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Kellam PJ, Amin AA, Anthony RT, Saiz AM, Schultz BJ, Mayer RR, Achor TS, Warner SJ, Choo AM. Mini-fragment plate fixation after olecranon osteotomy for distal humerus fractures. J Shoulder Elbow Surg 2025; 34:1254-1261. [PMID: 39427730 DOI: 10.1016/j.jse.2024.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 08/12/2024] [Accepted: 08/19/2024] [Indexed: 10/22/2024]
Abstract
PURPOSE Although olecranon osteotomies are helpful for distal humerus visualization, traditional methods of fixation are commonly irritating for patients and require hardware removal. Recent studies have shown lower hardware removal rates for medullary screw constructs and 3.5-mm plates, but no studies have investigated the use of 2.7-mm plates for olecranon osteotomy fixation. The purpose of this study is to report on the outcomes of single 2.7-mm mini-fragment plate fixation of olecranon osteotomies for distal humerus intra-articular fractures. METHODS Patients who sustained an intra-articular distal humerus fracture, as identified by Current Procedural Terminology codes, were reviewed retrospectively over a 5-year study period (2016-2020) at a single level 1 trauma center after institutional review board approval. Only patients who underwent an olecranon osteotomy for distal humerus visualization during their definitive operation and that was subsequently fixed with a single 2.7-mm plate were included. Primary outcomes were implant removal and osteotomy union. Secondary outcomes included indications for implant removal, implant failure, infection, and revision surgery. Hardware removal rates were compared to historically reported rates in the literature. χ2 vs. Fisher exact tests were used to compare fixation groups based on number of patients in each cohort (5 or less was used for the cutoff for Fisher exact test). RESULTS Thirty-eight patients were included in the final analysis. The average age was 50 years (standard deviation [SD] 18), 58% (22 patients) were female, and the average follow-up time was 9.7 months (SD 5). All patients with mini-fragment plate fixation went on to union of their olecranon osteotomy. Three patients (7.8%) had their olecranon hardware removed for all causes: 1 for revision open reduction and internal fixation (ORIF), 1 for irritation, and 1 removal during concomitant capsulectomy and manipulation. There was a 21% (8 patients) revision surgery rate in the cohort but only 3 of those were for issues related to the olecranon osteotomy. One patient required revision ORIF of the olecranon osteotomy for hardware loosening. Compared with other fixation constructs, mini-fragment plates had a lower removal rate than tension band wiring (P = .0002) and 3.5-mm plates (P = .05) and similar among medullary screws ± wires. Nonunion rates were similar between all constructs (P = .07). CONCLUSION Single 2.7-mm mini-fragment plate fixation of olecranon osteotomies for distal humerus fractures is safe and effective with low rates of revision, hardware removal, and nonunion. This type of fixation should be considered when treating intra-articular distal humerus fractures that require an olecranon osteotomy.
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Affiliation(s)
- Patrick J Kellam
- Department of Orthopaedics, UT Health Houston, Houston, TX, USA.
| | - Adeet A Amin
- Department of Orthopaedics, UT Health Houston, Houston, TX, USA
| | - Ryan T Anthony
- Department of Orthopaedics, UT Health Houston, Houston, TX, USA
| | | | - Blake J Schultz
- Department of Orthopaedics, UT Health Houston, Houston, TX, USA
| | - Ryan R Mayer
- Department of Orthopaedics, UT Health Houston, Houston, TX, USA
| | - Timothy S Achor
- Department of Orthopaedics, UT Health Houston, Houston, TX, USA
| | | | - Andrew M Choo
- Department of Orthopaedics, UT Health Houston, Houston, TX, USA
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Martinelli F, Rota C, Rodà D, Coppola M, Celli A. Posterior approaches for articular distal humeral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2025; 35:161. [PMID: 40240652 DOI: 10.1007/s00590-025-04280-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Accepted: 03/30/2025] [Indexed: 04/18/2025]
Abstract
Approaching the elbow joint posteriorly is the most used method to visualize closed fractures of the distal humerus in adults. Treatment can span from open reduction and internal fixation to elbow hemiarthroplasty and total elbow arthroplasty. Different approaches were developed in the necessity of balancing an adequate visualization with minimizing complications and these surgical exposures can be divided into four main categories: paratricipital, triceps reflecting, triceps splitting and olecranon osteotomy. In this article are described the positive and negative features of the principal posterior elbow approaches and their best clinical uses for the treatment of distal humerus complete articular fractures classified according to AO/OTA classification 13C.
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Affiliation(s)
| | - Clelia Rota
- Hesperia Hospital, Modena, Italy
- Università Degli Studi di Torino, Turin, Italy
| | - Domenico Rodà
- Hesperia Hospital, Modena, Italy
- Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Martina Coppola
- Hesperia Hospital, Modena, Italy
- University of Naples Federico II, Naples, Italy
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McClelland D, Blackwell JR, Dover C, Grocott N, Ogrodnik PJ, Mataliotakis GI, Kim E. Validation of minimally invasive articular cartilage sparing technique for olecranon osteotomy. ANZ J Surg 2025; 95:169-174. [PMID: 39601405 DOI: 10.1111/ans.19297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 09/09/2024] [Accepted: 10/15/2024] [Indexed: 11/29/2024]
Abstract
BACKGROUND The authors present a cadaveric validation of a minimally invasive articular cartilage preserving olecranon osteotomy technique for use in the operative management of distal humeral fractures. METHODS Twenty-four elbows in six male and six female formaldehyde embalmed cadavers were dissected. With the cadaver placed in a lateral decubitus position, a posterior sub-periosteal dissection was performed to the medial and lateral aspects of the olecranon at the level of the joint and Mini Hohmann retractors were inserted into each side of the ulnohumeral joint. The medial (M) and the lateral (L) points where the retractors touch the articular surface were marked with a fine marker pen (Crown point) and a line drawn between the two points. The midpoint formed the apex of the chevron osteotomy. An osteotomy was performed and analysis of the osteotomy relative to the ulnar bare area (UBA) was undertaken. RESULTS The distal boundary of the UBA can be reliably found at a distance of 4.8 ± 0.4 mm (females) and 5.4 ± 0.8 mm (males) distal to the Crown point using this technique. CONCLUSION Identifying the Crown of the olecranon articular surface is a reliable and accurate technique which identifies the ulnar bare area reproducibly for the safe performance of a cartilage sparing, and minimally invasive, olecranon osteotomy for the surgical management of distal humeral fractures.
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Affiliation(s)
- Damian McClelland
- Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke on Trent, ST4 6QG, Staffordshire, UK
| | - John R Blackwell
- Department of Trauma and Orthopaedics, Walsall Healthcare NHS Trust, Walsall, WS2 9PS
| | - Caroline Dover
- Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke on Trent, ST4 6QG, Staffordshire, UK
| | - Natalie Grocott
- Department of Trauma and Orthopaedics, Royal Stoke University Hospital, Stoke on Trent, ST4 6QG, Staffordshire, UK
| | - Peter J Ogrodnik
- Department of Biomedical Engineering, Keele University, Keele, ST5 5BG, Staffordshire, UK
| | - George I Mataliotakis
- Department of Trauma and Orthopaedics, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Edward Kim
- Department of Biomedical Engineering, Keele University, Keele, ST5 5BG, Staffordshire, UK
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Sinkler MA, Adelstein JM, Kodsy MM, Ochenjele G, Sontich JK, Wetzel RJ, Napora JK. Postoperative dorsal step-off predicts olecranon osteotomy union: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 35:49. [PMID: 39731688 DOI: 10.1007/s00590-024-04169-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Accepted: 12/13/2024] [Indexed: 12/30/2024]
Abstract
PURPOSE Olecranon osteotomy has been associated with loss of reduction, nonunion, implant failure, and migration of wires. We aim to evaluate quality of reduction of the osteotomy site as a predictor of olecranon osteotomy nonunion. METHODS One hundred and twenty-five distal humerus fractures that underwent open reduction internal fixation (ORIF) were reviewed. Amount of dorsal step-off was measured from the lateral radiograph from the second postoperative visit. A receiver operating curve (ROC) analysis was used to assess the predictability of nonunion based on dorsal displacement of the olecranon osteotomy. RESULTS Between 2014 and 2022, 36 patients underwent a chevron olecranon osteotomy (29%). Of the 36 patients, 7 (19%) failed to successfully unite at the osteotomy site. Two experienced aseptic nonunion, 2 were malreduced leading to nonunion, 2 malunited, and 1 had persistent fracture lines following poor osteotomy cut. Patients that developed nonunion had a mean dorsal displacement of 3.87 mm versus 1.15 mm (p < 0.001). The ROC demonstrated excellent prediction for nonunion based on displacement (AUC = 0.896, p = 0.002). Youden's index was determined at a sensitivity of 86% and a specificity of 73% corresponding to a dorsal step-off of 2.07 mm. This finding was confirmed on multivariate logistic regression showing a step-off over 2.07 mm is an independent predictor of olecranon osteotomy nonunion (p = 0.021). CONCLUSION A malreduction resulting in a dorsal step-off larger than 2.07 mm is predictive of olecranon osteotomy nonunion or malreduction. Therefore, the success of the olecranon osteotomy approach is directly dependent on quality of anatomic reduction. LEVEL OF EVIDENCE III; Retrospective Cohort Study.
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Affiliation(s)
| | | | - Mark M Kodsy
- University Hospitals Cleveland Medical Center, Cleveland, USA
| | | | - John K Sontich
- University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Robert J Wetzel
- University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Joshua K Napora
- University Hospitals Cleveland Medical Center, Cleveland, USA
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Holte AJ, Dean RE, Chang G. Distal humerus fractures: review of literature, tips, and tricks. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:639-646. [PMID: 39157236 PMCID: PMC11329030 DOI: 10.1016/j.xrrt.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Andrew J. Holte
- Department of OrthopedicSurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ryan E. Dean
- Department of OrthopedicSurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Gerard Chang
- Department of OrthopedicSurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Bašković M, Pešorda D, Zaninović L, Hasandić D, Lohman Vuga K, Pogorelić Z. Management of Pediatric Elbow Fractures and Dislocations. CHILDREN (BASEL, SWITZERLAND) 2024; 11:906. [PMID: 39201841 PMCID: PMC11352739 DOI: 10.3390/children11080906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 09/03/2024]
Abstract
Pediatric elbow fractures and dislocations have always been a challenge from a diagnostic and therapeutic point of view, primarily due to the complex nature of the pediatric elbow, especially its developmental anatomy. They must be diagnosed and treated on time to prevent numerous complications with long-term consequences. With the development of radiology and pediatric surgery and orthopedics, as well as the development of modern osteosynthesis materials, concerning current scientific and professional knowledge, the outcomes are getting better, with fewer acute and chronic complications. This comprehensive review aims to provide clinicians current knowledge about pediatric elbow fractures and dislocations so that in daily practice they have as few doubts as possible with the best possible treatment outcomes.
