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Ma P, Zheng J, Chen H, Yang W, Gao H. Safety and effectiveness of the three-dimensional-printed guide plate-assisted rotation axis positioning of a hinged external fixator for the elbow. INTERNATIONAL ORTHOPAEDICS 2024; 48:1799-1808. [PMID: 38451310 DOI: 10.1007/s00264-024-06134-3] [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: 11/30/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE We aimed to evaluate the safety and effectiveness of three-dimensional (3D)-printed guide plates for assisting in the positioning of the rotation axis of an elbow-hinged external fixator. METHODS Terrible triad (TT) patients, who were screened using the predefined inclusion and exclusion criteria, underwent installation of a hinged external fixator on the basis of internal fixation; 3D-printed guide plates, generated from the patient's imaging data, assisted in positioning the rotation axis. All patients received the same peri-operative management and were followed up at six, 12, 24, and 48 weeks postoperatively. The duration of positioning pin placement, the number of fluoroscopies, pin placement success rate, types and incidence of post-operative complications, and the Mayo elbow performance score (MEPS) of the diseased elbow and range of motion (ROM) of both elbows were assessed. RESULTS In 25 patients who completed the follow-up, the average time required for positioning pin placement was 329.32 ± 42.38 s (263-443 s), the average number of fluoroscopies was 2.32 ± 0.48 times (2-3 times), and the pin placement success rate was 100%. At the last follow-up, the mean MEPS of the diseased elbow was 97.50 ± 6.92 (75-100), with an excellent and good rate of 100%, and all patients demonstrated stable concentric reduction. The average range of flexion and extension was 135.08° ± 17.10° (77-146°), while the average range of rotation was 169.21° ± 18.14° (108-180°). No significant difference was observed in the average ROM between the both elbows (P > 0.05). Eight (32%) patients developed post-operative complications, including elbow stiffness due to heterotopic ossification in three (12%) patients, all of whom did not require secondary intervention. CONCLUSION Utilizing 3D-printed guide plates for positioning the rotation axis of an elbow-hinged external fixator significantly reduced intra-operative positioning pin placement time and the number of fluoroscopies with excellent positioning results. Satisfactory results were also obtained in terms of post-operative complications, elbow ROM, and functional scores.
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Affiliation(s)
- Pengcheng Ma
- Department of Trauma Surgery, Shandong Public Health Clinical Center, Jinan, Shandong, China
| | - Jiachun Zheng
- Department of Trauma Surgery, Shandong Public Health Clinical Center, Jinan, Shandong, China
| | - Huizhi Chen
- Department of Trauma Surgery, Shandong Public Health Clinical Center, Jinan, Shandong, China
| | - Weijie Yang
- Department of Trauma Surgery, Shandong Public Health Clinical Center, Jinan, Shandong, China
| | - Hongwei Gao
- Department of Trauma Surgery, Shandong Public Health Clinical Center, Jinan, Shandong, China.
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Miyaoka S, Yamazaki H, Hayashi M, Isobe F, Abe Y, Sakurai T. Elbow Flexion Reconstruction after Traumatic Amputation Using Hinged External Fixator and Muscle Transfer: A Case Report. JBJS Case Connect 2024; 14:01709767-202409000-00063. [PMID: 39303048 DOI: 10.2106/jbjs.cc.24.00189] [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: 09/22/2024]
Abstract
CASE A 40-year-old man sustained a traumatic elbow disarticulation without any fracture, accompanied by severe damage of the biceps and brachialis. After replantation, passive elbow motion was used with a hinged external fixator to facilitate elbow joint reduction and mobility. Eight months after the injury, a functional latissimus dorsi transfer for elbow flexion restoration was performed. Ten years postoperatively, he achieved antigravity elbow flexion and 120° of flexion and -15° extension of the elbow. CONCLUSION This reconstruction technique was useful for reconstructing elbow flexion after traumatic elbow disarticulation.
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Affiliation(s)
- Shunsuke Miyaoka
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Yamazaki
- Department of Orthopedic Surgery, Aizawa Hospital, Matsumoto, Japan
| | - Masanori Hayashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Fumihiro Isobe
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yukiho Abe
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Heifner JJ, Davis TA, Rowland RJ, Gomez O, Gray RR. Comparing internal and external stabilization for traumatic elbow instability: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:196-203. [PMID: 38706679 PMCID: PMC11065758 DOI: 10.1016/j.xrrt.2023.12.004] [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: 05/07/2024]
Abstract
Background Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS. Methods A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment. Results The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals. Discussion The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.
