Using an anatomically preshaped low-profile locking plate system leads to reliable results in comminuted radial head fractures

Analysis of Surgical Stabilization Results of Radial Head Fractures

Background/Objectives: According to the modified Mason classification, radial head fractures can be treated with open reduction and internal fixation (ORIF), radial head arthroplasty, or resection. This study by the Department of Traumatology and Orthopedics of the Military Institute of Medicine aimed to compare the clinical and radiological outcomes of fractures treated with ORIF. Methods: This retrospective study analyzed 55 patients with radial head fractures treated between April 2020 and February 2023. Fractures were classified using Mason system as 15 type II, 26 type III, and 14 type IV. Clinical outcomes were evaluated using the VAS for pain, Broberg-Morrey scale, and the DASH questionnaire, alongside assessments of range of motion, grip strength, and elbow stability. Follow-up radiographs examined bone union, bone fragments displacement, degenerative changes and periarticular ossification. Results: The mean follow-up period was 21.0 ± 10.2 months. There were no statistically significant differences in VAS scale results for Mason types II, III, and IV fractures (4.0 vs. 6.0 vs. 5.0, respectively; p = 0.825), the Broberg-Morrey scale (82.0 ± 15.2 vs. 80.9 ± 15.5 vs. 84.2 ± 15.1, respectively; p = 0.845), or the DASH questionnaire (10.0 vs. 11.7 vs. 17.5, respectively; p = 0.937). Mean extension deficit and supination angles were at the limit of statistical significance (p = 0.076 and p = 0.051). No cases of lateral instability were observed, whereas medial instability was seen in only one case. Bone union was observed in 97.5% of cases, with elbow joint osteoarthritis and periarticular ossification in 15.0% and 45.0% of cases, respectively. Conclusions: Mason type II, III and IV radial head fractures treated with open reduction and internal fixation showed good functional and radiological outcomes with rare complications, including degenerative changes, periarticular ossifications and nonunion.

Plate or Arthroplasty for complex Mason Type-III Radial Head Fractures? Mid-to-long term results from a blinded outcome assessor study

BACKGROUND

The surgical treatment of radial head fractures like Mason type III comminuted radial head fractures is challenging and controversial. Whether to use open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) as treatment methods is under constant debate.

METHODS

We retrospectively analyzed clinical and radiographic mid- to long-term results of 42 patients with a mean follow-up time of 4.56 years (1.92-7.58 years). Patients were grouped according to fragment numbers and the type of intervention performed (3-4 fragments vs. 4+ fragments; ORIF vs. RHA). At the final follow-up, range of motion (ROM), functional rating scores and subjective pain and function levels were documented by a blinded outcome assessor.

RESULTS

Although minor differences in the mean values were detected when comparing the results of the functional scores, ROM and subjective pain and function levels, only the movement in pronation and supination direction yielded statistically better results in the group of 4+-fragments for the RHA compared to ORIF. However, the 33 % rate of required implant removal amongst the ORIF group should be considered.

CONCLUSIONS

This study provides evidence that 3- and 4-part Mason type III fractures are prone to plate osteosynthesis. In contrast, greater than 4-part fractures can more reliably be treated by replacement. This leads to a proposed increase in fragment numbers to four, where ORIF most likely leads to good clinical results. However, in patients with 4+ fragment patterns, ORIF did not show statistically significantly worse results concerning the collected clinical values. This study supports the use of the ORIF approach to save the radial head.