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Affiliation(s)
- Marko Bašković
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Domagoj Pešorda
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10000 Zagreb, Croatia
| | - Luca Zaninović
- School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia
| | - Damir Hasandić
- Department of Pediatric Surgery, Clinical Hospital Center Rijeka, Vjekoslava Dukića 7, 51000 Rijeka, Croatia
- School of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Katarina Lohman Vuga
- Special Hospital for Medical Rehabilitation Varaždinske Toplice, Trg Svetog Martina 1, 42223 Varaždinske Toplice, Croatia
| | - Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Spinčićeva ulica 1, 21000 Split, Croatia
- School of Medicine, University of Split, Šoltanska ulica 2a, 21000 Split, Croatia
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Kamineni S, Pooley J, Bachoura A, Yoshida R, Cummings J. Triceps brachii insertional footprint: Under-estimated complexity. Shoulder Elbow 2024; 16:321-329. [PMID: 38818100 PMCID: PMC11135194 DOI: 10.1177/17585732221135633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/02/2022] [Accepted: 10/05/2022] [Indexed: 06/01/2024]
Abstract
Background The detailed complexity of triceps brachii insertional footprint continues to challenge surgeons as evidenced by continued reports of triceps-associated complications following elbow procedures. The purpose of this study is to describe the three-dimensional footprint of the triceps brachii at its olecranon insertion at the elbow. Methods 22 cadaveric elbows were dissected leaving only the distal insertion of the triceps intact. The insertion was defined and probed with a three-dimensional digitizer to create a digital three-dimensional footprint allowing width, height, and surface area of the footprint to be recorded relative to the bare area. The insertional soft tissues of tendon versus muscle along with the shape of the footprints were qualitatively described. Results The mean width and surface area of the lateral segment was greater in males than in females (30.07 mm vs. 24.37 mm, p = 0.0339 and 282.1 mm vs. 211. 56 mm, p = 0.0181, respectively). No other statistically significant differences between the sexes were noted. The triceps insertional footprint was "crescent-shaped" and consisted of three regions: central tendon, medial muscular extension, and lateral muscular extension. Discussion These findings can help explain the importance of avoiding these muscular structures during triceps-off approaches and provides the framework for future clinical studies. Clinical Relevance: Basic Science, anatomy study, cadaver dissection.
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Affiliation(s)
- Srinath Kamineni
- Department of Orthopaedic Surgery and Sports Medicine, Elbow Shoulder Research Center, University of Kentucky, Lexington, KY, USA
| | - Joseph Pooley
- Orthopaedic Department, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Ruriko Yoshida
- Department of Operations Research, Naval Postgraduate School, Monterey, CA, USA
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Lanham NS, Tropf JG, Johnson JD. Olecranon Osteotomy Exposure for Distal Humeral Fracture Treatment. JBJS Essent Surg Tech 2024; 14:e23.00041. [PMID: 38975589 PMCID: PMC11221848 DOI: 10.2106/jbjs.st.23.00041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Background Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing1. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques1,2. Description The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular "bare area" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner. Alternatives Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate. Rationale The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures1-3. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches3. OO has not been associated with triceps weakness, unlike some of the alternative techniques2. Expected Outcomes The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures4. Osteotomies united in all patients in 2 reported series, totaling 84 cases1,2. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients1,2. Important Tips Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the OO because of its natural lack of cartilage5,6. This non-articular bare area is located just distal to the deepest portion of the trochlear notch, approximately 2 to 2.5 cm distal to the olecranon tip5,6.An (apex-distal) chevron osteotomy angle of ∼130° will help to keep the osteotomy within the non-articular bare area6.Beginning on the dorsal surface of the ulna, directly posterior to the bare area, an oscillating saw is utilized to create a chevron osteotomy to subchondral bone, perpendicular to the long axis of the ulna5,6.The OO is completed by fracturing through the osteochondral surface, which leaves an irregular chondral cancellous surface that can accurately interdigitate. This facilitates later reduction and stability of the osteotomy.Anatomic articular reduction of the OO is not solely judged on the dorsal cortical bone because of the kerf removed by the saw blade. Instead, examination of the articular surface of the trochlear notch is the primary assessment of reduction.Placement of suture through the proximal portion of the plate aids in the repair of the longitudinal split of the distal triceps.Successful treatment of distal humeral fractures requires accurate reduction and rigid fixation aided by adequate exposure achieved through OO. Acronyms and Abbreviations ORIF = open reduction and internal fixationOT = occupational therapyHWR = hardware removalK-wire = Kirschner wireROM = range of motion.
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Affiliation(s)
- Nathan S. Lanham
- Department of Orthopaedic Surgery, Womack Army Medical Center, Fort Liberty, North Carolina
| | - Jordan G. Tropf
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John D. Johnson
- Department of Orthopaedic Surgery, Womack Army Medical Center, Fort Liberty, North Carolina
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Ailani R, Bhuyan SK, Prasad BK, Kumar A, Dawani N. Clinical outcomes of triceps reflecting anconeus pedicle and olecranon osteotomy approach for distal humerus intercondylar fractures. World J Orthop 2024; 15:570-577. [PMID: 38947270 PMCID: PMC11212544 DOI: 10.5312/wjo.v15.i6.570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/14/2024] [Accepted: 04/26/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND The preferred treatment for distal humeral intercondylar fractures is open reduction and internal fixation. While there is consensus about the posterior approach, several posterior approaches have been developed. It is debatable as to which approach is best. AIM To compare triceps reflecting anconeus pedicle (TRAP) and olecranon osteotomy approaches for internal fixation of distal humeral intercondylar fracture. METHODS In total, 40 cases of Arbeitsgemeinschaft für Osteosynthesefragen/Association of the Study of Internal Fixation type C, closed, and Gustilo type I intercondylar humeral fractures were included. Patients ranged in age from 18 years to 70 years. The patients were randomized into two groups: TRAP group and olecranon osteotomy group, with 20 cases in each. All were followed up at 6 wk, 3 months, 6 months, and 12 months. Functional outcomes were measured in terms of flexion-extension arc, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score. RESULTS The mean age was 43.2 years in the TRAP group and 37.5 years in the olecranon osteotomy group. The mean operative time and mean duration of hospital stay in the TRAP group were significantly higher than in the olecranon osteotomy group (119.5 vs 111.5 min and 9.85 vs 5.45 d, respectively). The mean arc of flexion-extension, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score were comparable without any significant difference in the groups at the 12-month follow-up (107.0 vs 106.2, 18.3 vs 15.7, and 84.2 vs 86.2, respectively). Ulnar paresthesia and superficial infections were comparable in both groups (2 cases vs 3 cases and 3 cases vs 2 cases, respectively). Hardware prominence was significantly higher in the olecranon osteotomy group, mostly due to tension band wiring. CONCLUSION Both approaches were equivalent, but there is a need for further study including higher numbers of subjects and longer study duration to prove the benefits of one approach over the other.
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Affiliation(s)
- Rohit Ailani
- Department of Orthopaedics, Lovee Shubh Hospital, Lucknow, Uttar Pradesh 226002, India
| | | | - Brejesh Kumar Prasad
- Department of Orthopaedics, ESIC Medical College and Hospital, Faridabad, Haryana 121001, India
| | - Amit Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences, Kalyani, West Bengal 741245, India
| | - Namrata Dawani
- Department of Obstetric and Gynecology, Kannauj Medical College, Kannauj, Uttar Pradesh 209732, India
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Gallusser N, Goetti P, Lallemand G, Terrier A, Vauclair F. Surgical approaches to the capitellum: a comparative anatomic study. J Shoulder Elbow Surg 2024; 33:798-803. [PMID: 37890766 DOI: 10.1016/j.jse.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach). METHODS The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach. RESULTS The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface. CONCLUSION Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.
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Affiliation(s)
- Nicolas Gallusser
- Department of Orthopaedic and Trauma Surgery, Valais Hospital, Sion, Switzerland
| | - Patrick Goetti
- Department of Orthopaedic and Trauma Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Geoffroi Lallemand
- Department of Orthopaedic and Trauma Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexandre Terrier
- Department of Orthopaedic and Trauma Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Laboratory of Biomechanical Orthopedics, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Frédéric Vauclair
- Department of Orthopaedic and Trauma Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Bone and Motion Center, Hirslanden Clinique Bois-Cerf, Lausanne, Switzerland.
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Liu Y, Gao Y, Xu X, Zhao Y, Wang H, Sun Q, Zhao B, Wang S, Zhou J. Elbow dislocation approach for complex elbow fractures: a cadaveric study. J Orthop Surg Res 2023; 18:978. [PMID: 38124085 PMCID: PMC10734051 DOI: 10.1186/s13018-023-04478-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Approach need to be considered when surgeons dealt with complex elbow injuries and the choice of the approach is a challenge for surgeons due to the complex anatomy. On the basis of releasing the lateral collateral ligament, we modified the dislocation technique to pursue the superior exposure including not only the distal humeral surface but also the anterior facet of the coronoid process. METHODS A total of 4 cadaver specimens and 8 elbows were included in the study. Each cadaver provided one elbow for either the elbow dislocation approach or the posterior olecranon approach. The exposed distal articular surface of humerus, humeral capitulum, humeral trochlea, anterior trochlea of distal humerus, posterior trochlea of distal humerus and the ulnar coronoid process surface were marked by image J software and calculated for a comparison for each surgical approach. RESULTS The total distal humeral surface was exposed as a median of 98.2 (97.6, 99.6)% and 62.0 (58.3, 64.5)% for the elbow dislocation approach and the olecranon osteotomy approach (P < 0.001), the capitulum 100% and 32.4 (28.0, 39.2)% (P < 0.001), the trochlea 93.2(90.1, 96.9)% and 72.5 (65.2, 78.8)% (P < 0.001), the anterior trochlear articular surface 96.0(93.0, 97.4)% and 50.3 (43.6, 59.1)% (P < 0.001), the posterior trochlear articular surface 95.4 (93, 100)% and 100% (P = 0.76) and the articular surface of the coronoid process of ulna 71.3 (66.0, 74.2)% and 0% (P < 0.001). CONCLUSION For complex elbow fractures, the technique of elbow dislocation provides complete exposure of the distal humerus surface and a significant portion of the coronoid process surface, facilitating direct visualization for reduction and fixation. Level of evidence Anatomy Study; Cadaver Dissection.
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Affiliation(s)
- Yang Liu
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Yuling Gao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Xiaopei Xu
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Yanrui Zhao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Hanzhou Wang
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Qingnan Sun
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Binzhi Zhao
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Siyuan Wang
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China
| | - Junlin Zhou
- Affiliated Beijing Chaoyang Hospital of Capital Medical University, Bejing, China.
- Beijing Chaoyang Hospital, Capital Medical University, Gongtinan Road 8#, Beijing, 100020, China.
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12
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Zhou SC, Jin SY, Wang QY, Ren GK, Peng CG, Wang YB, Wu DK. Surgical flip-dislocation of the bicolumnar approach without olecranon osteotomy versus olecranon osteotomy in type AO 13C3 distal humeral fracture: a matched-cohort study. J Orthop Surg Res 2023; 18:913. [PMID: 38031095 PMCID: PMC10688126 DOI: 10.1186/s13018-023-04405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Our experience with the surgical flip-dislocation of the bicolumnar (SFDB) approach for type AO 13C3 humeral fractures indicates that this surgical approach can be performed safely and effectively in appropriately selected patients. We aimed to evaluate the clinical outcomes of the SFDB approach without olecranon osteotomy (OO) for type AO 13C3 distal humeral fractures. METHODS We retrospectively reviewed 65 cases of type AO 13C3 distal humeral fractures treated between April 2008 and July 2018; 33 patients were treated with the SFDB approach, and the remaining were treated with OO. Propensity score matching was used to control for sex, age, and the American Society of Anesthesiology score. Elbow pain, range of motion, stability, and function were assessed using the Mayo Elbow Performance Index (MEPI) and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Clinical complications, reoperation rates, and radiographic results were compared between the groups. RESULTS Operative time and blood loss were significantly lower in the SFDB group than in the OO group (P = 0.001, P = 0.002, respectively). At the final follow-up, the mean postoperative MEPI did not significantly differ between the groups (P = 0.628). According to Morrey's criteria, a typical functional range of elbow motion was achieved in 12 and 15 patients in the SFDB and OO groups, respectively. CONCLUSIONS The SFDB approach achieves superior exposure of the articular surface without injury to the extensor mechanism in type 13C3 articular surface fracture treatment. This approach also results in good early functional recovery and clinical outcomes, with a low risk of complications.