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Affiliation(s)
| | - Ty A. Davis
- Larkin Hospital Department of Orthopaedics, Coral Gables, FL, USA
| | | | - Osmanny Gomez
- Larkin Hospital Department of Orthopaedics, Coral Gables, FL, USA
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Deemer AR, Solasz S, Ganta A, Egol KA, Konda SR. External fixation about the elbow: Indications and long-term outcomes. J Clin Orthop Trauma 2024; 48:102335. [PMID: 38282805 PMCID: PMC10821167 DOI: 10.1016/j.jcot.2024.102335] [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: 10/04/2022] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/30/2024] Open
Abstract
Background Operative management is often required for fractures of the elbow, with treatment goals aiming to restore stability, reduction, and early range of motion. The purpose of this study was to determine risk factors for necessitating the application of an external fixator, and to compare range of motion and functional outcomes between patients who required an elbow external fixator to those who did not. Hypothesis We hypothesize that patients who require an external fixator will have worse elbow range of motion and functional outcomes when compared to those who did not. Patients and methods This is a retrospective study of 391 patients who presented at a Level-I trauma center between March 2011 and January 2021 for operative management of a fracture/fracture-dislocation of the distal humerus (AO/OTA 13A-C) and/or proximal ulna and/or radius (AO/OTA 21A-C). A primary analysis was performed to determine risk factors for necessitating the application of an external fixator. A secondary analysis was performed comparing elbow range-of-motion and functional outcomes between cases and controls. Results 391 patients were identified; 26 required external fixation (cases) and 365 did not (controls). Significant risk factors for necessitating placement of an external fixator included large BMI (OR = 1.087, 95 % CI = 1.007-1.173, p = 0.033), elbow dislocation (OR = 7.549, 95 % CI = 2.387-23.870, p = 0.001), open wound status (OR = 9.584, 95 % CI = 2.794-32.878, p < 0.001), and additional non-contiguous orthopaedic injury (OR = 9.225, 95 % CI = 2.219-38.360, p = 0.002). Elbow ROM was poorer in the external fixator group with regards to extension (-15°), flexion (+19.4°), and pronation (+14.3°) (p < 0.05). In addition, those who did not need external fixation had better functional scores (+20.4 points MEPI) (p < 0.05). Discussion The use of external fixation about the elbow is associated with significantly worse initial injuries and results in poorer outcomes. These results can be used to inform the surgeon-patient discussion regarding treatment options and expected functional outcomes. Level of evidence III.
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Affiliation(s)
- Alexa R. Deemer
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Sara Solasz
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Abhishek Ganta
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Kenneth A. Egol
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
| | - Sanjit R. Konda
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, NY, USA
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van der Windt AE, Colaris JW, den Hartog D, The B, Eygendaal D. Persistent elbow dislocation. JSES Int 2023; 7:2605-2611. [PMID: 37969499 PMCID: PMC10638553 DOI: 10.1016/j.jseint.2022.12.021] [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: 01/19/2023] Open
Abstract
Acute elbow dislocation is a common injury with an incidence in the general population estimated at around 5/100,000. Persistent (or static) elbow dislocation is a relatively rare problem but might occur due to inappropriate assessment or treatment of acute simple or complex elbow dislocations. Persistent elbow dislocation can be an invalidating and painful condition with a more ominous prognosis than an acute elbow dislocation with appropriate treatment. Surgical treatment of persistent elbow dislocation is a complex intervention that requires extended surgical exposure and arthrolysis in combination with circumferential ligamentous and osseous stabilization. Satisfactory results are described, but complication and reintervention rates are high. After-treatment with a dynamic external fixator is often necessary.
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Affiliation(s)
- Anna E. van der Windt
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Joost W. Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis den Hartog
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bertram The
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Hamada D, Inokuchi K, Morii H, Yamanaka Y, Sakai A, Sawano M. Hinged elbow fixation and treatment of unstable elbow dislocation with ipsilateral arteriovenous shunts: A case report. J Orthop Sci 2023; 28:1461-1466. [PMID: 34420842 DOI: 10.1016/j.jos.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/19/2021] [Accepted: 06/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Daishi Hamada
- Emergency and Critical Care Medicine Service, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan; Department of Orthopedic Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan.
| | - Koichi Inokuchi
- Emergency and Critical Care Medicine Service, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Hokuto Morii
- Emergency and Critical Care Medicine Service, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Yoshiaki Yamanaka
- Department of Orthopedic Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
| | - Akinori Sakai
- Department of Orthopedic Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
| | - Makoto Sawano
- Emergency and Critical Care Medicine Service, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
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Ling M, Liang Z, Wang Y, Cheng M, Lu S, Pan Y, Hu H, Chen B, Ding J. Elbow Kinematics and Function Following Treatment with Open Arthrolysis and Hinged External Fixator. Orthop Surg 2023; 15:2102-2109. [PMID: 37052066 PMCID: PMC10432452 DOI: 10.1111/os.13714] [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: 08/31/2022] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVE Open arthrolysis (OA) combined with hinged external fixator (HEF) is a promising surgical option for patients with elbow stiffness. This study aimed to investigate elbow kinematics and function following a combined treatment with OA and HEF in elbow stiffness cases. METHODS Patients treated with OA with or without HEF due to elbow stiffness were recruited between August 2017 and July 2019. Elbow flexion-extension motion and function (Mayo elbow performance scores, MEPS) were recorded and compared between patients with and without HEF during a 1-year follow-up period. Additionally, those with HEF were assessed by dual fluoroscopy at week 6 postoperatively. Flexion-extension and varus-valgus motions, as well as ligament insertion distances of the anterior medial collateral ligament (AMCL) and lateral ulnar collateral ligament (LUCL), were compared between the surgical and intact sides. RESULTS This study included 42 patients, of which 12 with HEF demonstrated a similar flexion-extension angle and range of motion (ROM) and MEPS as the other patients. In patients with HEF, the surgical elbows showed limitations in flexion-extension (maximal flexion, 120.5° ± 5.3° vs 140.4° ± 6.8°; maximal extension, 13.1° ± 6.0° vs 6.4° ± 3.0°; ROM, 107.4° ± 9.9° vs 134.0° ± 6.8°; all Ps < 0.01) compared with the contralateral sides. During elbow flexion, a gradual valgus-to-varus transition of the ulna, increase in the AMCL insertion distance, and steady change in the LUCL insertion distance were observed, with no significant differences between the bilateral sides. CONCLUSIONS Patients treated with OA and HEF demonstrated similar elbow flexion-extension motion and function to those treated with OA alone. Although the use of HEF could not restore an intact flexion-extension ROM and might result in some minor but not significant changes in kinematics, it contributed to clinical outcomes comparable to that of the treatment with OA alone.