Patient-specific finite element analysis of four different fixation methods for transversely unstable radial head fractures

Plate fixation is a common treatment option for radial head fractures (RHFs). Due to the benefits of less invasiveness and fewer complications of internal fixation, the application of small-diameter headless compression screws (HCSs) to treat RHFs has become a new trend. This study aimed to compare the mechanical stability of four distinct internal fixation protocols for transversely unstable RHFs via finite element analysis. Using computed tomography data from 10 patients, we developed 40 patient-specific FE models of transversely unstable RHFs fixed by parallel, crossed, and tripod HCSs and mini-T plate (MTP). Under simulated physiological loading of the elbow joint, the construct stiffness, displacement, and von Mises stresses were evaluated and verified by a biomechanical experiment. Under shear loading, the MTP group exhibited lower construct stiffness, larger displacement, and higher Von Mises stress than the HCSs group. The stiffness of tripod HCSs was greater than parallel and crossed screw fixation techniques. There was a strong relationship between apparent bone density and construct stiffness (R = 0.98 to 0.99). In the treatment of transversely unstable RHFs, HCSs have superior biomechanical stability than MTP. The tripod technique was also more stable than parallel and crossed fixation.

Usefulness of multiple bioabsorbable Mg screws/K‑wires for comminuted radial head fractures

PURPOSE

We hypothesized that multiple absorbable screws/K-wires would be effective for native head preservation in comminuted radial head fracture fixation (com-RHFs).

METHODS

Seventeen patients who met the inclusion criteria between 2018 and 2020 were included. Radiologic findings indicating proper union and clinical outcomes such as the range of elbow motion, visual analog scale score, and Mayo Elbow Performance Score were assessed prospectively after surgery and at least three years of follow-up.

RESULTS

The mean follow-up period was 4.6 years. Eleven, one, three, and two patients presented with isolated com-RHFs, type 2 (accompanied injury of medial collateral ligament), type 4 ("terrible triad") fractures, and type 5 posterior olecranon fracture-dislocations, respectively. Union was achieved after a mean of nine weeks postoperatively. The head and shaft angles did not differ significantly from the contralateral normal values (p = 0.778 and 0.872, coronal and sagittal, respectively). At the final follow-up, the mean flexion-extension/pronation-supination arcs were 126.47 ± 4.92°/135.59 ± 10.13°, and thus were significantly different from those on the contralateral side (p < 0.001, both), however the arcs were functional ranges for ordinary daily life. Also, functional status was satisfactory in all individuals. The arthritis grade and extent of heterotrophic ossification were satisfactory in all cases, and there were no serious complications requiring revision surgery.

CONCLUSIONS

Absorbable screw/K-wire fixation for com-RHFs is an option before radial head arthroplasty associated with a low complication rate and no need for revision.

Open reduction and internal fixation of modified Mason type III/IV radial head fractures with more than three fragments: an analysis of the clinical outcome and reoperation rate

PURPOSE

It is generally accepted that a radial head fracture (RHF) with more than three parts is not suitable for repair; therefore, most authors suggest straightforward radial head arthroplasty (RHA). With up to 20% risk for reoperation after RHA, improvement in reduction and fixation techniques may represent a valuable alternative before further extending the indications for arthroplasty. To determine the functional results and radiological failure rate after osteosynthesis of multi-fragmentary RHF with more than three articular fragments. We specifically determined (1) the one-year Broberg and Morrey functional elbow score, (2) duration of fracture healing, (3) complication rate, and (4) number of patients converted to RHA.

METHODS

This study is a retrospective single-center case series. All patients who underwent primary osteosynthesis for RHF between 2012 and 2019 were included. Nine patients with an average age of 52 years had an average clinical and/or radiological follow-up of 49 months.

RESULTS

The preoperative imaging identified nine fractures with four fragments. Three patients underwent osteosynthesis with plates and screws, whereas six patients underwent osteosynthesis with only screws. The mean Broberg and Morrey score was 95 points. Overall, eight of the nine patients had satisfactory results. All patients retained their radial heads and showed radiological fracture healing. Only two patients presented with low-grade complications requiring no further surgery.

CONCLUSION

Our study showed that osteosynthesis of RHF with up to four fragments can achieve good functional results with a low complication rate and seems to be a valid alternative to RHA.