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Affiliation(s)
- Shi-Cheng Zhou
- Orthopaedic Medical Center, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, Jilin, People's Republic of China
| | - Sheng-Yu Jin
- Orthopaedic Medical Center, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, Jilin, People's Republic of China
| | - Qing-Yu Wang
- Orthopaedic Medical Center, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, Jilin, People's Republic of China
| | - Guang-Kai Ren
- Orthopaedic Medical Center, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, Jilin, People's Republic of China
| | - Chuan-Gang Peng
- Orthopaedic Medical Center, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, Jilin, People's Republic of China
| | - Yan-Bing Wang
- Orthopaedic Medical Center, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, Jilin, People's Republic of China.
| | - Dan-Kai Wu
- Orthopaedic Medical Center, The Second Hospital of Jilin University, No. 218, Ziqiang Street, Nanguan District, Changchun, Jilin, People's Republic of China.
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13
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Feinstein SD, Paterno AV, Allen AD, Jewell E, Wright ST, Draeger RW. Techniques and Fixation of Olecranon Osteotomy: A Systematic Review. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:643-649. [PMID: 37790831 PMCID: PMC10543770 DOI: 10.1016/j.jhsg.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/12/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose We aimed to characterize the incidence of complications regarding olecranon osteotomy, looking more specifically at the type of osteotomy and the fixation construct used to repair the osteotomy. Methods In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search was performed. A study was included if it was an adult clinical study, a transverse or chevron olecranon osteotomy was performed, and the study explicitly states the fixation construct used to repair the osteotomy. A quality assessment was performed in each study prior to data extraction. Results We included 39 studies with a total of 1,445 patients. Most studies included patients who were being treated primarily for a distal humerus fracture. The overall incidence of delayed union was 27/643 (4.2%), with a higher rate in transverse osteotomy than in chevron osteotomy (5/49 (10.2%) vs 22/595 (3.7%)). Nonunion occurred in 43/811 (5.4%) of patients, with a higher rate in transverse osteotomy (6/73 (8.2%) vs. 37/712 (5.2%)). Implant failure or loss of reduction occurred in 44/746 (5.9%) of patients, with a higher rate in transverse osteotomy (11/49 (22.4%) vs 33/688 (4.8%)). The removal of implants occurred in 236/1078 (21.9%) of all patients, with the highest rate in those studies that used plate fixation 44/99 (44.4%). Conclusions Compared with chevron osteotomy, patients who underwent transverse osteotomy had a higher incidence of delayed union, nonunion, and implant failure or loss of reduction requiring revision surgery. The incidence of implant removal indicates that patients should be informed that nearly half of the osteotomy fixed with a plate was removed after implantation. Type of study/level of evidence Therapeutic III.
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Affiliation(s)
- Shawn D. Feinstein
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Anthony V. Paterno
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Andrew D. Allen
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Emily Jewell
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Sarah T. Wright
- University Libraries, University of North Carolina, Chapel Hill, NC
| | - Reid W. Draeger
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
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14
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Daneshvar P, Gee A, Brzozowski P, Schemitsch EH, Rasoulinejad P, Zdero R. Biomechanics of plate fixation following traditional olecranon osteotomy versus novel proximal ulna osteotomy for visualizing a distal humerus injury. Proc Inst Mech Eng H 2023; 237:1052-1060. [PMID: 37485996 DOI: 10.1177/09544119231189108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
After a distal humeral injury, olecranon osteotomy (OO) is a traditional way to visualize the distal humerus for performing fracture fixation. In contrast, the current authors previously showed that novel proximal ulna osteotomy (PUO) allows better access to the distal humerus without ligamentous compromise. Therefore, this study biomechanically compared plating repair following OO versus PUO. The left or right ulna from eight matched pairs of human cadaveric elbows were randomly assigned to receive OO or PUO and repaired using pre-contoured titanium plates. Destructive and non-destructive mechanical tests were performed to assess stability. Mechanical tests on OO versus PUO groups yielded average results for ulna cantilever bending stiffness at a 90° elbow angle (29.6 vs 30.5 N/mm, p = 0.742), triceps tendon pull stiffness at a 90° elbow angle (28.2 vs 24.4 N/mm, p = 0.051), triceps tendon pull stiffness at a 110° elbow angle (61.9 vs 59.5 N/mm, p = 0.640), and triceps tendon pull failure load at a 110° elbow angle (1070.1 vs 1359.7 N, p = 0.078). OO and PUO elbows had similar failure mechanisms, namely, tendon tear or avulsion from the ulna with or without some fracture of the proximal bone fragment, or complete avulsion of the proximal bone fragment from the plate. The similar biomechanical stability (i.e., no statistical difference for 4 of 4 mechanical measurements) and failure mechanisms of OO and PUO plated elbows support the clinical use of PUO as a possible alternative to OO for visualizing the distal humerus.
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Affiliation(s)
- Parham Daneshvar
- Department of Surgery, Division of Orthopaedic Surgery, Queen's University, Kingston, Canada
| | - Aaron Gee
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada
| | | | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada
- Department of Surgery, Division of Orthopaedic Surgery, Western University, London, Canada
| | - Parham Rasoulinejad
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada
- Department of Surgery, Division of Orthopaedic Surgery, Western University, London, Canada
| | - Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada
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15
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Teng L, Zhong G, Li H, Cen S, Liu D, Li L. Combined Medial and Lateral Approach Versus Paratricipital Approach in Open Reduction and Internal Fixation for Type C Distal Humerus Fracture: A Randomized Controlled Study. Orthop Surg 2023; 15:2062-2073. [PMID: 36702763 PMCID: PMC10432446 DOI: 10.1111/os.13658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Olecranon osteotomy and paratricipital approaches were widely used in the treatment of type C distal humerus fracture but some disadvantages exist, so a combined medial and lateral approach was designed. The objective of this study was to investigate and compare the clinical outcomes of combined medial and lateral approach with the paratricipital approach in open reduction and internal fixation of type C distal humerus fractures. METHODS From May 2018 to April 2020, 37 patients with type C distal humerus fracture who accepted open reduction and internal fixation in our hospital were enrolled in this study. All cases were randomly divided into two groups according to the surgical approach: combined medial and lateral approach group (19 cases), paratricipital approach group (18 cases). All of the patients received open reduction and double vertical plates fixation. The operation and follow-up indexes, including operation time, blood loss, incision length, triceps muscle strength, flexion-extension arc of elbow and forearm rotation arc, were recorded and compared. Caja score was used to assess the quality of fractures reduction. Mayo Elbow Performance Score (MEPS) was used to evaluate the elbow function in the follow-up. Complications such as incision infection, ulnar nerve injury, degenerative osteoarthritis, and heterotopic ossification were analyzed. RESULTS The differences in age, gender, and AO classification of fractures between two groups were not statistically significant (p > 0.05). The sum of medial and lateral incision length of combined approach group was longer than the midline incision of paratricipital approach group (15.4 ± 0.8 vs. 14.6 ± 0.8, p < 0.05), but there was no significant difference in operation time (103.5 ± 10.2 vs. 106.0 ± 8.8, p > 0.05), blood loss (71.3 ± 24.5 vs. 72.8 ± 24.6, p > 0.05), and Caja score (16.05 ± 5.67 vs. 15.56 ± 5.66, p > 0.05). During the follow-up, the MEPS of combined approach group was higher than that of paratricipital approach group at 3 months postoperatively (80.5 ± 5.7 vs. 68.9 ± 8.1, p < 0.05), but there was no significant difference in MEPS at 6 months postoperatively (83.9 ± 6.6 vs. 79.7 ± 7.0, p > 0.05) and at the last follow-up (86.8 ± 7.1 vs. 86.9 ± 7.7, p > 0.05) between the two groups. There was no significant difference in triceps muscle strength (p > 0.05), flexion-extension arc (126.8 ± 5.3 vs. 128.9 ± 6.0, p > 0.05), and forearm rotation arc (163.2 ± 5.3 vs. 163.6 ± 4.8, p > 0.05) at the last follow-up. Although the incidence of complication of combined approach group (15.8%) was lower than that of paratricipital approach group (22.2%), the difference was not statistically significant (p > 0.05). CONCLUSIONS The combined medial and lateral approach was an effective and safe way of open reduction and internal fixation for type C distal humerus fractures. Compared with the paratricipital approach, the combined medial and lateral approach could restore the elbow function more quickly postoperatively, and the long-term results were comparable.
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Affiliation(s)
- Lin Teng
- Department of Orthopedics, the First People's Hospital in Shuangliu District/West China Airport HospitalSichuan UniversityChengduChina
| | - Gang Zhong
- Department of Orthopedics, West China HospitalSichuan UniversityChengduChina
| | - Hai‐Bo Li
- Department of Orthopedics, the First People's Hospital in Shuangliu District/West China Airport HospitalSichuan UniversityChengduChina
| | - Shi‐qiang Cen
- Department of Orthopedics, West China HospitalSichuan UniversityChengduChina
| | - Da‐Hai Liu
- Department of Orthopedics, the First People's Hospital in Shuangliu District/West China Airport HospitalSichuan UniversityChengduChina
| | - Liang Li
- Department of Orthopedics, the First People's Hospital in Shuangliu District/West China Airport HospitalSichuan UniversityChengduChina
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16
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Zhang Q, Xiang M, Yang J, Dai F. Clinical and Radiographic Outcomes of Total Elbow Arthroplasty Using a Semi-constrained Prosthesis with a Triceps-preserving Approach over a Minimum Follow-up Period of 4 Years. Orthop Surg 2023; 15:2091-2101. [PMID: 37076437 PMCID: PMC10432419 DOI: 10.1111/os.13698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE Complications related to triceps after total elbow arthroplasty (TEA) have become a major surgical concern. The triceps-preserving approach has the advantage of not disturbing the insertion of triceps but is disadvantaged by the reduced exposure of the elbow joint. The aim of this study was to investigate the clinical and radiological outcomes of TEA with a triceps-preserving approach and to compare the outcomes of TEA to treat arthropathy with that of TEA to treat acute distal humerus fracture. METHODS From January 2010 to December 2018, 23 patients undergoing primary TEAs were retrospectively reviewed with a mean follow-up time of 92.6 months (range, 52-136 months). Each TEA was performed using the triceps-preserving approach with a semi-constrained Coonrad-Morrey prosthesis. Patient demographics, range of motion (ROM), pain visual analogue scale (VAS), and triceps strength (Medical Research Council [MRC] scale) were compared before and after surgery. The Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiographic outcome, and complications were evaluated at follow-up. RESULTS In total, seven males and 16 females were included in this study, with a mean age of 66.1 years (range:46-85 years). By the last follow-up, pain had been significantly relieved in all patients. The average MEPS in the arthropathy group and fracture group were 90.8 ± 10.3 points (range: 68-98 points) and 91.7 ± 0.4 (range: 76-100 points), respectively. The average DASH of the arthropathy group and fracture group was 37.3 ± 18.8 points (range: 18-52 points) and 38.4 ± 20.1 (range: 16-60 points). At the last follow-up after surgery, the mean flexion arcs in the arthropathy group and fracture group were 100.4° ± 24.1° and 97.8° ± 28.1°, respectively. The mean pro-supination arcs in the arthropathy group and fracture group were 142.4° ± 15.2° and 139.2° ± 17.5°, respectively. There were no significant differences in clinical outcomes between the two groups (P ≥ 0.05). Triceps strength was normal (MRC grade V) in 15 elbows and good in eight elbows. None of the cases experienced weakness of the triceps strength, infection, periprosthetic fractures, or prosthesis breakage. CONCLUSIONS The clinical and radiographical outcomes of TEA with the triceps-preserving approach were satisfactory in patients with distal humerus fracture, osteoarthritis and rheumatoid arthritis.