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Affiliation(s)
- Ming Ling
- Biomechanical Laboratory of Orthopaedic Surgery DepartmentShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
- Department of OrthopaedicsHuadong Hospital Affiliated to Fudan UniversityShanghaiChina
| | - Zhenming Liang
- Orthopaedic CenterAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Yanmao Wang
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Mengqi Cheng
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Shengdi Lu
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Yao Pan
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Hai Hu
- Biomechanical Laboratory of Orthopaedic Surgery DepartmentShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
| | - Bin Chen
- Department of Orthopaedics, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | - Jian Ding
- Department of OrthopaedicsShanghai Jiao Tong University Affiliated Sixth People's HospitalShanghaiChina
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Wynn M, Glass N, Fowler T. Comparison of direct surgical cost and outcomes for unstable elbow injuries: internal joint stabilizer versus external fixation. JSES Int 2023; 7:692-698. [PMID: 37426915 PMCID: PMC10328786 DOI: 10.1016/j.jseint.2023.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Background Unstable elbow injuries sometimes require External fixation (ExF) or an Internal Joint Stabilizer (IJS) to maintain joint reduction. No studies have compared the clinical outcomes and surgical costs of these 2 treatment modalities. The purpose of this study was to determine whether clinical outcome and surgical encounter total direct costs (SETDCs) differ between ExF and IJS for unstable elbow injuries. Methods This retrospective study identified adult patients (aged ≥ 18 years) with unstable elbow injures treated by either an IJS or ExF between 2010 and 2019 at a single tertiary academic center. Patients postoperatively completed 3 patient-reported outcome measures (the Disability of the Arm, Shoulder, and Hand, the Mayo Elbow Performance score, and EQ-5D-DL). Postoperative range of motion was measured in all patients, and complications tallied. SETDCs were determined and compared between the 2 groups. Results A total of 23 patients were identified, with 12 in each group. Clinical and radiographic follow-up for the IJS group averaged 24 months and 6 months, respectively, and for the ExF group, 78 months and 5 months, respectively. The 2 groups had similar final range of motion, the Mayo Elbow Performance score, and 5Q-5D-5L scores; ExF patients had better the Disability of the Arm, Shoulder, and Hand scores. IJS patients had fewer complications and were less likely to require additional surgery. The SETDCs were similar between the 2 groups, but the relative contributors to cost differed significantly between the groups. Conclusions Patients treated with an ExF or IJS had similar clinical outcomes, but complications and second surgeries were more likely in ExF patients. The overall SETDC was also similar for ExF and IJS, but relative contributions of the cost subcategories differed.
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Affiliation(s)
- Malynda Wynn
- Corresponding author: Malynda Wynn, MD, Department of Orthopaedics & Rehabilitation, University of Iowa Hospital & Clinics, 200 Hawkins Dr., Iowa City, IA 52242, USA.
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Sheth M, Price MB, Taylor T, Mitchell S. Outcomes of elbow fracture-dislocations treated with and without an Internal Joint Stabilizer of the Elbow (IJS-E): A retrospective cohort study. Shoulder Elbow 2023; 15:328-336. [PMID: 37325390 PMCID: PMC10268135 DOI: 10.1177/17585732221088290] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 09/20/2023]
Abstract
Background The internal joint stabilizer of the elbow (IJS-E) adds to techniques for maintaining reduction of elbow fracture-dislocations while allowing early motion. Literature on this device is limited to small case series. Methods Retrospective comparison of function, motion and complications in patients who sustained elbow fracture-dislocations reconstructed with (30 patients) and without (34 patients) an IJS-E by a single surgeon. The minimum follow up was 10 weeks. Results The mean follow up was 16 ± 17 months. The mean final flexion arc did not differ between the two groups, however patients without an IJS achieved greater pronation. There were no differences in mean Mayo Elbow Performance, Quick-DASH and pain scores. Five patients (17%) underwent IJS-E removal. The rates of capsular releases for stiffness after 12 weeks and recurrent instability were similar. Conclusions The use of an IJS-E to supplement traditional repair of elbow fracture-dislocations does not appear to affect final function or motion, and appears to be effective in reducing the risk of recurrent instability in a group of patients deemed high risk. However, its use is weighed against a 17% rate of removal at early follow up and possibly inferior forearm rotation. Level of Evidence Retrospective Cohort study, Level 3.
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Affiliation(s)
- Mihir Sheth
- Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Matthew Bent Price
- Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Tristen Taylor
- Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Scott Mitchell
- Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, United States
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Moses MJ, Tejwani NC. The Role of External Fixation in the Management of Upper Extremity Fractures. J Am Acad Orthop Surg 2023:00124635-990000000-00671. [PMID: 37071879 DOI: 10.5435/jaaos-d-22-00077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/19/2023] [Indexed: 04/20/2023] Open
Abstract
External fixation is a powerful tool in the armamentarium of the active orthopaedic surgeon. The upper extremity, however, poses unique challenges in the techniques of external fixation because of the smaller soft-tissue envelope and the proximity of neurovascular structures, which may be entrapped in fracture fragments or traversing in line with pin trajectories. This review article summarizes the indications, techniques, clinical outcomes, and complications of external fixation of the upper extremity in the setting of proximal humerus, humeral shaft, distal humerus, elbow, forearm, and distal radius fractures.