[Monteggia-like injuries : Pitfalls of surgical treatment]

The term Monteggia-like lesions or Monteggia equivalent injuries includes fractures of the proximal ulna with dislocation and dislocation fractures of the radial head from the proximal radio-ulnar joint. The complexity of the injury requires a dedicated understanding of the anatomical structures and their biomechanical properties. Particularly due to the rarity, the complication and revision rates are high. A conservative treatment is not usually effective. Three-dimensional imaging by computed tomography is part of the surgical preparation. The goal of surgical treatment is osteosynthetic reconstruction of the fractures and restoration of joint congruency. In cases of nonreconstructable radial head fractures, radial head arthroplasty may be necessary. In addition to reconstruction of the bony stabilizers, refixation of the ligamentous structures is essential for treatment success. The combination of complex fracture patterns and possible dislocation positions in the ulnohumeral, radiohumeral and proximal radio-ulnar joints poses a great challenge to the surgeon. The most frequent complications are peri-implant infections, implant failure, loss of reduction, stiffness or instability. Especially the anatomical configuration of the proximal ulna is complex and requires accurate reconstruction. Therefore, reconstruction of the proximal ulna in length and rotation, including the coronoid process, is considered to be a key factor in the surgical treatment of Monteggia-like injuries.

The use of intramedullary devices for adult radial head and neck fractures. A systematic review

The management of isolated radial neck and head fractures is controversial. Plate fixation and tripod fixation are two commonly employed techniques but risk damage to soft tissues and implant-related complications. Intramedullary fixation is commonly used in pediatric cases and reduces the potential drawbacks of open fixation. This systematic review aimed to analyze outcomes of intramedullary fixation in adults in terms of function, union, and complication rates. A systematic review of the literature was conducted following the PRISMA guidelines using Medline and EMBASE's online databases. The review was registered on the PROSPERO database. Studies were appraised using the Methodological Index for non-randomized studies (MINORS) tool. Seven studies were deemed eligible for inclusion (n=55). Mean ages of patients ranged from 31.3 to 44.2 years, and mean follow-up ranged from 9 to 86 months. The Mayo Elbow Performance score (MEPs) was reported in five case series (mean scores 81.8 -97.9) and the prevalence of excellent results ranged from 71% and 83%. Although 100% of fractures united, the pooled complication rate was 24% (range 0-50%). The most common complications were elbow stiffness (7%), superficial radial nerve neuropraxia (7%), malunion (5%), and AVN (1.8%). No study reported any patients requiring revision surgery. Intramedullary fixation for radial head and neck fractures appears to provide a reliable alternative treatment option in terms of union, range of motion, and functional outcomes. Further robust trials direct comparing against open fixation techniques are required.

Complications, Reoperations, and Long-Term Outcomes after Open Reduction Internal Fixation of Mason Classification Type II and Type III Radial Head Fractures

Introduction  The objectives of this study were to assess long-term outcomes, complications, and reoperations after open reduction internal fixation (ORIF) of radial head fractures. Materials and Methods  35 adult patients, who underwent ORIF of an isolated, displaced radial head fracture without elbow instability (Mason classification type II or III) at two tertiary care referral centers from 2000 to 2017, were identified. Patient satisfaction, pain, and QuickDASH scores were assessed by telephone follow-up at median 12.9 years. Results  The mean age of the 35 patients in our study was 39 years, and 54% were women. The median length of clinical follow-up was 175 days. Postoperative complications occurred in 54% of patients, and reoperations in 23% of patients. Multivariable logistic regression identified fixation with plate and screws versus screws alone as a risk factor for complications and reoperations. The long-term telephone follow-up response rate was 54%. At 13-year median follow-up, the average patient satisfaction was 9.6/10, the average patient-reported pain was 0.7/10, and the average QuickDASH score was 10.5. Conclusion  The long-term outcomes of ORIF of Mason classification type II and III radial head fractures are favorable; however, rates of complication and reoperation are notable and may be higher with plate-and-screw fixation.