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Affiliation(s)
- Qing Zhang
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
| | - Ming Xiang
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
| | - Jin‐song Yang
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
| | - Fei Dai
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
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17
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Amini DA, Thiele K, Hanlon J, Karczewski D, Wu C, Stöckle U, Bäcker HC, Dahne M. Percutaneous elevation of radial head fractures without fixation - a promising technique. Acta Orthop Belg 2023; 89:213-216. [PMID: 37924537 DOI: 10.52628/89.2.9106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023]
Abstract
The aim of the study is to describe the surgical technique and to report the outcomes of triceps reflecting anconeus pedicle (TRAP) approach for intercondylar fractures of the humerus. Twenty two patients with intercondylar fractures of the humerus were operated on by open reduction via the TRAP approach and internal fixation with dual precontoured locking plates. Data were collected on union time, postoperative complications, range of motion (ROM), triceps power, and objective clinical measurement. All fractures were united with a mean union time of 16.5 weeks (range 12-22). All patients had good-to-excellent Mayo Elbow Performance (MEP) score results with a mean ROM of 118.2 degrees (range 90-135). Triceps power was grade 5 in 16 patients and grade 4 in 6. There were 3 transient ulnar nerve palsy and 1 heterotopic ossification. TRAP approach is safe and effective in terms of utility for articular reduction, restoration of elbow motion, and triceps function for intercondylar fractures of the humerus.
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18
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Davey AP, Wellington IJ, Ford BT, Hawthorne BC, Obopilwe E, Mazzocca AD, Ferreira JV. Plate versus intramedullary screw fixation of chevron olecranon osteotomies: a biomechanical study. JSES Int 2023. [DOI: 10.1016/j.jseint.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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19
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Winek NC, Rubinstein AJ, Hwang M, Amadio JM, Hammarstedt JE, Regal S. Percent articular exposure of the distal humerus with triceps fascial tongue approach compared with olecranon osteotomy. J Shoulder Elbow Surg 2023; 32:401-406. [PMID: 36206985 DOI: 10.1016/j.jse.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/28/2022] [Accepted: 08/27/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Distal humerus fractures are common and can be difficult to treat. No one approach to the distal humerus has been shown to be superior to another; however, the olecranon osteotomy remains the gold standard for complex, intra-articular fractures. Understanding the percent of articular exposure with approaches to the distal humerus is important for success. The goal of this study is to show the percent of articular exposure of the triceps fascial tongue approach as compared with the olecranon osteotomy. METHODS Twelve fresh frozen cadavers were separated randomly into 2 groups of 6 each. The first group of 6 specimens was allocated to the triceps fascial tongue approaches with the collaterals maintained and with the collaterals released off the ulna and elbow dislocated. The second group of 6 was allocated to the triceps fascial tongue approach while maintaining the collaterals followed by an olecranon osteotomy. The articular exposure was marked after performing each approach, and the percent of articular exposure was quantified by using 3D scanning. Standard deviations were calculated for each. RESULTS The average percent visualization of the distal humerus articular surface in the fascial tongue approach while maintaining the collaterals was 36% in the first cohort and 37% in the second cohort with a standard deviation of 5% in both cohorts. The average percent of the distal humerus articular surface exposed in the fascial tongue approach with the collaterals released off the ulna and elbow dislocated was 85.09% with a standard deviation of 4%. The average percent of the distal humerus articular surface exposed in the olecranon osteotomy group was 57.9% with a standard deviation of 5%. CONCLUSION The triceps fascial tongue approach allows for visualization of about one-third of the joint, which may be adequate for many intra-articular distal humerus fractures. For added exposure of the articular surface, the collaterals may be elevated from the ulna and the elbow dislocated allowing for a substantial increase in percent of articular exposure compared with the collateral retaining fascial tongue approach and the olecranon osteotomy.
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Affiliation(s)
- Nathan C Winek
- Allegheny Health Network Department of Orthopedics, Pittsburgh, PA, USA.
| | | | - Minju Hwang
- Allegheny Health Network Department of Orthopedics, Pittsburgh, PA, USA
| | - Joseph M Amadio
- Allegheny Health Network Department of Orthopedics, Pittsburgh, PA, USA
| | - Jon E Hammarstedt
- Allegheny Health Network Department of Orthopedics, Pittsburgh, PA, USA
| | - Steven Regal
- Allegheny Health Network Department of Orthopedics, Pittsburgh, PA, USA
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Luciani AM, Baylor J, Akoon A, Grandizio LC. Controversies in the Management of Bicolumnar Fractures of the Distal Humerus. J Hand Surg Am 2023; 48:177-186. [PMID: 36379867 DOI: 10.1016/j.jhsa.2022.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/20/2022] [Accepted: 10/10/2022] [Indexed: 11/14/2022]
Abstract
Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.
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Affiliation(s)
- Alfred Michael Luciani
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jessica Baylor
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Anil Akoon
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
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21
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Erickson J, Poon P, Barrett M, Chatindiarah I, Albers C. Triceps Split and Snip Approach for Distal Humerus Fractures. J Hand Surg Asian Pac Vol 2023; 28:13-21. [PMID: 36866825 DOI: 10.1142/s2424835523500157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Background: The senior author adopted a Triceps Split and Snip approach in 2011. This paper details the results of patients for whom this approach was utilised for open reduction and internal fixation of complex AO type C distal humerus fractures. Methods: A retrospective analysis of a single surgeon's cases was conducted. Range of movement, as well as Mayo Elbow Performance Score (MEPS), and QuickDASH scores were evaluated. Two independent consultants with upper extremity practises evaluated pre- and post-operative radiographs. Results: Seven patients were available for clinical review. The mean age at the time of surgery was 47.7 years (range, 20.3-83.2) and the mean follow-up time was 3.6 years (range, 0.58-8). The average QuickDASH score was 15.85 (range, 0-52.3), average MEPS was 86.88 (range, 60-100) and average total arc of movement (TAM) was 103° (range, 70°-145°). All patients demonstrated 5/5 MRC triceps strength compared to the contralateral side. Conclusions: The Triceps Split and Snip approach for complex distal humerus fractures provided comparable mid-term clinical outcomes when compared to other published data regarding distal humerus fractures. It is versatile and does not compromise the intra-operative option of conversion to a total elbow arthroplasty. Level of Evidence: Level IV (Therapeutic).
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Affiliation(s)
- John Erickson
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | - Peter Poon
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | - Matthew Barrett
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | - Idah Chatindiarah
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | - Christiaan Albers
- Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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22
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Kim BS, Jung KJ, Kim KB, Park SS. Treating AO Type C2-3 Distal Humerus Fractures With the Anconeus Flap Transolecranon Approach. Orthopedics 2022; 45:e326-e334. [PMID: 35947456 DOI: 10.3928/01477447-20220805-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We evaluated the outcomes of precontoured locking plate fixation with the anconeus flap transolecranon (AFT) approach to treating AO type C2-3 comminuted intra-articular distal humerus (IDH) fractures among active patients. Thirty-six patients (age <65 years) with IDH fractures treated with precontoured distal humerus locking plate fixation were divided into 2 groups: group 1 (n=18; transolecranon [TO] approach) and group 2 (n=18; AFT approach). The radiographic examination included assessments of implant failure, fracture site union, and olecranon osteotomy site union. Clinical examination included assessments of operating time, range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disability of the Arm, Shoulder and Hand (DASH) score, and complications. The mean follow-up time was 25.2 months (range, 18-79 months). The mean operating time was 134.3 minutes and was significantly longer for group 2 (AFT; 141.2 minutes) than for group 1 (TO; 124.2 minutes). The mean olecranon osteotomy site union time was significantly longer in group 2 (7.4 weeks) than in group 2 (4.0 weeks). Olecranon osteotomy site resorption occurred among 6 of 18 patients only in group 2. No significant difference in ROM (flexion, 130°; extension, -0.7°), MEPS (85.7 points), DASH score (20.0 points), or frequency of major complications (TO, 5; AFT, 6) was observed between the groups. Our results showed no advantage of the AFT approach over the TO approach, despite preserving the anconeus. Prospective randomized trials will be necessary to compare the AFT and TO approaches for treating comminuted IDH fractures. [Orthopedics. 2022;45(6):e326-e334.].
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23
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Su Y, Xie Y, Nan G. A novel method of lateral closing wedge osteotomy for cubitus varus deformity in children. BMC Surg 2022; 22:408. [PMID: 36434582 PMCID: PMC9701051 DOI: 10.1186/s12893-022-01854-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Humeral osteotomy is the best method for treatment of severe cubitus varus in children. Many osteotomy methods have been developed in the past. In this study, we describe a novel corrective technique by applying the principles described by Paley involving lateral osteotomy using Kirschner wires (K-wires). Vertices of the osteotomy should be located at the center of rotation of angulation. The anatomical and mechanical axes can be corrected with precision. PATIENTS AND METHODS In this retrospective study, 21 patients (17 male, 4 female) who fulfilled the study criteria and underwent lateral closing osteotomy for cubitus varus deformity from July 2015 to October 2017 were included into the study. The osteotomy line of all patients was designed according to Paley's principles. An isosceles triangle template was made according to the design preoperatively. The lateral osteotomy was made with the assistance of C-arm radiographs. The osteotomy was fixed by K-wires laterally. Patients were followed up, and elbows were evaluated by radiography and using the Mayo Elbow Performance Index (MEPI) score. RESULTS The mean correction angle obtained was 32.33°±2.83°. According to the MEPI score assessment, 19 of the 21 patients had an excellent outcome and two had a good outcome. Two patients complained of conspicuous scars; however, no further cosmetic surgery was performed. The range of motion was 135.0° preoperatively and 133.7° postoperatively, showing no significant difference (p = 0.326). None showed evidence of neurovascular injury or complained of prominence of the lateral humerus. CONCLUSION Paley's principles for correcting cubitus varus deformity in children are effective and reliable for treating such a condition. LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Yuxi Su
- grid.488412.3Department of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Yuzhong District Zhongshan 2road 136#, 400014 Chongqing, China
| | - Yan Xie
- Lab Medicine Department, Chongqing Yubei Maternal and Children Health Hospital, 73# Shuanghu Branch Road, Yubei District, Chongqing, China
| | - Guoxin Nan
- grid.488412.3Department of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Yuzhong District Zhongshan 2road 136#, 400014 Chongqing, China
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24
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Butala RR, Samant PD, Mehra S. Olecranon Osteotomy by a Gigli Saw versus Chevron's Osteotomy for Exposure of Intra-articular Distal Humerus: A Comparative Study. Malays Orthop J 2022; 16:61-69. [PMID: 36589383 PMCID: PMC9791905 DOI: 10.5704/moj.2211.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/07/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Olecranon osteotomy is employed for the fixation of intraarticular distal humeral fractures. We conducted a prospective, randomised study comparing Chevron's osteotomy with olecranon osteotomy by a Gigli saw for exposure of the intraarticular distal humerus in terms of functional outcome and intra-operative ease of the surgery. Materials and methods Thirty patients with skeletally mature AO/OTA type 13- B and 13-C distal humerus fractures were randomly allocated to Chevron's or Gigli saw groups. Each group consisted of a total of 15 patients. Both the groups were assessed on post-operative parameters including arm, shoulder or hand pain, ability to perform certain routine activities, tingling sensations and pain while sleeping. Results In the Gigli saw group, 12 patients had no gross limitation of activity and 13 were able to perform moderate activities with ease. Similar results were observed in the Chevron's group. The mean difference between the two groups in Oxford Score was 0.60, within the 95% confidence interval and in line with QuickDASH-11 Score. Conclusion Chevron's technique offers stability and better healing, providing a larger surface area for bone union. However, it is challenging and time-consuming. Also, literature suggests that the Gigli saw has multiple benefits, saves time and effort, and heals by switching blood supply from centrifugal to centripetal post-operatively. Our study suggests that both Chevron's technique and the use of the Gigli saw are effective in distal humeral intra-articular fractures as assessed by multiple parameters. Hence both techniques can be equally used depending on the surgeon's preference.