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Affiliation(s)
- Michael J Moses
- From the Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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Ozdag Y, Baylor JL, Nester JR, Foster BK, Daly CA, Grandizio LC. Lateral Ulnar Collateral Ligament Repair With Suture-Tape Augmentation for Traumatic Elbow Instability. J Hand Surg Am 2023; 48:117-125. [PMID: 36539319 DOI: 10.1016/j.jhsa.2022.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/04/2022] [Accepted: 10/26/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Ligament repair with suture-tape augmentation has been used in the operative treatment of joint instability and may have advantages with respect to early motion and stability. The purpose of this investigation was to describe the clinical results of traumatic elbow instability treated with lateral ulnar collateral ligament repair with suture-tape augmentation. METHODS All cases of acute and chronic elbow instability treated surgically between 2018 and 2020 were included if they underwent ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament as part of the procedure. Cases with <6 months of follow-up were excluded. A manual chart review was performed to record patient demographics as well as injury and surgery characteristics. Radiographic outcomes, range of motion, and patient-reported outcome measures, including the visual analog pain scale and Disabilities of the Arm, Shoulder, and Hand, were recorded. Range of motion measurements were recorded at the end of the clinical follow-up, as were surgical complications. RESULTS Eighteen cases were included with a mean follow-up of 20 months. Five (28%) cases involved a high-energy mechanism, and 11 (62%) cases involved terrible triad fracture dislocations. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire and visual analog pain scale scores were 17 and 2, respectively. The mean flexion-extension arc was 124°, and 2 (11%) cases had <100° flexion-extension arc. There were 2 (11%) postoperative complications, and both cases had postoperative instability requiring reoperation. We observed no cases of capitellar erosion from the suture-tape material. CONCLUSIONS For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Yagiz Ozdag
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jessica L Baylor
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jordan R Nester
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Brian K Foster
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Charles A Daly
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
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12
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Chiu YC, Wu CH, Tsai KL, Jou IM, Tu YK, Ma CH. Using an Internal Joint Stabilizer Through a Single Posterior Approach for Elderly Patients With Terrible Triad Injury. Geriatr Orthop Surg Rehabil 2023; 14:21514593231162193. [PMID: 36896295 PMCID: PMC9989442 DOI: 10.1177/21514593231162193] [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: 10/09/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 03/08/2023] Open
Abstract
Introduction Treating a terrible triad injury of the elbow remains a challenge for orthopedic surgeons, especially in elderly patients due to the poor quality of the surrounding soft tissue and bony structures. In the present study, we propose a treatment protocol using an internal joint stabilizer through a single posterior approach and analyze the clinical results. Materials and Methods We retrospectively reviewed 15 elderly patients with terrible triad injuries of the elbow who underwent our treatment protocol from January 2015 to December 2020. The surgery involved a posterior approach, identification of the ulnar nerve, bone and ligament reconstruction, and the application of the internal joint stabilizer. A rehabilitation program was initiated immediately after the operation. Surgery-related complications, elbow range of motion (ROM), and functional outcomes were evaluated. Results The mean follow-up period was 21.7 months (range, 16-36 months). ROM at the final follow-up was 130° in extension to flexion and 164° in pronation to supination. The mean Mayo Elbow Performance Score was 94 at the final follow-up. Major complications included breaking of the internal joint stabilizer in 2 patients, transient numbness over the ulnar nerve territory in one, and local infection due to irritation of the internal joint stabilizer in one. Conclusions Although the current study involved only a small number of patients and the protocol comprised two stages of operation, we believe that such a technique may be a valuable alternative for the treatment of these difficult cases. Level of Clinical Evidence 4.
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Affiliation(s)
- Yen-Chun Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chin-Hsien Wu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kun-Ling Tsai
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-Ming Jou
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Ching-Hou Ma
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.,School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
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Abstract
OBJECTIVES To report early results of the "Internal Joint Stabilizer of the Elbow" (IJS-E) in the treatment of terrible triad injuries and other unstable traumatic elbow dislocations. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Seventeen patients with traumatic elbow instability treated with IJS-E over a 2-year period; 7 of whom sustained terrible triad-type injuries. INTERVENTIONS Open reduction internal fixation with the "IJS-E". MAIN OUTCOME MEASURES Elbow stability and arc of motion were assessed radiographically and clinically. Disabilities of the Arm, Shoulder and Hand scores were collected by telephone. RESULTS All elbows were radiographically stable at the time of IJS-E removal. Mean time of follow-up was 9 months from index operation (range, 2.5-24 months). Mean elbow arc of motion was restored to flexion-extension 92 degrees (range, 5-125; SD, 31 degrees) and forearm pronation-supination 139 degrees (range, 0-180; SD, 48 degrees). Mean Disabilities of the Arm, Shoulder and Hand score was 22.2 (range, 7.5-45.7; SD, 13.3) for patients at least 1 month from surgery on the ipsilateral extremity. Five patients (30%) developed complications, and -2 (12%) required revision for implant failure. CONCLUSIONS The IJS-E offered reliable treatment of traumatic elbow instability, particularly terrible triad-type injuries. It permited early range of motion and was effective in restoring elbow stability. We believe that the use of this relatively novel system should be further explored. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Stenson JF, Lynch JC, Cheesman QT, DeBernardis D, Kachooei A, Austin LS, Rivlin M. Biomechanical comparison of elbow stability constructs. J Shoulder Elbow Surg 2022; 31:1938-1946. [PMID: 35247577 DOI: 10.1016/j.jse.2022.01.145] [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: 11/09/2021] [Revised: 01/16/2022] [Accepted: 01/23/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined. METHODS Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct. RESULTS Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight. CONCLUSION The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.