Clinical and radiological outcome of Mason-Johnston types III and IV radial head fractures treated by an on-table reconstruction

Background

Only few methods treating comminuted radial head fractures have been established providing sufficient joint reconstruction, restoring radial length and enabling early joint mobilization. When an anatomical reconstruction using open reduction and internal fixation is not possible, radial head resection or primary arthroplasty is often conducted. An “Ex situ/on-table” reconstruction is widely disregarded but can be an option. The purpose of this study was to evaluate the functional and radiological outcome of comminuted radial head fractures treated with an “on-table” reconstruction and internal fixation using a low profile plate.

Methods

Fourteen patients who sustained a radial head fracture (9 Mason-Johnston type III and 5 Mason-Johnston type IV) and were treated with an “on-table” reconstruction between 2010 and 2020 were evaluated retrospectively. The patients mean age was 41.3 years (range 21–69). The clinical evaluation included active range of motion, grip strength, pain level and elbow stability. The functional outcome was assessed using the Disability of Arm, Shoulder and the Hand (DASH) score, Mayo Elbow Performance Index (MEPI), Broberg and Morrey score. The radiological examination included a.p. and lateral views of the injured elbow to evaluate nonunions, loss of reduction, joint alignment, avascular radial head necrosis, heterotopic ossifications and posttraumatic osteoarthritis.

Results

The inclusion rate was 74% with a mean follow-up of 50 months (range 16–128). The mean elbow flexion of the injured side was 126° (range110–145°) with an average extension loss of 8° (range 0–40°). Pronation was 65° (15–90°) and supination 66° (5–90°). The mean MEPI was 87 points (range 45–100). The mean DASH score was 13 points (range 1–88). According to the Broberg and Morrey functional scoring system, the average score was 92 points (range 88–100). Complete bone union was achieved in 9 cases, partial union in 4 cases and nonunion in one case. There were no signs of avascular necrosis of the radial head. Signs of post-traumatic osteoarthritis were seen in 11 cases. Five patients needed an implant removal due to a radio-ulnar impingement and one patient a revision surgery due to the nonunion and implant breakage.

Conclusions

An on-table (ex situ) reconstruction of the radial head is a reliable option with a good clinical outcome and low complication rate in the surgical treatment of comminuted radial head fractures. It can restore joint alignment and maintain radial length. The risk for avascular necrosis is neglectable, and the bone healing rate is high.

Does implant removal of superior clavicle plate osteosynthesis affect the functional outcome: a prospective trial

BACKGROUND

Elective implant removal (IR) accounts for up to 30% of all orthopaedic surgeries. While there is general acceptance about the need of implant removal for obvious reasons, such as infections or implant failure, little is known about the beneficial aspects in cases of minor reasons such as patients' wish for IR. Therefore, we initiated this study to define patients' benefit of elective implant removal following plate osteosynthesis of displaced clavicle fractures.

PATIENTS AND METHODS

Prospective evaluation of patients was conducted before implant removal and 6 weeks postoperative. Subjective and objective criteria included pain rating on a visual analogue scale (VAS) and active range of motion (ROM) pre- and 6 weeks postoperative. Functional scoring included Constant-Murley Score, DASH (Disabilities of Arm, Shoulder and Hand Score), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index).

RESULTS

37 patients were prospectively enrolled in this study and implant removal was performed after 16 ± 6.1 months. No re-fractures nor other complications were detected during routine follow up. Functional outcome increased through all scores (Constant score 73.3 ± 14.6 preoperative to 87.4 ± 12.0 postoperative (p = 0.000), MSQ 85.0 ± 7.3 preoperative to 91.8 ± 9.0 postoperative (p = 0.005), DASH Score 7.4 ± 8.2 preoperative to 5.7 ± 9.5 postoperative (p = 0.414), SPADI 93.4 ± 6.6 preoperative to 94.0 ± 10.1 postoperative (p = 0.734).