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Affiliation(s)
- RR Butala
- Department of Orthopaedics, Padmashree Dr DY Patil University, Navi Mumbai, India
| | - PD Samant
- Department of Orthopaedics, Padmashree Dr DY Patil University, Navi Mumbai, India
| | - S Mehra
- Department of Orthopaedics, Padmashree Dr DY Patil University, Navi Mumbai, India,Corresponding Author: Shivam Mehra, 569/153 Kha, Bargawan Barabirwa, Kanpur road, Lucknow, Uttar Pradesh-226012, India
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25
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Li J, Martin VT, Li DT, Su ZW, Wu YH, Gan JY, Liu QL, Yu B. Lateral epicondyle osteotomy approach vs. olecranon osteotomy approach: an anatomic study of cadavers. J Shoulder Elbow Surg 2022; 31:2339-2346. [PMID: 35613695 DOI: 10.1016/j.jse.2022.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Exposure of the articular surface is the key to successful open reduction and internal fixation treatment for coronal shear fractures of the distal humerus. The olecranon osteotomy approach has previously been described as one of the most effective exposure approaches. Nevertheless, this approach cannot expose the anterior trochlea, and it is impossible to reduce and fix the capitellum under direct vision. The purpose of this study was to compare the exposure of the articular surface of the distal humerus between the lateral epicondyle osteotomy approach (group L) and the olecranon osteotomy approach (group O). METHODS Each approach was performed on 8 freshly frozen upper limbs of adult cadavers. After each approach was completed, a 0.5-mm Kirschner wire is inserted along the edge to mark the visible part of the articular surface. Then, the soft tissue of each elbow is removed, and a surface-scanning system is used to create a digital 3-dimensional model. The visible part of the articular surface obtained by each surgical approach was mapped and quantified using markers created by Kirschner wires. RESULTS The lateral epicondyle osteotomy approach and the olecranon osteotomy approach exposed 0.8 ± 0.0 and 0.6 ± 0.0 of the distal humeral articular surface (P < .001), 1.0 ± 0.0 and 0.3 ± 0.1 of the capitellum (P < .001), 0.6 ± 0.0 and 0.7 ± 0.0 of the trochlea (P < .001), 0.7 ± 0.0 and 0.5 ± 0.1 of the anterior trochlea (P < .001), and 0.5 ± 0.0 and 1.0 ± 0.0 of the posterior trochlea, respectively (P < .001). CONCLUSION Compared with the olecranon osteotomy approach, the lateral epicondyle osteotomy approach could more fully expose the total articular surface of the distal humerus, capitellum, and anterior trochlea, but the olecranon osteotomy approach could more fully expose the trochlea and posterior trochlea.
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Affiliation(s)
- Jie Li
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Vidmi Taolam Martin
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Dong-Tai Li
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Wen Su
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - You-Hui Wu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jing-Yue Gan
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qiao-Lan Liu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
| | - Bo Yu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
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26
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Gurhan U, Ozgur Yildirim A, Alper Yavuz I, Gul Yurdakul F, Civgin E, Erler K, Ceyhan E, Sivas F. Is there any clinical significance of axillary nerve electrophysiological changes in the deltoid split approach? J Orthop 2022; 33:81-86. [PMID: 35879940 PMCID: PMC9307494 DOI: 10.1016/j.jor.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/31/2022] [Accepted: 07/10/2022] [Indexed: 10/17/2022] Open
Abstract
Purpose The clinical effects of axillary nerve injury in the deltoid splitting approach are controversial. This study investigated the axillary nerve function with clinical and electrophysiologically in proximal humeral fracture patients with internal fixation using the deltoid split approach. We also aimed to investigate the effects of this damage on deltoid muscle volume and discuss the effects of volumetric changes and nerve damage on patients' clinical outcomes. Methods study designed prospectively with 25 consecutive patients who received open reduction and internal fixation of proximal humerus fracture through a deltoid splitting approach. We performed clinical, electrophysiological, and radiological examinations during minimum follow-up time of 24 months. Electrophysiological examination comprised electromyoneurography (EMNG). Functional results followed by Constant-Murley and Disabilities of the Arm, Shoulder, and Hand scores. Deltoid volumes were evaluated with magnetic resonance imaging. Results Twenty-five patients operated on with open reduction internal fixation were prospectively observed. In the EMNG measurements of the patients on the 45th postoperative day, partial degeneration was observed in the anterior part of the axillary nerve in all cases (100%). In the control EMNG measurements performed at the 12th month, normal values were obtained for 15 (60%) of the patients, while findings of ongoing regeneration were detected for 10 (40%) of the patients and normal values at all patients at the 24th month. The difference between abnormal and normal EMNG groups' on 12th month Constant-Murley scores was not statistically significant in any period. Only anterior muscle thickness was statistically higher in the normal patient group than with abnormal EMNG results. Conclusions In proximal humeral fractures treated with the deltoid split approach, there may be iatrogenic damage of the anterior branch of the axillary nerve. Axillary nerve damage does not affect the patients' clinical scores in the early and mid-terms. Level of evidence LEVEL III.
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Affiliation(s)
- Utku Gurhan
- Department of Orthopaedic Surgery, University of Kyrenia, KKTC Kyrenia, Mersin 10, Turkey
| | - Ahmet Ozgur Yildirim
- Department of Orthopedic Surgery, Health Sciences University Ankara City Hospital Üniversiteler, 06800, Çankaya/Ankara, Turkey
| | - Ibrahim Alper Yavuz
- Department of Orthopedic Surgery, Health Sciences University Eskişehir City Hospital, Turkey
| | - Fatma Gul Yurdakul
- Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara City Hospital Üniversiteler, 06800 Çankaya/Ankara, Turkey
| | - Esra Civgin
- Department of Radiology, Health Sciences University Ankara City Hospital Üniversiteler, 06800, Çankaya/Ankara, Turkey
| | - Kaan Erler
- Department of Orthopaedics Surgery, Near East University Hospital, KKTC Nicosia, Mersin 10, Turkey
| | - Erman Ceyhan
- Department of Orthopedic Surgery, Health Sciences University Ankara City Hospital Üniversiteler, 06800, Çankaya/Ankara, Turkey
| | - Filiz Sivas
- Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara City Hospital Üniversiteler, 06800 Çankaya/Ankara, Turkey
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27
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Jeong HS, Yang JY, Jeon SJ, Shon HC, Oh JK, Lim EJ. Comparison of olecranon osteotomy and paratricipital approach in distal humerus intra-articular fracture: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e30216. [PMID: 36042686 PMCID: PMC9410592 DOI: 10.1097/md.0000000000030289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Surgical outcomes of the paratricipital approach (PT) and olecranon osteotomy (OO) for the treatment of distal humerus intra-articular fracture have been reported. However, there is no consensus regarding which approach is better in terms of functional outcomes and complications. This study aimed to compare the operation time, functional outcomes, and complications of OO and PT. METHODS The databases of MEDLINE, Embase, and Cochrane Library were systematically searched for studies published before June 1, 2021. We performed synthetic analysis of the operation time, functional outcomes, and incidence of complication after the conduct of OO group or PT group in patients with distal humerus intra-articular fractures. RESULTS Five studies were included representing a total of 243 patients who underwent surgery for distal humerus intra-articular fractures. A pooled analysis showed that there was a longer operation time in the OO group compared with the PT group (mean difference [MD] = 13.32, 95% CI: 3.78-22.87; P = .006). There was no significant difference between the functional outcomes of the OO and PT groups (elbow flexion: MD = 2.4, 95% CI: -0.82 to 5.79, P = .14; elbow extension: MD = 0.36, 95% CI: -2.20 to 2.92, P = .78; elbow arc of motion: MD = 0.40, 95% CI: -4.05 to 4.84, P = .86; Mayo Elbow Performance score: MD = -1.37, 95% CI: -4.73 to 1.98, P = .42). The incidence of infection was significantly higher in the OO group compared with that of the PT group (odds ratio [OR] = 3.82, 95% CI: 1.03-14.16, P = .04). There was no significant difference between the 2 groups in terms of the heterotopic ossification and ulnar neuropathy (OR = 1.85, 95% CI: 0.51-6.71, P = .35 and OR = 2.74, 95% CI: 0.60-12.48, P = .19, respectively). CONCLUSIONS Since the choice of surgical approach does not influence outcomes, surgeons can base their choice of approach on the basis of their own experience and familiarity with the procedure and the need to visualize the entire articular surface in complex intra-articular fracture patterns.
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Affiliation(s)
- Ho-Seung Jeong
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Jae Young Yang
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Seung Jun Jeon
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Hyun-Chul Shon
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
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Giordano V, Glória RC, Dos Santos TA, Koch HA, Giannoudis PV. Extra-articular Olecranon Osteotomy for Reconstruction of Distal Humerus Fractures: Technique and Clinical Results. Orthopedics 2022; 45:e220-e225. [PMID: 35245137 DOI: 10.3928/01477447-20220225-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Articular fractures of the distal humerus in adults are challenging fractures requiring adequate surgical exposure for optimum reconstruction. Most commonly, an articular osteotomy of the olecranon is performed, but complications have been reported related to both creating and repairing the articular osteotomy. We describe the use of an extra-articular olecranon osteotomy for approaching articular fractures of the distal humerus. We highlight the surgical steps required to obtain adequate exposure facilitating anatomical reduction, stable fixation, and early range of motion of the elbow joint. This technique can be added to the surgeon's armamentarium for the management of these complex injuries. [Orthopedics. 2022;45(4):e220-e225.].