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Affiliation(s)
- James F Stenson
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Jeffrey C Lynch
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | | | - Amir Kachooei
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Luke S Austin
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Ma CH, Hsueh YH, Wu CH, Yen CY, Tu YK. Does an Internal Joint Stabilizer and Standardized Protocol Prevent Recurrent Instability in Complex Persistent Elbow Instability? Clin Orthop Relat Res 2022; 480:1354-1370. [PMID: 35266916 PMCID: PMC9191335 DOI: 10.1097/corr.0000000000002159] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/08/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The treatment of complex persistent elbow instability after trauma is challenging. Previous studies on treatments have reported varied surgical techniques, which makes it difficult to establish a therapeutic algorithm. Furthermore, the surgical procedures may not sufficiently restore elbow stability, even with an additional device, and a noted high rate of arthritis progression.While a recently developed internal joint stabilizer effectively treats elbow instability, its clinical application for complex persistent elbow instability is limited and the standardized protocol is not well described. Additionally, we want to know whether the arthritis progression will cause a negative impact on the functional outcomes of complex persistent elbow instability. QUESTIONS/PURPOSES (1) Does treatment of complex persistent elbow instability with a hinged internal joint stabilizer and a standardized protocol prevent recurrent instability and other complications? (2) What are the pre- to postoperative improvements in pain, disability, elbow performance, and ROM? (3) Is the development of post-traumatic arthritis associated with worse pain, disability, elbow performance, and ROM? METHODS Between September 2014 and October 2019, we treated 22 patients for persistent dislocation or subluxation after initial treatment of traumatic elbow fracture-dislocations. Of those, we considered patients who were at least 20 years of age, with an interval of 6 weeks or more between the injury (initial treatment) and the index reconstructive procedure, which had been performed at our institute, as potentially eligible. During that time, we used an internal joint stabilizer with a standardized protocol for posttraumatic complex persistent elbow instability. We performed total elbow replacements in patients older than 50 years who had advanced elbow arthritis. Based on that, 82% (18 of 22) of patients were eligible; 14% (3 of 22) were excluded because total elbow replacements was undertaken, and another 5% (1 of 22) were lost before the minimum study follow-up of 1 year (median 24 months [range 12 to 63]), leaving 64% (14 of 22) for analysis in this retrospective study. We treated 14 patients (14 elbows) with posttraumatic complex persistent elbow instability with an internal joint stabilizer and a standardized protocol that comprised debridement arthroplasty with ulnar neurolysis, restoration of bony and ligamentous (reattachment) structures, application of an internal joint stabilizer, and early rehabilitation. There were eight men and six women in this study, with a median (range) age of 44 years (21 to 68). The initial elbow fracture-dislocation injury pattern was a terrible triad injury in seven patients, a posterolateral rotatory injury in four patients, and a posterior Monteggia fracture in three patients. Preoperative and follow-up radiographs were reviewed for evidence of recurrent instability and arthritis. Complications such as wound infection, seroma, neurovascular injury, and hardware complications were ascertained through chart review. Preoperative and postoperative VAS score for pain, DASH, and Mayo Elbow Performance Scores (MEPS) were collected and compared. Furthermore, extension-flexion and supination-pronation arcs were collected by chart review. We divided the patients into two groups according to whether or not they developed posttraumatic arthritis. We then presented the differences between pain, disability, elbow performance, and ROM. The hinged internal joint stabilizer was removed using another open procedure under general anesthesia 6 to 8 weeks after surgery. RESULTS There were no recurrent instability during and after device removal. Seven patients developed complications, including wound infection, seroma, neurovascular injury, hardware complications, and heterotopic ossification. Two patients had complications related to internal joint stabilizers and three had complications linked to radial head prostheses. Median (range) preoperative to postoperative changes included decreased pain (VAS 5 [2 to 9] to 0 [0 to 3], difference of medians -5; p < 0.001), decreased disability (DASH 41 [16 to 66] to 7 [0 to 46], difference of medians -34; p < 0.001), improved function (MEPS 60 [25 to 70] to 95 [65 to 100], difference of medians 35; p < 0.001), improved extension-flexion arc (40° [10° to 70°] to 113° [75° to 140°], difference of medians 73°; p < 0.001), and supination-pronation arc (78° [30° to 165°] to 148° [70° to 175°], difference of medians 70°; p < 0.001). Between patients with and without development of post-traumatic arthritis, there were no differences in postoperative pain (VAS 0 [0 to 3] to 0 [0 to 1], difference of medians 0; p = 0.17), disability (DASH 7 [0 to 46] to 7 [0 to 18], difference of medians 0; p = 0.40), function (MEPS 80 [65 to 100] to 95 [75 to 100], difference of medians 15; p = 0.79), extension-flexion arc (105° [75° to 140°] to 115° [80° to 125°], difference of medians 10°; p = 0.40), and supination-pronation arc (155° [125° to 175°] to 135° [70° to 160°], difference of medians -20°; p < 0.18). CONCLUSION In this small, retrospective study, we found that an internal joint stabilizer with a standardized treatment protocol could maintain concentric reduction while allowing early functional motion, and that it could improve clinical outcomes for patients with complex persistent elbow instability. However, patients must be counseled that the complications related to the radial head prostheses may occur, and that the benefits of early motion must compensate for an additional removal procedure and the risk of seroma formation. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Ching-Hou Ma
