Arthrolysis combined with reconstruction for treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention

Reported outcome measures in complex fracture elbow dislocations: a systematic review

BACKGROUND

Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for nonrandomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded.

RESULTS

Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n = 70), extension (n = 62), pronation (n = 68), or supination (n = 67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (n = 69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n = 28 [34%]), the visual analog scale for pain (n = 27 [33%]), QuickDASH score (n = 13 [15.7%]), and Oxford Elbow score (n = 5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P = .313), study type (P = .689), complex fracture pattern (P = .211), or number of elbows included (P = .152).

CONCLUSION

There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the Mayo Elbow Performance Score and DASH outcomes measures as well as visual analog scale pain rating scale in future studies to facilitate cross-study comparisons.

Hidden instability in posttraumatic stiff elbows

BACKGROUND

Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet.

HYPOTHESIS

The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow.

METHODS

From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12 months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed.

RESULTS

Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7 months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%).

CONCLUSION

Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations.

LEVEL OF EVIDENCE

IV.

Restoring independency with an osteochondral graft of the navicular for coronoid process reconstruction

INTRODUCTION

The coronoid is a crucial element for elbow stability. In case of posttraumatic instability or reduced range of motion, a complex reconstruction might be necessary.

CASE

We present the case of a polytraumatized patient with complex upper extremity injury and initial poor outcome. Subluxation after initial surgery was treated by sublime tubercle reconstruction with a corticocancellous iliac crest graft. Due to massive ossification, the elbow remained stiff and the paraplegic patient was unable to use a manually propelled wheelchair. After arthrolysis, the unstable elbow was treated with an osteocartilaginous graft from the navicular of the foot as well as ulnar and radial collateral ligamentoplasties. At the time of follow-up, the patient had a stable joint and was able to independently perform activities of daily living.

CONCLUSION

An autologous navicular graft seems to be an excellent option for our paraplegic patient as the shape matches the sublime tubercle of the ulna.

Reconstruction of medial collateral ligament defects with a flexor-pronator fascia patch in complete open release of stiff elbows

BACKGROUND

Because medial elbow stability is essential for stiff elbow release, surgical techniques have been reported for reconstructing medial elbow stability. However, medial collateral ligament (MCL) defects, caused by inevitable detachment and resection performed for complete release, make the reconstruction more challenging. To our knowledge, no study has evaluated the outcomes after using a flexor-pronator fascia patch in medial elbow reconstruction for open release of stiff elbows. We hypothesized that this technique is effective for repairing MCL defects.

METHODS

We retrospectively reviewed the records of 10 patients. The MCL defects were all reconstructed with a flexor-pronator fascia patch. An external fixator was used in all patients. One patient could not be contacted and was thus excluded from the study. Outcome measures included stability, range of motion, Mayo Elbow Performance Score, ulnar nerve symptoms, power grip, and radiographic findings.

RESULTS

The mean follow-up period was 19.6 months; all elbows were stable by the last follow-up. One patient presented with moderate elbow instability and then regained stability 3 months after the external fixator was removed. The Mayo Elbow Performance Score improved from 58 points to 94 points, and the mean flexion arc improved from 40° to 133°. No radiographic manifestations of elbow dislocation or suture anchor looseness were observed.

CONCLUSION

A flexor-pronator fascia patch provides sufficient stability for repairing MCL defects without restricting the range of motion gained during arthrolysis.