-injured-knee.html?emc=edit_tnt_20131228&tntemail0=y

PROTOTYPE

A Second Wind From an Injured Knee

By CLAIRE MARTIN

Published: December 28, 2013

When Kim Gustafson moved to Vail Valley in Colorado more than a decade ago, he was 54 and had recently retired as an executive in the office-equipment business. But he wasn’t ready to stop working. “I’m not the type of person who wanted to play checkers,” he says.

Zach Mahone for The New York Times

After leaving the executive life, Kim Gustafson became a ski instructor. But complications involving an earlier injury would lead to a new calling: starting a company that sells knee-support tights.

They tights feature bands of stiff fabric that descend down the legs from the hips, wrap around the knees and extend to the ankles.

Mr. Gustafson is one of a growing number of baby boomers starting businesses later in life — though that was not his original plan. Initially, he worked as a ski instructor. But he found that degenerative arthritis and the wear-and-tear of his rigorous skiing schedule were exacerbating an injury he had sustained several years earlier after falling from a ladder.

Mr. Gustafson sought treatment at the Steadman Clinic, an orthopedic surgery center based in Vail, eventually undergoing five knee surgeries. To continue to teach skiing, he was told, he would need to wear a hard, cumbersome knee brace every time he hit the slopes.

As he grew accustomed to the brace, he began to wonder whether people with less vulnerable joints than his might benefit from a more pliable and comfortable form of knee support — perhaps a pair of tights. To explore this possibility, he turned to a group of biomechanical experts at the Steadman Philippon Research Institute, a branch of the Steadman Clinic.

Coincidentally, the researchers had been contemplating something similar, and they began drawing sketches of nylon and spandex tights embedded with bands of rigid fabric to protect the knees by restoring them to their natural alignment.

Mr. Gustafson and scientists from the institute struck up an unusual agreement: They would develop the tights together, and if the product reached the marketplace, the institute would receive royalties to be applied to future research projects or the hiring of scientists. Within two years, Mr. Gustafson started a company he eventually called Opedix and began selling the biomechanically engineered tights online.

His decision to start a business in his late 50s is far from unusual. A report this year by the Ewing Marion Kauffman Foundation found that late-in-life entrepreneurs — ages 55 to 64 — now comprise 23 percent of new business owners, up from 14 percent in 1996. And the results of a survey released this month by the Pew Research Center showed that baby boomers were less likely to say that job security was “extremely important” to them compared with two younger groups: millennials and members of Generation X — suggesting an inclination toward entrepreneurship.

The trend is partly rooted in a quest for personal fulfillment, says Stewart Friedman, director of the Work/Life Integration Project at the Wharton School of Business at the University of Pennsylvania. “Among boomers, of which I am one, our whole early life in the ’60s and ’70s was about self-actualization,” Mr. Friedman says, adding that many in his generation are finally now revisiting career aspirations that they abandoned years ago.

Age and experience, however, aren’t always considered assets in wider entrepreneurial circles, says Elizabeth Isele, founder of Senior Entrepreneurship Works, which runs entrepreneurship training courses for those over 50. She says that many lenders are skeptical of older people’s ability to repay loans and that the biggest challenge for this age group is access to capital.

“Part of that is because people haven’t heard of senior entrepreneurship,” she says.

So far, Mr. Gustafson has self-funded his venture along with his brother, David, who serves as president. But even for older entrepreneurs investing their own money in start-ups, the financial risks of a new venture can be daunting.

Opedix faces several challenges, including the fact that it is competing in a crowded field. “There’s a long history of companies trying to come up with technologies to restore normal function to an injured joint or prevent injury to a joint that’s at risk,” says Bruce Beynnon, director of research at the department of orthopedics and rehabilitation at the University of Vermont’s College of Medicine.

Opedix has struggled to differentiate itself from another type of garment that’s popular with runners and looks very similar: compression tights. What sets Opedix tights apart, Mr. Gustafson says, are the bands of stiff fabric that descend down the leg from the hips, wrap around the knees and extend to the ankles.

The added complexity confers a higher price: Opedix tights sell for $225 a pair, usually twice the price of compression tights. But to the uneducated eye, the two tights are virtually indistinguishable, which can confuse shoppers. (Earlier this year, Opedix also began selling shorts designed to restore the pelvis’s natural alignment; they cost $165.)