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- The School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Huan Hsueh
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chin-Hsien Wu
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Cheng-Yo Yen
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Orthopedics, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
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16
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Van Tunen B, Van Lieshout EMM, Mader K, Den Hartog D. Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:4889-4896. [PMID: 35750865 DOI: 10.1007/s00068-022-02013-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Elbow dislocations are at risk for persistent instability and stiffness of the joint. Treatment with a hinged external fixation provides elbow joint stability, and allows early mobilization to prevent stiffness. Mounting a hinged elbow fixator correctly, however, is technically challenging. The low incidence rate of elbow dislocations with persistent instability suggests that centralization would result in higher surgeon exposure and consequently in less complications. This study aimed to investigate the results of treatment of elbow dislocations with a hinged elbow fixator on the rate of complications, range of motion, level of pain and restrictions in activities of daily living. METHODS A retrospective observational cohort study in a level I trauma center, in which the majority of patients was treated by a dedicated elbow surgeon, was performed. All patients of 16 years or older treated with a hinged external elbow fixator between January 1, 2006 and December 31, 2017 were included. The fixator could be used (1) for the treatment of persistent instability in acute/residual simple and complex dislocations or (2) as revision surgery to treat joint incongruency or a stiff elbow. Patient and injury characteristics, details on treatment, complications, secondary interventions, and range of motion were extracted from the patients' medical files. RESULTS The results of treatment of 34 patients were analyzed with a median follow-up of 13 months. The fixator was removed after a median period of 48 days. Fixator-related complications encountered were six pintract infections, one redisclocation, one joint incongruency, one muscle hernia, and one hardware failure. The median range of motion at the end of follow-up was 140° flexion, 15° constraint in extension, 90° pronation, and 80° supination. CONCLUSION A hinged elbow fixator applied by a dedicated elbow surgeon in cases of elbow instability after elbow dislocations can result in excellent joint function. Fixator-related complications are mostly mild and only temporary.
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Affiliation(s)
- Bart Van Tunen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Konrad Mader
- Division Hand, Forearm and Elbow Surgery, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Current concepts in diagnosis, classification, and treatment of acute complex elbow dislocation: a review. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Xiao D, Gong M, Chen C, Zha Y, Li T, Ji S, Hua K, Sun W, Jiang X. Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness. BMC Musculoskelet Disord 2021; 22:941. [PMID: 34758796 PMCID: PMC8582181 DOI: 10.1186/s12891-021-04796-3] [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: 06/03/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To evaluate and compare the functional outcomes of combined medial-lateral approach open arthrolysis with and without hinged external fixation. METHODS We retrospectively collected and analyzed the clinical data of patients with severe elbow stiffness who were treated in our institution from January 2018 to January 2019. All of them were treated with combined medial-lateral approach arthrolysis. There were 20 patients who had the hinged external fixation placed and 29 patients without the placement of the external fixation. Their baseline characteristics and functional outcomes were evaluated and compared. RESULTS The average follow-up time was 28.4 ± 3.7 months. There were no significant differences in the ROM of the elbow, MEPS, VAS, DASH, or complications between the two groups. The operation time and treatment cost of the patients without external fixation were significantly lower than patients with external fixation. CONCLUSION Combined medial-lateral approach open elbow arthrolysis without external fixation is a safe and effective way to treat elbow stiffness. LEVEL OF EVIDENCE Therapeutic Level III; Retrospective Cohort Comparison; Treatment Study.
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Affiliation(s)
- Dan Xiao
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Maoqi Gong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Chen Chen
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yejun Zha
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Shangwei Ji
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Kehan Hua
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Weitong Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Xieyuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, No.31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
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19