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Hackl M, Lanzerath F, Ries C, Harbrecht A, Leschinger T, Wegmann K, Müller LP. Trans-fracture approach for ORIF of coronal shear fractures of the distal humerus. Arch Orthop Trauma Surg 2022; 143:2519-2527. [PMID: 35731264 PMCID: PMC10110670 DOI: 10.1007/s00402-022-04501-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Open reduction and internal fixation (ORIF) of comminuted coronal shear fractures of the distal humerus is challenging. When a concomitant lateral condyle fracture is present, it may be used for a trans-fracture approach to facilitate exposure and fracture reduction. This study aimed to investigate the frequency of lateral condyle fractures in coronal shear fractures of the distal humerus and analyze fracture reduction, fracture union and clinical results following ORIF through a trans-fracture approach. MATERIALS AND METHODS All adult patients who underwent treatment for an acute distal humerus fracture during a three-year period in our level-one trauma center were identified. All fractures were classified according to the Orthopaedic Trauma Association (OTA/AO) fracture classification system and all B3 fractures were classified according to the Dubberley classification. B3 fractures with a concomitant radial condyle fracture were identified. The clinical and radiological results, (Mayo Elbow Performance Score = MEPS, Visual Analogue Scale = VAS, range of motion), complications and revision surgeries were analyzed. RESULTS 53 patients (mean age 52 ± 19 years) were identified. 13 fractures (24.5%) were B3 fractures. Four of them (30.8%) had a concomitant radial condyle fracture. All of these patients underwent ORIF with headless cannulated compression screws and a (postero-)lateral locking plate through a trans-fracture approach. At a minimum follow-up of 24 months, the MEPS was 88 ± 12 points, the VAS was 2 ± 1 and the range of motion was 118° ± 12°. All fractures showed anatomic reduction. One patient developed partial avascular necrosis and underwent arthrolysis at 6 months. One patient underwent partial hardware removal and lateral collateral ligament bracing at 6 months. CONCLUSIONS Lateral condyle fractures are present in about one third of coronal shear fractures of the distal humerus. This injury can be used for a trans-fracture approach to facilitate exposure and to reliably achieve anatomic fracture reduction.
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Affiliation(s)
- Michael Hackl
- Faculty of Medicine, University of Cologne, Cologne, Germany. .,Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany.
| | - Fabian Lanzerath
- Faculty of Medicine, University of Cologne, Cologne, Germany.,Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Christian Ries
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Harbrecht
- Faculty of Medicine, University of Cologne, Cologne, Germany.,Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Tim Leschinger
- Faculty of Medicine, University of Cologne, Cologne, Germany.,Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Kilian Wegmann
- Faculty of Medicine, University of Cologne, Cologne, Germany.,Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Lars Peter Müller
- Faculty of Medicine, University of Cologne, Cologne, Germany.,Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
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30
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Weber MB, Cho E, Evans PJ, Styron J, Bafus BT. Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study. J Shoulder Elbow Surg 2022; 31:1215-1223. [PMID: 35172209 DOI: 10.1016/j.jse.2022.01.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures. METHODS We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared. RESULTS A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7). CONCLUSIONS The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.
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Affiliation(s)
| | - Elizabeth Cho
- MetroHealth Medical Center, Cleveland, OH, USA; Cleveland Clinic Foundation, Cleveland, OH, USA
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Bilateral triceps tendon approach is flexible and efficient in the treatment of type C distal humerus fractures. Chin J Traumatol 2022; 25:145-150. [PMID: 34920951 PMCID: PMC9125722 DOI: 10.1016/j.cjtee.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/28/2021] [Accepted: 11/12/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The purpose of this study was to assess and compare elbow range of motion, triceps extension strength and functional results of type C (AO/OTA) distal humerus fractures treated with bilateral triceps tendon (BTT) approach and olecranon osteotomy (OO). At the same time, we are also trying to know whether BTT approach can provide sufficient vision for comminuted intra-articular fractures of the distal humerus, and whether it is convenient to convert to the treatment to total elbow arthroplasty (TEA) or OO. METHODS Patients treated with OO and BTT approaches for type C distal humerus fractures between July 2014 and December 2017 were retrospectively reviewed. Inclusion criteria include: (1) patients' age were more than 18 years old, (2) follow-up was no less than 6 months, and (3) patients were diagnosed with type C fractures (based on the AO/OTA classification). Exclusion criteria include: (1) open fractures (Gustillo type 2 or type 3), (2) treated by other approaches, and (3) presented with combined injuries of ipsilateral upper extremities, such as ulnar nerve. Elbow range of motion and triceps extension strength testing were completely valuated, when the fractures had healed. Assessment of functional results using the Mayo elbow performance score and complications were conducted in final follow-up. The data were compared using the two tailed Student's t-test. All data were presented as mean ± standard deviation. RESULTS Eighty-six patients of type C distal humerus fractures, treated by OO and BTT approach were retrospectively reviewed between July 2014 and December 2017. Fifty-five distal humerus fractures (23 males and 32 females, mean age 52.7 years) treated by BTT approach or OO were included in this study. There were 10 fractures of type C1, 16 type C2 and 29 type C3 according to the AO/OTA classification. Patients were divided into two surgical approach groups chosen by the operators: BTT group (28 patients) and OO group (27 patients). And the mean follow-up time of all patients was 15.6 months (range, 6-36 months). Three cases in BTT group were converted to TEA, and one converted to OO. Only one case in BTT group presented poor articular reduction with a step more than 2 mm. There were not significantly different in functional outcomes according to the Mayo elbow performance score, operation time and extension flexion motion are values between BTT group and OO group (p > 0.05). Complications and reoperation rate were also similar in the two groups. Triceps manual muscle testing were no significant difference in the two groups, even subdivided in elder patients (aged >60 years old). CONCLUSION BTT is a safe approach to achieve similar functional result comparing with OO. BTT were not suitable for every case with severe comminuted pattern, but it avoids the potential complications related to OO, and has no complications concerning with triceps tendon. It is convenient for open reduction internal fixation and flexible to be converted to OO, as well as available to be converted to TEA in elder patients.
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Spierings KE, Schoolmeesters BJ, Doornberg JN, Eygendaal D, van den Bekerom MPJ. Complications of olecranon osteotomy in the treatment of distal humerus fracture. Clin Shoulder Elb 2022; 25:163-169. [PMID: 35545245 PMCID: PMC9185118 DOI: 10.5397/cise.2021.00591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/08/2022] [Indexed: 11/25/2022] Open
Abstract
Distal humerus fractures (DHFs) are challenging to treat due to the locally complex osseous and soft tissue anatomy. Adequate exposure of the articular surface of the distal humerus is crucial when performing an anatomical reconstruction of the elbow. Even though “triceps-on” approaches are gaining popularity, one of the most commonly used surgical treatments for DHF is olecranon osteotomy. The incidence of complications related to this approach is unclear. This review was performed to assess the type and frequency of complications that occur with the olecranon osteotomy approach in the treatment of DHF. A literature search was conducted in the PubMed/Medline, Embase, and Cochrane Library digital databases up to February 2020. Only English articles describing complications of olecranon osteotomy in the treatment of DHF were included. Data on patient and surgical characteristics and complications were extracted. Statistical analysis was performed using SPSS. A total of 41 articles describing 1,700 osteotomies were included, and a total of 447 complications were reported. Of these 447 complications, wound infections occurred in 4.2% of osteotomies, of which 1.4% were deep infections and 2.8% were superficial. Problems related with union occurred in 3.7% of osteotomies, 2% of which represented non-union and 1.7% delayed union. The high risk of complications in olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of DHF.
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Daneshvar P, Gee A, Schemitsch EH, Pike J, Huang A, Jarvie G, Zdero R, Rasoulinejad P. Proximal Ulna Osteotomy for Complex Fractures of the Distal Humerus: A 3-Dimensional Laser Analysis and Comparison With Olecranon Osteotomy. J Hand Surg Am 2022; 47:320-328. [PMID: 35082086 DOI: 10.1016/j.jhsa.2021.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/21/2021] [Accepted: 11/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The current methods of distal humerus (DH) articular surface visualization only allow a limited view of the joint. This study describes an osteotomy procedure that increases the visualization of and access to the DH articular surface for fixation without compromising ligaments. METHODS Eighteen fresh-frozen human elbows (9 matched pairs) underwent proximal ulna osteotomy (PUO) or transverse olecranon osteotomy (OO) contralaterally. The visualized articular surface of the DH was demarcated, and the surface areas of the DH, capitellum, and trochlea were measured using 3-dimensional scanning. The angular arc of the articular surface of the capitellum and trochlea was measured using a goniometer. RESULTS The 3-dimensional scans showed that 87.6% of the total DH surface area was visualized using PUO versus 65.6% using OO. When the trochlea and capitellum surface areas were separated, 94.0% versus 75.9% of the trochlea and 74.8% versus 44.7% of the capitellum were visualized using PUO and OO, respectively. The goniometric angles demonstrated that 98.2% versus 70.9% of the trochlea and 75.1% versus 43.5% of the capitellum articular surface arc angles were visualized using PUO and OO, respectively. After PUO with further release of the flexor-pronator mass was performed, 100% of the DH articular surface was visualized. CONCLUSIONS Proximal ulnar osteotomy improves the visualization of the DH articular surface. CLINICAL RELEVANCE Proximal ulna osteotomy spares ligaments, avoids osteotomizing the greater sigmoid notch, involves more robust metaphyseal bone for potentially better fixation, and may permit DH arthroplasty without compromising primary ligamentous elbow stabilizers. Further clinical studies are needed to assess the utility of this type of osteotomy.
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Affiliation(s)
- Parham Daneshvar
- Kingston Health Sciences Centre, Kingston General Hospital Site, Kingston, Canada; Department of Surgery, Queen's University, Kingston, Canada; St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
| | - Aaron Gee
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada
| | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada; Department of Surgery, Division of Orthopaedic Surgery, Western University, London, Canada
| | - Jeff Pike
- St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Adrian Huang
- St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Geoff Jarvie
- St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada; Department of Surgery, Division of Orthopaedic Surgery, Western University, London, Canada; Department of Mechanical and Materials Engineering, Western University, London, Canada
| | - Parham Rasoulinejad
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, Canada; Department of Surgery, Division of Orthopaedic Surgery, Western University, London, Canada
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Jitprapaikulsarn S, Chantarapanich N, Gromprasit A, Mahaisavariya C, Patamamongkonchai C. Modified pin and plate fixation for low intercondylar fractures of the humerus: biomechanical study corroborated with a case series. Musculoskelet Surg 2022; 107:207-221. [PMID: 35362865 DOI: 10.1007/s12306-022-00743-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 03/10/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Establishing fracture union of low and comminuted intercondylar fractures of the humerus is inherently challenging. The purposes of the present study were to investigate the biomechanical effectiveness of pin & plate (PP) fixation compared to other dual-plating techniques by finite element analysis, and to present a technical description as well as retrospectively review the outcomes of PP fixation in such difficult fractures. METHODS Low-level intercondylar fracture 3D models of the humerus were virtually stabilized with three fixations on lateral side including PP, lateral pre-contoured locking compression plate (L-LCP), and variable angle lateral pre-contoured locking plate (VA-L-LCP) whereas medial pre-contoured locking compression plate (M-LCP) on medial side. Loading conditions under consideration were axial compression, internal rotation, posterior bending, and valgus rotation. Regarding the clinical series, eight patients with intra-articular and comminuted fractures of the distal humerus (6 intercondylar fractures, 1 fracture-subluxation, and 1 isolated lateral condylar fracture) were operated by isolated PP fixation or combinations of PP and the other standard implants. Data were collected on fracture union, perioperative complications, and objective clinical outcomes. RESULTS Biomechanical results revealed the most instability of the fracture occurring under posterior bending. PP fixation presented comparable fracture stability and fragment displacement compared to other dual-plating fixations, except stress on the Kirschner wire under internal rotation which was higher than other fixations. Regarding the clinical series, fracture union was achieved in all cases with an average union time of 17 weeks (range 12-20). All except one patient had good-to-excellent MEPS results with an average Disabilities of the Arm, Shoulder, and Hand (DASH) score of 14.6 (range 0-45) and an average arc of elbow motion of 107.5 degrees (range 60-140). CONCLUSION By the biomechanical performance, PP fixation is a reliable technique for fixation of low intercondylar fractures of the humerus. Supported by the clinical outcomes, the present technique could be an alternative for this particular fracture especially when severe comminution prevents the use of the standard dual plating technique.