One of Mr. Gustafson’s strategies for educating potential customers is to put the tights in the hands of physical therapists, trainers, sports instructors and professional athletes who are likely to understand the banding technology — and, he hopes, to spread the word. 

Mr. Gustafson sees an advantage in making a product geared toward the boomer population. The tights could hold wide appeal for the many members of this generation who have benefited from medical advances and plan to stay active into their 70s and 80s. By 2017, the over-50 set will control 70 percent of the disposable income in the United States and is expected to comprise about half of the population, according to data compiled by Nielsen.

Mr. Gustafson says he believes the experience and skills he cultivated in his earlier career, which included tenures at two start-ups, have been a plus in his work at Opedix. For instance, he knew how laborious it would be to develop and test a new product, and he understood the benefits of working in a field he liked.

“I love the ski business,” he says. “It’s a whole lot more exciting and interesting than office equipment, I’ll tell you.”

Osteomyelitis

http://www.ipcphysicaltherapy.com/Osteomyelitis.aspx

Osteomyelitis

What is osteomyelitis?

Osteomyelitis is infection in the bone. Osteomyelitis can occur in infants, children ,
and adults. Different types of bacteria typically affect the different age groups. In children, osteomyelitis most commonly occurs at the ends of the long bones of the arms and legs, affecting the hips, knees, shoulders, and wrists. In adults, it is more common in the bones of the spine (vertebrae), feet, or in the pelvis.

What causes osteomyelitis?

There are several different ways to develop the bone infection of osteomyelitis. The first is for bacteria to travel through the bloodstream ( bactermia) and spread to the bone, causing an infection. This most often occurs when the patient has an infection elsewhere in the body, such as pneumonia  or a urinary tract infection , that spreads through the blood to the bone.

An open wound over a bone can lead to osteomyelitis. This happens most commonly with underlying peripheral vascular disease , peripheral neuropathy, or diabetes. With an open fracture (compound fracture), the bone that punctures through the skin is exposed to bacteria.

A recent surgery or injection around a bone can also expose the bone to bacteria and lead to osteomyelitis.

Patients with conditions or taking medications that weaken their immune system are at a higher risk of developing osteomyelitis.

Risk factors include cancer, chronicsteroid use,human immunodeficiency virus (HIV), diabetes, hemodialysis, intravenousdrug users, and the elderly.

What are osteomyelitis symptoms and signs?

In children, osteomyelitis most often occurs more quickly. They develop pain or tenderness over the affected bone, and they may have difficulty or inability to use the affected limb or to bear weight or walk due to severe pain. They may also have fever, chills, and redness at the site of infection.

In adults, the symptoms often develop more gradually and include fever, chills, irritability, swelling or redness over the affected bone, stiffness, andnausea. In people with diabetes, peripheral neuropathy, or peripheral vascular disease, there may be no pain or fever. The only symptom may be an area of skin breakdown that is worsening or not healing.

Acute osteomyelitis occurs with a rapid onset and is usually accompanied by the symptoms of pain, fever, and stiffness. It generally occurs after a break in the skin from injury, trauma, surgery, or skin ulceration from wounds.

Chronic osteomyelitis is insidious (slow) in onset. It may be the result of a previous infection of osteomyelitis. Despite multiple courses of antibiotics, it may reoccur. Symptoms of chronic osteomyelitis are subtle but may include fever, pain, redness, or discharge at the site of infection.

In adults, the symptoms often develop more gradually and include fever, chills, irritability, swelling or redness over the affected bone, stiffness, andnausea. In people with diabetes, peripheral neuropathy, or peripheral vascular disease, there may be no pain or fever. The only symptom may be an area of skin breakdown that is worsening or not healing.

Acute osteomyelitis : occurs with a rapid onset and is usually accompanied by the symptoms of pain, fever, and stiffness. It generally occurs after a break
in the skin from injury, trauma, surgery, or skin ulceration from wounds.

Chronic osteomyelitis : is insidious (slow) in onset. It may be the result of a previous infection of osteomyelitis. Despite multiple courses of antibiotics, it may reoccur. Symptoms of chronic osteomyelitis are subtle but may include fever, pain, redness, or discharge at the site of infection.

How is osteomyelitis diagnosed?

The diagnosis of osteomyelitis begins with a complete medical history and physical examination. During the medical history, the doctor may ask questions about recent infections elsewhere in the body, past medical history, medication usage, and family medical history.