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Static and Dynamic External Fixation are Equally Effective for Unstable Elbow Fracture-Dislocations. J Orthop Trauma 2021; 35:e82-e88. [PMID: 32576775 DOI: 10.1097/bot.0000000000001876] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the clinical outcomes of static versus dynamic external fixation for elbow fracture-dislocations with persistent instability after surgical management. DESIGN Comparative, retrospective review. SETTING Two tertiary referral upper-extremity centers. PATIENTS Twenty-four elbows requiring external fixation for persistent elbow instability within 90 days of surgical management of an elbow fracture-dislocation. INTERVENTION Static and dynamic external fixation was used in 16 and 8 patients, respectively, for a median of 39 days (interquartile range, 33-48 days). MAIN OUTCOME MEASUREMENTS Elbow range of motion, complications, and revision surgeries. RESULTS Immediately after static and dynamic external fixation removal, there was no difference in elbow extension [33 degrees ± 16 degrees vs. 41 degrees ± 13 degrees, mean difference (MD) 7 degrees, 95% confidence interval (CI) -6 degrees-22 degrees] or flexion (114 degrees ± 35 degrees vs. 118 degrees ± 11 degrees, MD 4 degrees, 95% CI -23 degrees-132 degrees), respectively. At last follow-up, static and dynamic external fixation groups had no difference in elbow extension (27 degrees ± 13 degrees vs. 24 degrees ± 10 degrees, MD -3 degrees, 95% CI -15 degrees-7 degrees) or flexion (129 degrees ± 12 degrees vs. 128 degrees ± 14 degrees, MD -1 degree, 95% CI -13 degrees-10 degrees), respectively. Static and dynamic external fixation groups had no difference in complications [7 (44%) vs. 5 (63%), difference 19%, 95% CI -23%-54%] or revision surgeries [6 (38%) vs. 4 (50%), difference 13%, 95% CI -27%-49%]. CONCLUSIONS No difference in range of motion, complications, and revision surgeries was detected after static versus dynamic external fixation of persistently unstable elbow fracture-dislocations. Due to ease of application, static external fixation is our preferred treatment for these injuries. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Chamseddine AH, Asfour AH, Rahal MJH, Dib AA, Wardani HM, Boushnak MO. The adjunct use of lateral hinged external fixator in the treatment of traumatic destabilizing elbow injuries. INTERNATIONAL ORTHOPAEDICS 2021; 45:1299-1308. [PMID: 33624209 DOI: 10.1007/s00264-021-04985-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/11/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study is to evaluate the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries. METHODS A retrospective review was performed on the medical records of patients in whom a lateral monolateral elbow hinged external fixator was applied by the senior author. The indication to apply the fixator corresponded to a variety of acute injury patterns ranging from simple elbow trauma or dislocation to complex fracture-dislocation, and the decision was based on either the presence of recurrent or persistent instability in any direction and/or to secure a vulnerable or weak bony fixation or soft tissue repair as intra-operatively judged by the surgeon. The fixator was inserted in the same setting after the repair of the associated ligamentous and/or bony structures. Patients operated after one month of the trauma and those presented with open elbow injury or associated humeral or ulnar shaft fracture were excluded. Rehabilitation was immediately started and the fixator removed at six to eight weeks with elbow testing and gentle manipulation under general anaesthesia, and resuming of rehabilitation after removal. Clinical assessment was performed for all patients according to the Mayo Elbow Performance Score (MEPS) with evaluation of range of motion at regular intervals till the end of the post-operative first year, then at final follow-up for the purpose of the study with radiographic assessment for evaluation of elbow reduction and concentricity. RESULTS There were 13 patients with a mean age of 42 years. Two patients had instability secondary to LCL rupture; one patient had redislocation because of associated coronoid process fracture; one patient had radial head fracture with rupture of both collateral ligaments; five patients had terrible triad injury with variable association of collateral ligaments lesions; and four patients had posterior Monteggia fracture-dislocation. The mean MEPS was 90 at a mean follow-up of seven years with six excellent, six good, and one fair result. All patients had a concentrically reduced and stable elbow as assessed clinically and radiologically with a mean functional arc of motion of 132° for extension-flexion and 178° for pronation-supination. CONCLUSION The hinged elbow external fixator represents a valuable adjunct in the therapeutic arsenal for the treatment of unstable elbows after bony and soft tissue repair. It provides satisfactory results in terms of stability and function and should be available in the operating room when a surgeon treats a complex elbow dislocation or fracture-dislocation.
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Affiliation(s)
- Ali Hassan Chamseddine
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25, Ghoubeiry, Beirut, Lebanon.
| | - Ali H Asfour
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25, Ghoubeiry, Beirut, Lebanon
| | - Mohammad Jawad H Rahal
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25, Ghoubeiry, Beirut, Lebanon
| | - Abbas A Dib
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25, Ghoubeiry, Beirut, Lebanon
| | - Hassan M Wardani
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25, Ghoubeiry, Beirut, Lebanon
| | - Mohammad O Boushnak
- Division of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25, Ghoubeiry, Beirut, Lebanon
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Abstract
Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. It is a complex trauma, associating severe bone and ligament lesions, with high more-or-less long-term risk of residual instability, stiffness, pain and osteoarthritis. During the last 20 years, pathologic, biomechanical and clinical knowledge has greatly progressed. Prevention of these severe complications requires initial understanding of the lesion mechanism and precise analysis of all lesions. Surgery aims to restore perfect stability by sequential anatomic repair, enabling early mobilization to prevent onset of stiffness. The aims of the present paper were to summarize the anatomic and pathophysiological bases, highlight the crucial importance of the humeroradial column and lateral collateral ligament, and to determine the importance of the coronoid process. Some aspects of treatment are controversial: systematic medial collateral ligament repair, or use of an articulated external fixator. Finally, we propose a simple algorithm to guide repair.
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Luchetti TJ, Abbott EE, Baratz ME. Elbow Fracture-Dislocations: Determining Treatment Strategies. Hand Clin 2020; 36:495-510. [PMID: 33040962 DOI: 10.1016/j.hcl.2020.07.011] [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] [Indexed: 02/02/2023]
Abstract
Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.