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Affiliation(s)
- S Jitprapaikulsarn
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - N Chantarapanich
- Department of Mechanical Engineering, Faculty of Engineering at Sriracha, Kasetsart University, Sriracha, Chonburi, Thailand.
| | - A Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - C Mahaisavariya
- Golden Jubilee Medical Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Kahan JB, Schneble CA, Simcock X, Evans PJ, Maschke SD, Seitz W, Donohue KW. The Van Gorder approach for total elbow arthroplasty. J Shoulder Elbow Surg 2022; 31:495-500. [PMID: 34653613 DOI: 10.1016/j.jse.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA. METHODS All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed. RESULTS A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits. CONCLUSIONS This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.
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Affiliation(s)
- Joseph B Kahan
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher A Schneble
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Xavier Simcock
- Department of Orthopedic Surgery, Rush Medical Center, Chicago, IL, USA
| | - Peter J Evans
- Department of Orthopedic Surgery, The Cleveland Clinic Martin Health, Cleveland, OH, USA
| | - Steven D Maschke
- Department of Orthopedic Surgery, The Cleveland Clinic Martin Health, Cleveland, OH, USA
| | - William Seitz
- Department of Orthopedic Surgery, The Cleveland Clinic Martin Health, Cleveland, OH, USA
| | - Kenneth W Donohue
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA.
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Jamoh K, Tonk G. Como escolher entre as abordagens transolecraniana e por reflexão do tríceps para tratar fraturas distais do úmero em adultos: Um estudo prospectivo. Rev Bras Ortop 2022; 57:301-307. [PMID: 35652010 PMCID: PMC9142222 DOI: 10.1055/s-0041-1741444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/20/2021] [Indexed: 11/23/2022] Open
Abstract
Objective
To choose an appropriate posterior approach for distal humerus fractures in adults.
Methods
Fifty patients with distal humerus fractures were analyzed prospectively. The fractures were classified using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO, Working Group for Bone Fusion Issues, in German/OTA) classification. The patients were divided into group A and group B. Olecranon osteotomy (the transolecranon approach) was performed in 30 patients, and the triceps-reflecting approach was used in 20 patients. The functional results were evaluated using the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.
Results
The average operative time was of 92.62 ± 8.73 minutes for group A, and of 78.63 ± 7.02 minutes for group B, (
p
< 0.01), and the average blood loss was of 222.78 ± 34.93 mL for group A, and of 121.61 ± 19.85 mL for group B, (
p
< 0.01), which were statistically significant. The mean scores on the MEPS and DASH of both groups were found to be insignificant. Complications like infection, neurapraxia and soft tissue irritation where observed more in group A.
Conclusion
The triceps-reflecting approach results in a shorter operative time, a lower levels of blood loss, and a low rate of complications, and olecranon osteotomy provides better accuracy in terms of articular reduction. But there were no significant differences between the two groups regarding the functional outcome. Therefore, we have proposed a new classification that is a modification of the AO/OTA classification: type 1 includes AO grades 13A to C2 (B3 excluded); and type 2, AO 13C3. For type-1 fractures, the triceps-reflecting approach may be considered, and, for type-2 fractures, olecranon osteotomy.
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Affiliation(s)
- Kalom Jamoh
- Departamento de Ortopedia, ESIC-PGIMSR, Nova Deli, Índia
| | - Gyneshwar Tonk
- Departamento de Ortopedia, LLRM Medical College, Meerut, Uttar Pradesh, Índia
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Kong L, Wang Y, Lu Q, Han Y, Wang F. Biomechanical properties of a novel fixation system for intra-articular distal humerus fractures: a finite element analysis. J Orthop Surg Res 2021; 16:674. [PMID: 34784932 PMCID: PMC8594201 DOI: 10.1186/s13018-021-02836-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background The traditional strategy for fixing intra-articular distal humerus fractures is double plating placed in an orthogonal configuration, based on posterior approach. With a combined medial and lateral approach, a novel configuration of plating (combined anteromedial and anterolateral plating) has been used. In this study, we investigated the biomechanical properties of the novel plating by comparing it with some traditional strategies. Methods Based on the 3D morphology of a healthy subject’s humerus, models of three types of intra-articular distal humeral fractures were established using a variety of different internal fixation methods: (a) treatment of a simple intra-articular fracture of the distal humerus with the novel double plate and a traditional orthogonal plate; (b) treatment of a comminuted fracture of the lower distal humerus with the novel double plate, a traditional orthogonal plate and a traditional orthogonal plate combined with distally extended tension screws; (c) treatment of a coronal shear fracture of the distal humerus with the novel double plate, a traditional orthogonal plate and the intra-articular placement of three screws. The material properties of all plates and screws were isotropic and linearly elastic. The Poisson ratio of the implant and bone was 0.3, and the elastic modulus of the implant was 114,000 MPa. The axial loading is 200 N, the bending loading is 30 N and varus rotation is 7.5 Nm in the longitudinal direction. Results A simple model of intra-articular fracture of the distal humerus (AO C1 type) was established. Under all experimental conditions, the novel double plate showed greater stiffness than the orthogonal double plate. The axial straightening, bending compression and varus torsion increased by 18.00%, 16.00% and 44.00%, respectively. In the model of comminuted fracture of the lower distal humerus, the novel double plate showed the best stiffness under three experimental conditions (163.93 N/mm, 37.97 N/mm, 2697.84 N mm/°), and the stiffness of the traditional orthogonal plate combined with the distally extended tension screws was similar to that of the traditional orthogonal plate (121.21 N/mm, 32.61 N/mm, 1968.50 N mm/°). In the model of coronal shear fracture of the distal humerus, the novel double plate showed the best stiffness under all test conditions (194.17 N/mm, 38.46 N/mm, 2929.69 N mm/°), followed by the traditional plate (153.85 N/mm, 33.33 N/mm, 2650.18 N mm/°), while the stiffness of the three screws was the smallest (115.61 N/mm, 28.30 N/mm, 2180.23 N mm/°). Conclusions In terms of biomechanics, compared with other internal fixation methods, the novel combined anteromedial and anterolateral anatomical locking double-plate showed less stress, less displacement and greater stiffness. The novel double-plate method can be used to treat not only simple intra-articular fractures of the humerus but also complex comminuted fractures of the lower distal humerus and coronal shear fractures of the distal humerus, with a better effect than current traditional internal fixation methods.
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Affiliation(s)
- Lingpeng Kong
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
| | - Yan Wang
- Department of Medical Laboratory Diagnosis Center, Jinan Central Hospital, No. 105 Jiefang Road, Ji'nan, 250014, Shandong, People's Republic of China
| | - Qingsen Lu
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
| | - Yong Han
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China.
| | - Fu Wang
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China.
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Hess S, Bürki A, Moor BK, Bolliger L, Zysset P, Zumstein MA. A biomechanical study comparing the mean load to failure of two different osteosynthesis techniques for step-cut olecranon osteotomy. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:414-420. [PMID: 37588712 PMCID: PMC10426472 DOI: 10.1016/j.xrrt.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Olecranon osteotomies are frequently used to expose distal humeral intraarticular fractures. The step-cut olecranon osteotomy (SCOOT) is an augmented version of the oblique olecranon osteotomy, which has recently been evaluated biomechanically with tension band wiring (TBW) fixation. However, complications with TBW are common. In this study, we, therefore, compared the mean load to failure of TBW with compression screws for SCOOT fixation. We hypothesized a higher load to failure for the compression screw group. Methods We performed a SCOOT on 36 Sawbones. Eighteen were fixed with TBW, and another 18 with two compression screws. The humeroulnar joint was simulated using an established test setup, which allows the application of triceps traction force through a tendon model to the ulna, while the humeroulnar joint is in a fixed position. Eight models of each fixation group were tested at 20°, and eight at 70° of flexion by isometrical loading until failure, which was defined as either a complete fracture or gap formation of more than 2 mm at the osteotomy site. Results At 20° of flexion, mean load to failure was similar between the TBW group (1360 ± 238 N) and the compression screw group (1401 ± 261 N) (P = .88). Also, at 70° of flexion, the mean load to failure was similar between the TBW group (1398 ± 215 N) and the compression screw group (1614 ± 427 N) (P = .28). Conclusions SCOOTs fixed with TBW and compression screws showed similar loads to failure. A SCOOT fixed with compression screws might be a valuable alternative for surgeons when treating intraarticular distal humeral fractures. However, future in vivo studies are necessary to confirm our results in a clinical setting.
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Affiliation(s)
- Silvan Hess
- Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern Switzerland
| | | | - Beat K. Moor
- Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern Switzerland
| | - Lilianna Bolliger
- Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern Switzerland
| | | | - Matthias A. Zumstein
- Shoulder, Elbow and Orthopaedic Sports Medicine, Orthopaedics Sonnenhof, Bern, Switzerland
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Abstract
Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.
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Affiliation(s)
- Naoko Onizuka
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Julie Switzer
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Chad Myeroff
- TRIA Orthopedic Center, 155 Radio Drive, Woodbury, MN 55125, USA.
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40
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Abstract
Distal humerus fractures in the elderly population can be difficult to manage because of substantial articular comminution, poor bone quality, and soft tissue compromise. Important patient considerations for treatment include physiologic age, mental status, activity level, and independence with activities of daily living. Elderly patients may be reliant on their upper extremity as a weight-bearing limb when using a walker or rising to stand which creates additional demand. The goal of surgical treatment is to recreate a stable, painless elbow with a functional range of motion to preserve independence for daily activities and mobilization. The main surgical treatment options are open reduction and internal fixation and arthroplasty. Here, we discuss indications and operative goals in each clinical scenario.
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Wilson ES, Buckwalter JA, Henning G, Davison J, Fleury IG, Willey MC. Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications. J Orthop Trauma 2021; 35:e223-e227. [PMID: 33208714 DOI: 10.1097/bot.0000000000002006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13). DESIGN Retrospective comparative cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy). INTERVENTION Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy. MAIN OUTCOME MEASURE Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI). RESULTS Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001). CONCLUSIONS Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Erin S Wilson
- University of Iowa, Carver College of Medicine, Iowa City, IA; and
| | - Joseph A Buckwalter
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Grant Henning
- University of Iowa, Carver College of Medicine, Iowa City, IA; and
| | - John Davison
- University of Iowa, Carver College of Medicine, Iowa City, IA; and
| | - Ignacio G Fleury
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael C Willey
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
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Abstract
The objective of this review is to summarize the surgical options for primary osteoarthritis of the elbow, reported clinical outcomes, and suggested indications in previous literatures. The surgical management of primary elbow arthritis has evolved because of an improved understanding of pathologic mechanisms and manifestations as well as the development of novel surgical techniques and devices. Osteocapsular arthroplasty (OCA), elbow debridement, distraction arthroplasty, and total elbow arthroplasty (TEA) have been employed for managing elbow osteoarthritis. Elbow debridement and OCA can be helpful in most cases of symptomatic elbow arthritis. TEA is usually recommended for end-stage arthritis in elderly patients after prosthetic implants have been in place for long periods or after complications. Distraction arthroplasty might find a place in the treatment of younger, active patients with end-stage arthritis.