The physical examination will look for areas of tenderness, redness, swelling, decreased or painful range of motion, and open sores.

The doctor may then order tests to help diagnose osteomyelitis. Several blood tests can be used to help determine if there is an infection present. These include a complete  blood count (CBC), the erythrocytesedimentation rate (ESR), C-reactive protein (CRP), and blood cultures. None of these is specific for osteomyelitis but they can suggest that there may be some infection in the body.

Imaging studies may be obtained of the involved bones. These can include plain radiographs (X-rays), bone scans,computed tomography (CT) scans,magnetic resonance imaging (MRIs), and ultrasounds. These imaging studies can help identify changes in the bones that occur with
osteomyelitis.

After an area of bone is identified with possible osteomyelitis, a biopsy of the bone may be obtained to help determine precisely which bacteria are involved, and the culture of this can indicate the best choice for antibiotic treatment.

What is the treatment for osteomyelitis?

In many cases, osteomyelitis can be effectively treated with antibiotics and pain medications. If a biopsy is obtained, this can help guide the choice of the best antibiotic. The duration of treatment of osteomyelitis with antibiotics is usually four to eight weeks but varies with the type of infection and
the response to the treatments. In some cases, the affected area will be immobilized with a brace to reduce the pain and speed the treatment.

Sometimes, surgery may be necessary. If there is an area of localized bacteria ( abscess), this may need to be opened, washed out, and drained. If there is damaged soft tissue or bone, this may need to be removed. If bone needs to be removed, it may need to be replaced with bone graft or stabilized during surgery.

What is the prognosis for osteomyelitis?

With early diagnosis and appropriate treatment, the prognosis for osteomyelitis is good. Antibiotics regimes are used for four to eight weeks and sometimes longer in the treatment of osteomyelitis depending on the bacteria that caused it and the response of the patient. Commonly, patients can make a full recovery without longstanding complications.

However, if there is a long delay in diagnosis or treatment, there can be severe damage to the bone or surrounding soft tissues that can lead to permanent deficits or make the patient more prone to reoccurrence. If surgery or bone grafting is needed, this will prolong the time it takes to recover.

Chronic osteomyelitis is often a result of complication of treatment with open fractures, therefore, prevention of infection is highly important . Since the role of nutrition is vital in cases of infection,
patient need to be properly educated on proper nutrition in early post-surgical intervention due to the fact that most infections occur in the immediate post-operative period. Individuals who are at risk for developing osteomyelitis should also be taught proper preventative measures and be aware of early warning signs that infection may be present such as, excessive pus present coming from incision line, redness, extreme tenderness, increased skin temperature near area of injury or surgical procedure, and symptoms of nausea or vomiting.

Physical Therapy Management :

• 
  If treated surgically for osteomyelitis, physical therapy may be indicated post-operatively to address any impairments in :
• 
  Strength
• 
  ROM
• 
  Proprioception
• 
  treatment for any functional limitations or disabilities secondary to the infection.
• 
  maintain function and enhance mobility
• 
  Active range of motion physical therapy initially helps maintain flexibility

As strength continues to progress, endurance becomes a focus in the individual's rehabilitation program for osteomyelitis. Aerobic exercises that increase cardiovascular fitness are recommended. The American Heart Association recommends 30 to 60 minutes of aerobic activity 3 or 4 times a week.

Learning how to avoid injury is another important intervention in the rehabilitation of progressive osteomyelitis. 

Occupational therapy helps individuals arrange their homes and organize their lives in ways that support their physical and mental well-being. Activities are also provided to relieve the mental
boredom of inactivity. Devices and techniques that help the individual communicate are invaluable in maintaining peace of mind. The rehabilitation program varies among individuals with progressive osteomyelitis as the intensity and progression of the exercise depends on the stage of the disease and individual's overall health.

The type of rehabilitation for osteomyelitis depends on the location of the infected bone
and the underlying cause of infection. For rehabilitation purposes, osteomyelitis is subdivided into five types. Depending on the type of osteomyelitis (ranging from type I to type V, according to the degree of tibia and fibula involvement and the bone’s ability to withstand functional loads), the
rehabilitation time required varies.

Type I osteomyelitis (in which both tibia and fibula are intact and can withstand functional loads), the rehabilitation time is from 6 to 12 weeks.