CONCLUSIONS

Discomfort during daily activities or performing sports as well as limited range of motion were the main reasons for patients' wish for implant removal. We found increased functional outcome parameters and decreased irritation after implant removal. Therefore we suggest implant removal in case of patients' wish and completed fracture consolidation.

TRIAL REGISTRATION

Trial registration no: NCT04343118, Retrospective registered: www.clinicaltrials.gov .

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

Background

In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome.

Methods

In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively.

Results

Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22–64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II.

Conclusions

The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery.

Trial registration

Registered 20 April 2020, retrospectively on ClinicalTrails.gov (NCT04370561).

Epidemiology and Treatment of Radial Head Fractures: A Database Analysis of Over 70,000 Inpatient Cases

PURPOSE

We aimed to study the epidemiology of radial head fractures within a single national registry database while analyzing trends in available treatments.

METHODS

A retrospective analysis of data from 2007 to 2016 provided by a national inpatient database registry was performed using the International Classification of Diseases code for radial head fractures and associated German Procedure Classification (OPS) codes. All surgical interventions were evaluated according to fracture type, patient sex and age, and distribution differences over the last decade to detect changes in the treatment trends. The number of major revision procedures was identified and the revision burden for each procedure calculated.

RESULTS

Overall, 70,118 radial head fractures were included, with the annual number rising over 20% during this period. Women were significantly older than men (peak incidence, 55-64 years vs 30-39 years) and more frequently injured (women-to-men, 1.3:1). Surgical interventions increased during the study period, with locking plate fixation of comminuted fractures and radial head arthroplasty (RHA) becoming increasingly performed while radial head resections decreased. The revision burden differed significantly between the fixation techniques, with an increased occurrence of RHA revision procedures more recently.

CONCLUSIONS

The data show a higher number and incidence of surgical procedures, especially for comminuted radial head fractures over the study period. Open reduction and internal fixation remains the most frequently used option, with the use of new fixation devices (eg, locking plates) increasing. The use of RHA more than doubled over the past 10 years while the number of radial head resections decreased.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

[Monteggia-fractures and Monteggia-like Lesions]

Monteggia lesions and Monteggia-like lesions involve ulna and radius injuries, which can not be successfully treated using the surgical principles of isolated fractures. Proximal ulnar fracture, radio-humeral dislocation, and additional dislocation in the proximal radioulnar joint result in the disintegration of the functional unit, and there is a complex injury across the elbow to the forearm, resulting in poor clinical outcomes. Thus, addressing all osteo-ligamentous injuries is essential for the long-term course.

Complications after operatively treated distal radius fractures

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Ex situ reconstruction of comminuted radial head fractures: is it truly worth a try?

INTRODUCTION

Complex radial head fractures are difficult to treat. In cases where stable fixation cannot be achieved, radial head resection or primary arthroplasty are frequently performed. Ex situ reconstruction of comminuted fractures may also be an option. This technique has widely been neglected in the literature, and only two small case series report satisfactory results. The aim of the present case series was to determine the functional and radiological outcomes of ex situ reconstructed Mason III and Mason IV fractures. We expect that the on-table reconstruction of comminuted radial head fractures will lead to bony union with no avascular necrosis in the postoperative course, which will demonstrate that this operative procedure is a reasonable option.

PATIENTS AND METHODS

Two Mason type III and seven Mason type IV fractures (including four Monteggia-like lesions) were reconstructed ex situ. The mean age of the patients was 47 years (range 22-64). The clinical examination included RoM tests, elbow stability tests, and a neurological examination. The functional outcome was assessed with the MEPS and DASH score. The radiographic examination included a.p. and lateral views of the elbow to detect non-unions, inadequacy or loss of reduction, radial head necrosis, heterotopic ossifications and signs of posttraumatic arthritis.