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Affiliation(s)
- Jae-Man Kwak
- 65526Department of Orthopedic Surgery, Eulji Medical Center, College of Medicine, Eulji University, Uijeongbu, South Korea
| | - In-Ho Jeon
- 65526Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Seoul, South Korea
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Surgical Elbow Dislocation. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Aggarwal S, Paknikar K, Sinha J, Compson J, Reichert I. Comprehensive review of surgical approaches to the elbow. J Clin Orthop Trauma 2021; 20:101482. [PMID: 34262848 PMCID: PMC8254122 DOI: 10.1016/j.jcot.2021.101482] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/03/2021] [Accepted: 06/19/2021] [Indexed: 11/16/2022] Open
Abstract
The choice of the most suitable surgical approach to the elbow forms the foundation of any successful elbow surgery. The surgical approach is based on the injury or pathology to be addressed and therefore specific anatomical details need to be considered. The surgeon must be comfortable with the bony, ligamentous and neurovascular anatomy of the elbow to consider and execute the best approach for each problem. This is an imperative to avoid iatrogenic injury. This article provides a detailed analysis, valuable technical tips, advantages and disadvantages of the most common approaches to the elbow. The lateral approaches include the Kocher, Kaplan and Extensor Digitorum Communis (EDC) Split approaches, the medial approaches include the Hotchkiss, Flexor carpi ulnaris (FCU) splitting approach, the Taylor and Scham approach. The anterior approach includes the anterior neurovascular interval approach and the posterior approaches include the Olecranon osteotomy, triceps sparing, triceps reflecting approach and finally the Boyd interval approach. The text and illustrations will provide a structured overview for the practicing surgeon.
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Affiliation(s)
- Saurabh Aggarwal
- Princess Royal University Hospital, Kings College Hospital, NHS Foundation Trust, Farnborough Common, Orpington, BR6 8ND, UK
| | - Kiran Paknikar
- Princess Royal University Hospital, Kings College Hospital, NHS Foundation Trust, Farnborough Common, Orpington, BR6 8ND, UK,Corresponding author.
| | - Joydeep Sinha
- Kings College Hospital NHS Foundation Trust, Denmark Hill, Brixton, London, SE5 9RS, UK
| | - Jonathan Compson
- Kings College Hospital NHS Foundation Trust, Denmark Hill, Brixton, London, SE5 9RS, UK
| | - Ines Reichert
- Kings College Hospital NHS Foundation Trust, Denmark Hill, Brixton, London, SE5 9RS, UK
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Li J, Martin VT, Su ZW, Li DT, Zhai QY, Yu B. Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature. World J Clin Cases 2021; 9:4318-4326. [PMID: 34141796 PMCID: PMC8173410 DOI: 10.12998/wjcc.v9.i17.4318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/24/2021] [Accepted: 04/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage. Open reduction and internal fixation (ORIF) has become the preferred treatment because it provides anatomical reduction, stable internal fixation, and early motion, but the optimal surgical approach remains controversial. CASE SUMMARY We report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach, in which lateral epicondyle osteotomy was performed based on the extended lateral approach. We named the novel surgical approach the lateral epicondyle osteotomy approach. All patients underwent surgical treatment and were discharged successfully. All patients had excellent functional results according to the Mayo elbow performance score. The average range of motion was 118° in flexion/extension and 172° in pronation/ supination. Only case 2 had a complication, which was implant prolapse. CONCLUSION We demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.
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Affiliation(s)
- Jie Li
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Vidmi Taolam Martin
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Zhi-Wen Su
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Dong-Tai Li
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Qi-Yi Zhai
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Bo Yu
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
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Karslioglu B. Transverse olecranon osteotomy with Gigli saw: A fast and reliable technique. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2021. [DOI: 10.25083/2559.5555/6.1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective. Distal humerus fractures constitute of approximately 2% of all fractures and 30% of elbow fractures. Olecranon osteotomy provides excellent exposure of distal humerus and articular surface. In this study, we aimed to compare transverse osteotomy with gigli saw and classical chevron osteotomy techniques in terms of osteotomy duration and clinical results. Materials and Methods. 40 elbows of 40 patients with Type B intraarticular distal humerus fractures according to AO classification were included in our study. Patients were divided into 2 groups as transverse or chevron osteotomy groups. Patients were evaluated in terms of intraoperative osteotomy time, postoperative time to union, range of motion in the elbow joint and Quick Dash scores at 6th, 12th and 24th months. Results. The mean age of the patients was 45.6 years (19-62). 40% of the patients (8 patients) in the Chevron group had more than 2 mm stepping at articular surface, while this rate was 10% (2 patients) in the gigli saw group. Union was obtained in all patients for both techniques. There was no significant difference between the mean QuickDASH scores and range of motion of the elbow joints except flexion in both groups. Range of motion of flexion was statistically better in the gigli saw group (p<0.05). Conclusions. Transverse osteotomy technique significantly reduces osteotomy and fixation time and will not cause problems in fracture union. It may be preferred because it is simpler and faster to apply than chevron osteotomy and because intra-articular stepping is less common.
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Meldrum A, Kwong C, Archibold K, Cinats D, Schneider P. Olecranon Osteotomy Implant Removal Rates and Associated Complications. J Orthop Trauma 2021; 35:265-270. [PMID: 33086235 DOI: 10.1097/bot.0000000000001979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study reports on olecranon osteotomy implant removal rates, fixation types, and associated complications. DESIGN Multicentre case series. SETTING Patients were identified through an electronic medical database at one Level 1 trauma center and three Level 2 trauma centers. PATIENTS Two hundred thirty-five patients were identified through the database, of which 92 patients met inclusion criteria. INTERVENTION Patients underwent olecranon osteotomy for fixation of distal humerus fractures and the implant used was at the surgeon's discretion. MAIN OUTCOME MEASUREMENT Implant removal rate. RESULTS Thirty-four of 92 (37.0%) patients underwent removal of implant from their olecranon osteotomy. Implant removal rates were as follows: 28 of the 63 patients for tension band wiring (TBW) (44.4%), 6 of the 18 patients for plates (33.3%), 0 of the 1 patient for cable-pin, and 0 of the 10 patients for osteotomies fixed with a screw fixation. Screw fixation was removed less frequently than TBW (P = 0.01). Screws were less commonly removed than all other fixation types (P = 0.01). TBWs (28/63) were more commonly removed than all other implants (6/29) (P < 0.05). The nonunion rate for olecranon osteotomies was 3.3%. TBWs (18/18) are more likely to be removed for implant irritation than plates. TBWs had an odds ratio of 3.29 for requiring implant removal if they were left >1 mm off of the olecranon tip. CONCLUSION In this study, 34 of the 92 (37%) patients undergoing an olecranon osteotomy for treatment of a distal humerus fracture required removal of olecranon implant. Screw fixation (0/10) was found to be removed less frequently than TBW fixation 28 of the 63 patients (44.4%). LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander Meldrum
- Division of Orthopaedic Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Cory Kwong
- Southern California Orthopaedic Institute, University of Los Angeles, Los Angeles, CA
| | | | - David Cinats
- Department of Orthopedics, SUNY Upstate Medical University, Syracuse, NY; and
| | - Prism Schneider
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
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Comparison of double screw fixation versus tension-band fixation after olecranon osteotomy for complex distal humerus fractures. Orthop Traumatol Surg Res 2021; 107:102641. [PMID: 33129752 DOI: 10.1016/j.otsr.2020.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/23/2020] [Accepted: 02/18/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Supra- and intercondylar elbow fractures are surgically challenging given the intra-articular comminution. Various surgical approaches have been described. Among these-olecranon osteotomy-provides optimal joint exposure but is associated with several complications. Tension band wiring (TBW) is the most commonly used fixation method. We hypothesized that double screw fixation would lead to fewer surgical revisions than TBW (all causes included) after olecranon osteotomy. METHODS We carried out a single-center retrospective study of 39 patients, treated between January 2007 and April 2016, for a supra- or intercondylar elbow fracture using the transolecranon exposure. There were 34 type C fractures (13 C1, 6 C2 and 15 C3), 3 type B fractures and 2 type A fractures, based on the AO classification. Fourteen patients received double screw fixation and 25 received TBW. The primary outcome measure was the number of surgical revisions, regardless of cause. Secondary outcome measures were the number of surgical revisions for olecranon nonunion, fixation failure or fixation device removal due to pain. RESULTS There were significantly more surgical revisions in the TBW group than in the double screw fixation group: 3 (21%) versus 14 (56%) (p=0.049, Fisher test). The three main reasons for revision in the TBW and double screw fixation groups were removal of the fixation device due to soft tissue impingement (11 [44%] versus 2 [14%]; p=0.08), failure of the olecranon fixation (6 [24%] versus 1 [7%] p=0.38), and olecranon nonunion (4 [16%] versus 0 [0%] p=0.27). DISCUSSION There are no published studies on the outcomes of this surgical technique. The posterior transolecranon approach provides the best exposure at the elbow joint. TBW fixation is associated with multiple complications. Double screw fixation for olecranon fractures yields good clinical and radiological outcomes. CONCLUSION Based on our findings, double screw fixation of the olecranon results in fewer surgical revisions (all causes combined) than TBW in supra- and intercondylar elbow fractures operated by a transolecranon approach. LEVEL OF EVIDENCE IV.
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Surgical Elbow Dislocation Approach to the Distal Humerus for Apparent Capitellar and Lateral Condyle Fractures in Adults. J Orthop Trauma 2021; 35:e77-e81. [PMID: 33105453 DOI: 10.1097/bot.0000000000001923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Access to fractures of the distal humeral capitellum, trochlea, and lateral condyle is difficult through traditional approaches due to limited anterior articular exposure for direct reduction and fixation. The purpose of this study is to evaluate the relative articular exposure of a surgical dislocation (SD) approach to the distal humerus compared with olecranon osteotomy (OO). METHODS Eight paired elbows from 4 cadavers underwent either SD or OO approach. Methylene blue staining demarcated visualized articular surface before disarticulation of the elbows. The main outcome measures were average visualized total distal humeral articular surface and anterior and posterior surface, and capitellar surface relative to the total surfaces was compared for each surgical approach using unpaired parametric t-tests. RESULTS Intraclass correlation between raters was 0.995. The median exposed articular surface for SD and OO approaches was 90.0% and 62.8%, respectively. The overall exposure was significantly greater for the dislocation technique (P = 0.0003). With respect to specific regions of the distal humeral articular surface, SD allowed significantly greater visualization of the anterior surface (95.9% vs. 48.9%, P < 0.0001) and capitellum (100% vs. 40.4%, P < 0.0001). CONCLUSION The surgical elbow dislocation approach to the distal humerus permits near total exposure of the anterior articular surface and the entire capitellum. Our data support this approach for anterior articular fractures of the distal humerus, to include those fractures that extend to the medial surface of the trochlea.
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Abstract
Background Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost. Methods We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC. Results Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor). Conclusion Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.
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