Type II osteomyelitis (in which the tibia is intact, but a bone graft is needed), the rehabilitation
time required is from 3 to 6 months.

Type III osteomyelitis (in which the fibula is intact, but there is a tibial defect of no more than 6 cm), 6 to 12 months of rehabilitation are needed.

Type IV osteomyelitis (in which the fibula is intact, but there is a tibial defect of more than 6 cm), 12 to 18 months of rehabilitation are required.

Type V osteomyelitis (in which there is no usable intact fibula, and there is a tibial defect of more than 6 cm), 18 months or longer are required for rehabilitation.

http://www.condroprotectores.es/proyecto-articulate-para-estudiar-la-adherencia-terapeutica-en-la-artrosis/

INVESTIGACIÓN

Lunes 16 de diciembre de 2013 | 17:43

Proyecto Articúlate para estudiar la adherencia terapéutica en la artrosis

“Una buena adherencia al tratamiento puede ser la que marque la diferencia entre mantener la articulación o acabar necesitando una prótesis”, advierte a Europa Press el Dr. Julio Zarco, médico de Atención Primaria y director del Observatorio de la Adherencia Terapéutica (OAT).

Sin embargo, “en España no hay estudios que evidencien cuál es el porcentaje de no adherencia terapéutica en la artrosis“, añade. Precisamente ante la necesidad de que se conozcan los datos, desde el Observatorio se ha puesto en marcha un estudio piloto que pretende mostrar una “radiografía” de la situación de la artrosis de rodilla en España. El estudio va a contar con un grupo de pacientes (una muestra diseñada inicialmente con 200 o 300 pacientes), de entre 18 años y 65 años aproximadamente con artrosis leve o moderada en Cataluña.

El objetivo es ver qué problemas de adherencia existen en esos pacientes, cuantificar los costes de la no adherencia – fracturas, ingresos hospitalarios, fármacos, etc-, y saber qué consecuencias tiene para el paciente. Sin embargo, el proyecto, puesto en marcha bajo el nombre de Articúlate, va a ir más allá de este conocimiento, ya que pretende aplicar en una muestra de la población seleccionada un plan diseñado para mejorar la artrosis.

El proyecto ya tiene planificada su ejecución, a falta de obtener los permisos de los comités de ética de Cataluña y, teóricamente, comenzará entre los meses de diciembre y enero, mientras que el tiempo de duración estimado son seis o siete meses.

http://www.condroprotectores.es/premios-semergen-iii-cs-reduce-de-forma-efectiva-la-sinovitis/

Premios Semergen III: CS reduce de forma efectiva la sinovitis

El tercer trabajo premiado con una de las becas a la investigación en artrosis y condroprotección, que Semergen otorgó durante su congreso nacional el pasado mes de octubre, es un ensayo clínico piloto independiente del Hospital del Mar de Barcelona, liderado por el Dr. Jordi Monfort, que compara el efecto de dos fármacos, el condroitín sulfato y el paracetamol, sobre la sinovitis con pacientes de artrosis de rodilla. En este estudio participaron 45 pacientes que fueron tratados con condroitín sulfato o paracetamol durante 6 meses y monitorizados hasta los 9 meses para evaluar el efecto remanente de los fármacos.

Los resultados de este ensayo clínico muestran que el grupo tratado con condroitín sulfato presentó una reducción estadísticamente significativa (del 25,45%) de la sinovitis y de la hipertrofia sinovial (61,93%) en comparación con el grupo paracetamol. Asimismo, al cabo de 1,5 meses de tratamiento, el condroitín sulfato redujo significativamente la incapacidad funcional, efecto que mantuvo su significancia hasta el noveno mes tras la supresión del tratamiento, confirmando así su efecto remanente. Estos datos relativos a la sinovitis confirman los resultados publicados en la prestigiosa revista New England Journal of Medicine en 2006.

Según los autores del estudio, los resultados “sugieren que el condroitín sulfato es capaz de reducir la sinovitis en pacientes artrósicos, efecto no observado con paracetamol. Ambos tratamientos reducen los síntomas clínicos de la artrosis, sin embargo, en pacientes artrósicos con un componente inflamatorio añadido, el condroitín sulfato parece ser una herramienta terapéutica más efectiva que los analgésicos convencionales”.