RESULTS

The mean follow-up time was 39 months (range 11-64). The mean MEPS was 82 points (range 15-100), and the mean DASH score was 20 points (range 0-85). All ex situ-reconstructed radial heads survived, and no signs of avascular necrosis were observed. Bony union was achieved in all but one patient who presented with an asymptomatic non-union. Signs of posttraumatic arthritis were found in all patients. With regard to the radial head, neither secondary resection nor arthroplasty had to be performed. All patients returned to their pre-injury occupations.

CONCLUSION

Ex situ radial head reconstruction can be a reliable option in the surgical treatment of complex radial head fractures associated with severe elbow trauma. Even in the midterm follow-up, no signs of avascular necrosis were observed. Modern implants may even extend the indications for reconstruction in such cases.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Preserving the radial head in comminuted Mason type III fractures without fixation to the radial shaft: a mid-term clinical and radiographic follow-up study

BACKGROUND

The treatment of multifragment Mason type III fractures is challenging. Open reduction-internal fixation (ORIF), radial head arthroplasty, and in some cases, even radial head resection are the current options; however, each of these treatment methods is associated with characteristic benefits and complications. We present our experience with a radial head salvage procedure in comminuted radial head fractures irrespective of concomitant injuries, which are not accompanied by typical ORIF-related complications.

METHODS

The first group comprised 29 patients with multifragment Mason type III fractures treated surgically with biological radial head spacers (group S). The fragments were reduced and fixated in an extracorporeal manner, and the reconstructed radial head was placed in its anatomic position without fixation to the shaft. The second group comprised 12 patients treated with conventional ORIF using mini-fragment plates (group P).

RESULTS

Thirty patients were enrolled to undergo clinical and radiographic follow-up at an average of 76 months (range, 12-152 months). In group S, nonunion at the head-neck junction developed in 70% of the cases; however, the overall Mayo Elbow Performance Index averaged 94.8, which was superior to the average Mayo Elbow Performance Index of 83.1 in group P. Radiographic evaluation showed development of osteoarthritic changes in 75% of patients in group S and 62.5% in group P. None of the patients had wrist-joint pain.

CONCLUSIONS

Preserving the native radial head in comminuted Mason type III fractures without fixation to the radial shaft is a reliable option. Excellent functional results can be expected; however, the development of osteoarthritis cannot be impeded.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases

BACKGROUND

Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures.

METHODS

This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case.

RESULTS

The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision.

CONCLUSIONS

The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.

Preliminary exploration of a quantitative assessment index for the matching performance of anatomical bone plates using computer

BACKGROUND

To explore a new quantitative index to assess the matching performance of anatomical bone plates using digital technology.

METHODS

CT data of normal tibias of 40 adults were collected. Two brands of medial distal tibia plates were digitized. Two trained orthopedists simulated the surgical operation in Rhino 5.1 software by placing the plate curve on the medial distal tibia surface. The volume of the interstice between the plate curve and the bone surface was measured. The inverse value of this average interstice distance was used as the matching performance index (MPI). A wall thickness analysis tool was used to mark various interstice distances with varied colors.

RESULTS

The Kangli medial distal tibia plate had a MPI of 0.55 ± 0.08 by operator A and 0.55 ± 0.06 by operator B. The general care medial distal tibia plate had a MPI of 0.32 ± 0.06 by operator A and 0.31 ± 0.05 by operator B. There were significant variations in the MPI between the two types of plates by both operators (p < 0.001). And significant variations were observed in the MPI of general care medial distal tibia plates among various operator groups (p = 0.028).

CONCLUSION

This quantitative index of matching performance is straightforward and intuitive. However, we still need a method to improve the experimental repeatability, especially when it comes to a plate with poor matching performance.

Complex radial head and neck fractures treated with modern locking plate fixation

BACKGROUND

Internal fixation of complex radial head and neck (CRHN) fractures is difficult, and postoperative complications are common. This study evaluated elbow function and patient clinical status after internal fixation of CRHN fractures with modern locking plates.