CORONOID FRACTURES

http://networkedblogs.com/RV8Kx

CORONOID FRACTURES

Rajesh Purushothaman, MS, Associate Professor, Govt.Medical College , Kozhikode, India

• Coronoid fractures were once thought to be inconsequential. But they have been recognised to be of great importance as minor incongruity of the anteromedial facet have been shown to lead to elbow arthrosis and in presence of other fractures and elbow dislocation they have shown to lead to poor results. When olecranon or coronoid fracture is associated with elbow dislocation, restoration of trochlear notch is required for ulnohumeral stability.

Applied Anatomy

• The proximal ulna has 2 articular facets. The trochlear notch (incisura semilunaris) articulates with the trochlea and the lesser sigmoid notch articulates with the radial head. Trochlear notch forms an arc of 190 degrees. The central part of the notch is devoid of articular cartilage and olecranon osteotomy is ideally done through this area.

• The coronoid consists of an anterior projection and an medial projection. The anterior projection of coronoid makes it a key stabiliser of ulnohumeral joint by helping it resist the posteriorly directed forces. The medial projection forms sublime tubercle which supports the anteromedial facet. Anteromedial facet also helps in resisting varus forces. The anterior bundle of ulnar collateral ligament is attached to the anteromedial facet.

• The distal articular surface of the humerus is tilted anteriorly by 30 degrees, and the trochlear fossa is tilted posteriorly by 30 degrees. This helps in increasing the degree of flexion and also helps in increasing the height of coronoid process which deepens the trochlear notch increasing the stability of elbow. Trochlea is spool shaped with wide transverse width and a deep central groove. Trochlear notch covers 180 degrees of trochlea. Ulnohumeral joint is the most important stabiliser of elbow in varus stress. It also contributes significantly to anteroposterior and rotatory stability.

Biomechanics and Pathoanatomy

• The function of elbow is to alter the distance between the trunk and hand by flexion-extension. It also allows rotation of the forearm. Elbow is one of the most stable joints of the body. Stability is provided by the osteoarticular structures and capsuloligamentous structures. Capsuloligamentous structures provide 50% of the mediolateral stability. Osteoarticular components that provide stability are deep trochlear notch with a prominent coronoid process, presence of a ridge in the trochlear notch with a corresponding groove in the trochlea, interlocking of olecranon and coronoid into corresponding fossae in the humerus and provision of lateral stability by the intact radial head.

• Valgus stability is due to intact lateral radiocapitellar articulation and the ulnar collateral ligament (UCL). UCL has a thin posterior and transverse bundles and a thick anterior bundle. Anterior bundle provides 30-50% of valgus stability. It is attached proximally to the central 2/3rd of the anteroinferior surface of the medial epicondyle. Distally it is attached 18mm posterior to the tip of coronoid, to the sublime tubercle at the base of the coronoid. Thus anterior bundle is dysfunctional in fractures involving the base of the coronoid. The brachialis insertion extends distal to the coronoid and hence not involved in coronoid fractures. The anterior bundle of the UCL, lateral ulnar collateral ligament, anterior capsule of elbow and a part of brachialis muscle insert on the coronoid process and are often disrupted by elbow dislocation and coronoid fracture.

Clinical features

• Patients present with history of elbow injury. Careful elicitation of history will help in the identification of the exact mechanism of injury and the magnitude. As these injuries are often due to high velocity injuries, associated injuries are common. Look for life threatening and limb threatening injuries.

Imaging

• Usually AP and lateral views of the elbow are sufficient for emergency management. If there is a dislocation, it should be reduced by closed manipulation and stability after reduction should be assessed in the flexion and extension in supination. If unstable assess stability in pronation. If again unstable, assess stability in flexion. Take post-reduction x-rays. Ensure that the elbow is concentrically reduced and take special care to confirm anatomical reduction of radial head. Look for any loose fragments and subtle signs of subluxation. Look for other associated fractures. Coronoid fractures may be confused with radial head fragments.

• Commonest mechanism of injury to the elbow is a fall on the outstretched hand leading to compression, external rotation and supination of the forearm at the elbow leading to posterolateral rotatory instability of elbow. But an uncommon injury pattern is compression, internal rotation and varus leading to posteromedial instability of elbow characterised by fracture of the facet of coronoid. These fractures are different from classical transverse fracture as they are vertical or oblique with only subtle findings on the x-ray. Anteromedial facet fractures often show only subtle narrowing of joint space on the medial part of ulnohumeral joint on the AP view and also a double shadow for the articular surface. CT with 3D reconstruction is a must for proper evaluation of coronoid fractures. Often what appears as a small fragment on the x-ray will be revealed to be a large fragment on CT.

Classification

Regan and Morrey classification

Type I- Fracture of the tip. Suggestive of elbow dislocation. Soft tissue injury more than bony injury.

Type II- Upto 50% of coronoid involved. Ulnohumeral joint may or may not be unstable. If unstable fixation is required.

Type III- Fracture of more than 50% of coronoid. Usually not comminuted. Needs ORIF.

Size of the fragment cannot be used as a guideline for fixation. Fixation is indicated if the elbow is unstable and if more than 50% of the height of coronoid is involved.

O’Driscoll Classification

Tip fractures

Subtype 1 – ?2 mm of coronoid height

Subtype 2 – >2 mm of coronoid height

Anteromedial fractures

Subtype 1 – Fracture of the anteromedial rim

Subtype 2 – Fracture of the anteromedial rim and tip

Subtype 3 – Fracture of the anteromedial rim and sublime tubercle

Basal fractures

Subtype 1 – Fracture of the coronoid body (at least 50% of the height of the coronoid)

Subtype 2 – Associated with olecranon fractures

Treatment

The main indication for coronoid fixation is presence of varus or valgus instability. The method of treatment is determined by the following factors.

1. Presence or absence of ulnohumeral subluxation.
2. Presence or absence of radial head fracture.
3. Size and location of fragment.

• If there is persistent ulnohumeral subluxation or instability, if the fragment is small; repair the lateral collateral ligament and reattach the anterior capsule. Large coronoid fragment needs open reduction and internal fixation.

• Displaced radial head fracture should be fixed or replaced and if the fragment is small; repair the lateral collateral ligament and reattach the anterior capsule. Large coronoid fragment needs open reduction and internal fixation. Coronoid fracture is fixed first through the lateral approach followed by radial head and ligament repair.

• Biggest challenge in fixation of coronoid fracture is adequate surgical exposure. As the coronoid process is deep to the common flexor origin, exposure from medial side is difficult and limited. Anterior exposure carries the risk of injury to brachial artery and median nerve. Exposure from posterior aspect provide only limited visualisation.

• Medial approach may be done through FCU-Split approach or extended medial approach describe by Hotchkiss. Both approaches can be done through a global posterior approach or a medial incision.

• FCU-split approach is done by isolating the ulnar nerve, retracting it posteriorly and then separating the humeral and ulnar heads of flexor carpi ulnaris. Gently elevate the FCU and FDS from the proximal ulna in a distal to proximal direction to expose the coronoid. Anterior bundle of UCL should be carefully preserved. The flexor-pronator muscle belly is retracted anteriorly and the ulnar nerve is retracted posteriorly.

• Extended medial approach of Hotchkiss utilises the plane between the FCU and the humeral head of FDS. In presence of terrible triad of elbow (elbow dislocation with radial head and coronoid fracture) coronoid can be exposed from the lateral aspect through a modified Kocher approach by retracting the ruptured lateral collateral ligament. In comminuted fractures of the coronoid base, exposure may be an anterior approach.

Fractures of the coronoid may occur in following situations, and their management differs.

A)  As an isolated fracture.

B)  As a part of fracture dislocation of elbow.

C) As a part of comminuted fractures of proximal ulna.

• Isolated coronoid fractures usually involve the tip only. Most of these fractures have associated collateral ligament injury and careful assessment often reveal that there was an associated dislocation of the elbow at time of injury, which got reduced spontaneously. Type 1 coronoid fractures have very small fragments. Isolated tip fractures can be left alone if the elbow is stable and if there is no mechanical block to movement. Instability and anteromedial facet fractures are treated by surgery. Driscoll type 1 fractures are fixed with small screws, cerclage, suture anchor or K wires. Driscoll type 1 fractures are fixed with small screws, cerclage, suture anchor or K wires. If fragments are very small then Lasso type sutures are passed a through the attached anterior capsule around the fractured fragment and brought out through drill holes made from the posterior cortex of ulna and tied. TIbial ACL jig or Herbert screw jig may be utilised for making the drill holes.  An important part of surgical treatment is reattachment of anterior capsule and repair of lateral collateral ligament.