METHODS

We included 40 patients with 41 fractures (1 bilateral lesion). In 25 patients (61%), a concomitant injury was found. Patients were an average age of 46 years (range, 22-70 years). The mean follow-up time was 36 months (range, 2-70 months). Postoperative assessments included evaluation of range of motion, functional scores, and radiologic findings. We assessed fracture healing, surgical complications, revision surgery, and the need for metal removal.

RESULTS

Of the 34 fractures available for follow-up, 33 (97%) healed well. The mean extension deficit was 6° (range, 0°-30°). The average elbow flexion was 134° (range, 90°-160°), pronation was 70° (range, 30°-90°), and supination was 64° (range, 20°-90°). The Mayo Elbow Performance Score showed a mean of 90 points (range, 65-100 points). We observed no "poor" results. The mean Disability of Arm, Shoulder and Hand score was 16.5 (range, 2.5-58.3; n = 29). All patients continued activity without daily analgesics. There were 12 (34%) complications. In 11 (32%) patients, the plate was removed.

CONCLUSIONS

CRHN fractures fixed with modern locking plates and treated as an osseoligamentous lesion exhibited promising midterm results. The new fixation devices represent an improvement in the treatment of this difficult and common fracture while reducing the need for joint replacement or radial head resection. Diagnosis and treatment of concomitant injuries should be emphasized.

Use of surgical glue for Mason type III radial head fractures: A case report

RATIONALE

A Mason type III radial head fracture, which is characterized by comminuted fragments of the radial head, is a severe injury. Open reduction and internal fixation (ORIF) is an alternative treatment method; however, the technique of using an on-table reduction in combination with surgical glue is rarely reported.

PATIENT CONCERNS

A 48-year-old man was admitted to our department with complaints of elbow pain after falling down. Elbow radiography and computed tomography (CT) demonstrated characteristics of fractures before the operation.

DIAGNOSIS

Radiographic images showed a Mason type III radial head fracture.

INTERVENTIONS

The patient underwent ORIF at our hospital. During the operation, the technique of on-table reconstruction combined with surgical glue was used.

OUTCOMES

The patient recovered well and was able to participate in his usual work.

LESSONS

Mason type III radial head fractures could be treated with ORIF, and a satisfactory result could be anticipated, thus avoiding a radial head replacement or resection. Anatomical reduction of a comminuted radial head could be obtained via an on-table reconstruction and application of surgical glue.

Fractures of the proximal ulna: current concepts in surgical management

Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex).

In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity.

Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first).

The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation.

For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint.

Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability.

Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function.

The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness.

Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.

Excellent results and low complication rate for anatomic polyaxial locking plates in comminuted proximal ulna fractures

BACKGROUND

Comminuted fractures of the proximal ulna remain a great challenge in orthopedic surgery. The purpose of this study was to report the outcomes of comminuted proximal ulna fractures treated with a new construct type-anatomically preformed polyaxial locking compression plates.

METHODS

Between 2013 and 2016, 46 patients with isolated comminuted fractures were treated with a 2.7-/3.5-mm VA-LCP Olecranon Plate (Synthes, Umkirch, Germany). Of these, 44 were available for an assessment after a mean follow-up period of 2.5 years (range, 12-50 months). We evaluated range of motion, time to recovery, revision rate, and indications, as well as functional scores. Radiographs were analyzed.

RESULTS

The study included 8 Mayo IB, 29 Mayo IIB, and 7 Mayo IIIB fractures. All fractures showed bony union, and only 2 revision surgical procedures were performed because of a new trauma. No other complications occurred. Mean range of motion was 139° (range, 105°-150°), and the mean pain level was less than 1 on a visual analog scale. Regarding elbow function, we found a mean Mayo Elbow Performance Score of 98; a mean Oxford Elbow Score of 44; and a mean Disabilities of the Arm, Shoulder and Hand score of 6. Of the plates, 41% were removed after an average time of 16 months, whereby a significant improvement in extension deficit was detected (P < .01). Ninety-five percent of all patients returned to their pretrauma sports level.

CONCLUSION

The 2.7-/3.5-mm VA-LCP Olecranon Plate represents an effective option with excellent fracture reduction, sufficient stability for early postoperative functional rehabilitation, and a minimum of complications.

[Importance of self-assessment in functional evaluation of trauma patients]

The principle of self-assessment is performed successfully in a wide variety of medical disciplines and is increasingly gaining importance in orthopedic trauma surgery. Through the development and validation of joint-specific self-assessment questionnaires that enable estimation of the range of motion, a large number of patient-based instruments are available for comprehensive follow-up examination. A recently performed proof of concept study showed a high patient acceptance and therefore the development of a prospective, patient-centered fracture register based on the self-assessment functional analysis seems to be promising. The data obtained should reflect not only the reality of fracture treatment but also generate valuable epidemiological data with which evidence-based guidelines can be formed.

Polyaxial locking plates in treating distal humeral fractures: a comparative randomized trial for clinical outcome

Background

Management of distal humeral fractures remains to be one of the most challenging aspects in trauma surgery. Low profile plating systems with variable angle screw fixation represent a crucial advancement to the established angular stable locking plates with considerable attention in current research. The aim of the prospective randomized trial was to review the preliminary results and patients’ outcome following treatment with these newly developed implants and to rule out potential differences in fracture treatment of two different plating systems.

Methods

Twenty patients with distal humeral fractures (AO 13-A1 – AO 13-C3) were included in the current study since 2014. After completing the randomization plan, patients were distributed into two groups for different variable angle locking plates (DePuy Synthes® VA-LCP vs. Medartis® Aptus Elbow). Functional elbow scoring (ROM, MEPS, QuickDASH) served as primary outcome parameter, while radiological fracture consolidation served as secondary outcome parameter. Follow-ups were conducted 6 weeks, 12 weeks, 6 months and 12 months after the operation.

Results

Seventeen of 20 patients (85%) concluded all follow-up examinations. Postoperative elbow extension deficiencies showed significant differences between the two groups in all follow-up examinations with a mean of Ø 18 +/− 7.4 degrees in the DePuy Synthes® VA-LCP group compared to a mean of Ø 6.5 +/− 7.5 degrees in the Medartis® Aptus Elbow group (p = 0.002) 12 months postoperatively. Functional scoring showed a disparate pattern. The Medartis® Aptus Elbow group achieved significantly better MEP scores during follow-up. However, the analysis of the QuickDash revealed better results of the DePuy Synthes® VA-LCP group in the first half and better results of the Medartis® Aptus Elbow group in the second half of the follow-up examination instead.

Conclusions

Considering the complexity of distal humeral fractures, the usage of anatomically preshaped low profile variable angle locking plates for operative treatment leads to good clinical results. Even though there might be some advances of the Medartis® Aptus Elbow plating system concerning postoperative ROM and elbow function, a consistent difference in the overall clinical outcome between the two plating systems could not be detected.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT03272490 Retrospectively Registered 1. September 2017.

[Elbow dislocation fractures]

The treatment of complex elbow dislocation fractures is a challenge to both the treating surgeon as well as to the patient due to the complex bony and soft tissue anatomy of the joint. In order to establish an expedient treatment algorithm, all osseous and ligamentous injuries need to be thoroughly assessed. Furthermore, a detailed knowledge of the joint-stabilizing structures, practicable surgical approaches as well as the possible techniques for fracture fixation and/or arthroplasty are essential to facilitate early rehabilitation of the elbow and avoid injury-related complications. Any unnecessary delay in treatment of this complex injury can result in posttraumatic functional disorders, recurrent instability and secondary arthrosis. In conclusion, the goals of surgical treatment must be the correct restoration of the joint anatomy and stability as the prerequisites for any successful treatment of elbow fracture dislocations in order to enable early motion of the joint.