• A variant is a fracture involving the anteromedial facet, which is now considered to be posteromedial rotatory instability. O’Driscoll Type 2  anteromedial facet fractures are vertical or oblique fractures. They can be treated by screw fixation or mini fragment buttress plating. Specialised coronoid plates may be used for this purpose. Anteromedial facet fractures are fixed by medial plating through FCU-Split or Hotchkiss approach. An important part of surgical treatment is reattachment of anterior capsule and repair of lateral collateral ligament.

• O’Driscoll type 3 fractures require fixation using plates, screws and occasionally hinged external fixation. Screws may be directed from posterolateral to anteromedial direction if a posterior approach is utilised.

• In simple elbow dislocations without fracture, after reduction most joints are stable allowing early mobilisation. Simple elbow dislocations can be treated with closed reduction and early controlled mobilisation. If one of the bony components that contribute to stability is fractured then the chance of instability and recurrent dislocation increases. In complex fracture dislocations, the stability of elbow depends on the size and location of coronoid fracture, degree of comminution of radial head, severity of associated ligamentous injury and interposition of soft tissue or bone fragments.

• Treatment of elbow dislocation depends on the bony and ligamentous injuries. In complex fracture dislocations of the elbow, a structured protocol based treatment is necessary. Successful functional outcome can be achieved with  stable fixation of the fracture and early elbow mobilisation. Nonoperative treatment, is associated with high rate of early arthritis, recurrent dislocation, unstable elbow, post-traumatic joint stiffness, and nonunion. Hence coronoid fractures combined with elbow dislocation must be treated surgically.

Further reading

1. Ablove RH, Moy OJ, Howard C, Peimer CA, S’Doia S. Ulnar coronoid process anatomy: possible implications for elbow instability. Clin Orthop Relat Res 2006;(449):259-6
2. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg (Am) 1989;71:1348–54.
3. O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect 2003;52:113-34.
4. Ring D. Fractures of the coronoid process of the ulna. J Hand Surg [Am] 2006;31:1679-89.
5. Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg (Am) 2006;88(10): 2216–24.
6. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg [Am] 2004;86:1122-30.

http://www.bjj.boneandjoint.org.uk/content/95-B/12/1662.abstract

Screw fixation of medial malleolar fractures

A cadaveric biomechanical study challenging the current AO philosophy

1. L. Parker, BM, MRCS(Eng), FRCS(Tr & Orth), Specialist Registrar Trauma and Orthopaedic Surgery1 ; 
2. N. Garlick, FRCS(Orth), Consultant Orthopaedic Surgeon1; 
3. I. McCarthy, BSc, PhD, FIPEM, Principal Research Fellow2; 
4. S. Grechenig, Dr.med.Univ., Doctor3;
5. W. Grechenig, Prim.Prof.Dr., Professor4; and 
6. P. Smitham, PhD, MRCS(Eng), Clinical Lecturer, Specialist Registrar2

+Author Affiliations

1. 1The Royal Free Hospital, Pond Street, London NW3 2QG, UK.
2. 2Institute of Orthopaedics and Musculoskeletal Sciences, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.
3. 3University Hospital Regensburg, Department of Traumatology, Franz-Josef-Strauss Allee, Regensburg, Germany.
4. 4AUVA Trauma Hospital, Graz, Gostingerstrasse 24, 8020, Graz, Austria.

1. Correspondence should be sent to L. Parker; e-mail: lee.parker06@gmail.com

Abstract

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture.

We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar.

We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm2 (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm2 (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm2 (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case.

The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region.

Cite this article: Bone Joint J 2013;95-B:1662–6.

Footnotes

• The authors would like to thank Professor A. Weinberg, Department of Paediatric and Adolescent Surgery, Medical University of Graz, Austria, P. Ferlic and H. Dimai from Klinische Abteilung für Endokrinologie und Stoffwechsel, Graz, Austria for DEXA analysis, and S. Cro, Clinical Trials Unit, Medical Research Council, UK for statistical analysis.
  No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
  This article was primary edited by J. Scott and first-proof edited by G. Scott.
• Supplementary material. Two tables detailing the results of the studies of the compression at the fracture site for all four groups are available alongside the electronic version of this article on our website www.bjj.boneandjoint.org.uk

• Received July 20, 2012.
• Accepted May 24, 2013.

• ©2013 The British Editorial Society of Bone & Joint Surgery