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[External fixator of the elbow]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2020; 32:387-395. [PMID: 32959082 DOI: 10.1007/s00064-020-00676-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 07/04/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
AIM OF SURGERY The placement of an external elbow fixator can be statically carried out as temporary stabilization or as a hinged movement fixator. As a hinged movement fixator a functional follow-up treatment is possible due to control of the joint guidance and reduction of the compromising forces on the osteoligamentous structures. INDICATIONS As a temporary stabilization of the elbow, the external fixator is used as a damage control method. As a movement fixator it is used as an additional protection and movement control after complex osteoligamentous interventions and persisting tendency to dislocation of the joint and also as a standalone procedure. In some cases, the procedure is also used in distraction arthrolysis of stiff elbows and as a salvage procedure in patients with relevant comorbidities as part of fracture treatment. CONTRAINDICATIONS Inexperience in relation to the procedure as well as a local acute infection at the level of the intended pin locations should specifically be mentioned as contraindications. In addition, compliance and patient understanding of the procedure are essential for the success of treatment. SURGICAL TECHNIQUE Soft tissue preparation for pin placement should be preferred over percutaneous incisions to enable a safe bone exposure. Knowledge of the course of neurovascular structures (particularly the radial nerve) is essential. When placing a hinge, knowledge of the position and detection of the idealized center of rotation is of fundamental importance. POSTOPERATIVE MANAGEMENT The type of postoperative management required essentially depends on the underlying injury. When placing a hinged fixator, the aim is to enable movement as early as possible. Nevertheless, blocking of the hinged fixator may be useful for a short period of time. Adequate pin care over the duration of the treatment is essential in order to prevent complications. RESULTS Good functional results have been reported for the treatment of unstable elbows after primary and secondary placement of a hinged external fixator. Good functional scores and improvement in the range of motion were also recorded in the context of an arthrolysis (additive for open arthrolysis or distraction arthrolysis); however, in contrast a significant number of complications associated with this surgery are likely to emerge. As a definitive salvage procedure, satisfactory results were obtained in a small case series of a selected older patient group with relevant comorbidities.
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Biz C, Crimì A, Belluzzi E, Maschio N, Baracco R, Volpin A, Ruggieri P. Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review. Orthop Surg 2019; 11:974-984. [PMID: 31773896 PMCID: PMC6904592 DOI: 10.1111/os.12571] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/03/2019] [Accepted: 10/14/2019] [Indexed: 12/24/2022] Open
Abstract
Objective Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non‐professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non‐professional athletes and in non‐sport‐related trauma patients with MUCL lesions. Methods A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were “ulnar collateral ligament injury,” “elbow,” “surgery,” and “conservative treatment”. Patients were divided into three groups: patients who underwent conservative treatment (C‐group), surgical treatment (S‐group), and surgery after a failed conservative treatment (C&S‐group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan–Jobe Orthopaedic Clinic score (KJOC). Results A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C‐group had better results. Excellent results were found in 98.8% of the C‐group, in 88.1% of the S‐group, and in 87.7% of the C&S‐group. The complication rate in the C‐group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction. Conclusions There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair.
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Affiliation(s)
- Carlo Biz
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Alberto Crimì
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Elisa Belluzzi
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Nicola Maschio
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Riccardo Baracco
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Andrea Volpin
- Trauma and Orthopaedic Department, Royal Derby Hospital NHS Foundation Trust, Derby, UK
| | - Pietro Ruggieri
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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25
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Rao AJ, Cohen MS. The use of static external fixation for chronic instability of the elbow. J Shoulder Elbow Surg 2019; 28:e255-e264. [PMID: 30857992 DOI: 10.1016/j.jse.2018.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 12/01/2018] [Accepted: 12/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic elbow instability after trauma is a challenging problem. Clinical results of external elbow fixation in this setting are limited, with most studies focusing on hinged external fixation. A static fixator is an alternative for maintaining joint reduction. Advantages of a static frame include ease of application, decreased need for special instrumentation, and more secure maintenance of a concentrically reduced joint in the setting of bone or soft tissue instability. The primary limitation of static fixation is the potential for stiffness. METHODS This retrospective review represents the largest reported cohort evaluating the use of static elbow external fixation for the treatment of chronic elbow instability. Twenty-seven cases treated by a single surgeon between 2004 and 2015 were identified. RESULTS Twenty patients were available for a clinical evaluation, including radiographs and a physical examination at a mean follow-up of 5.8 years (range, 1.4-12.4 years). Of note, 19 of 20 were clinically obese or overweight. At final evaluation, range of motion averaged from 20° ± 13° of extension to 134° ± 9° of flexion. All patients had stable elbows, except 1 patient who had valgus and varus laxity on stress examination. Radiographs of this patient showed an incongruous joint. Eight patients required an additional operation after external fixator removal, 3 for infection and 5 for stiffness. CONCLUSIONS At almost 6 years of follow-up, static elbow external fixator resulted in a congruous joint with adequate functional and clinical outcomes in 95% of patients.
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Affiliation(s)
- Allison J Rao
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Mark S Cohen
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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Sochol KM, Andelman SM, Koehler SM, Hausman MR. Treatment of Traumatic Elbow Instability With an Internal Joint Stabilizer. J Hand Surg Am 2019; 44:161.e1-161.e7. [PMID: 30717829 DOI: 10.1016/j.jhsa.2018.05.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 04/30/2018] [Accepted: 05/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Current options for treating elbow instability include bony and/or ligamentous fixation with orthosis or cast immobilization, transarticular cross-pinning, temporary bridge plating, and hinged or rigid external fixation. Our purpose was to evaluate the recently developed internal joint stabilizer (IJS), which acts as an internal external fixator of the elbow. Our primary end point was to assess whether use of the device results in a stable and congruent reduction of the ulnohumeral and radiocapitellar joints in patients with acute or chronic elbow instability as a result of trauma. In our series, patients with elbow instability as a result of acute or chronic trauma were treated with an IJS. METHODS This retrospective study reviewed 20 patients who underwent placement of a U.S. Food and Drug Administration (FDA)-approved IJS for elbow instability. Serial physical examinations and radiographs were performed to verify stability. Patients were instructed that, if they are dissatisfied with their postoperative motion, a secondary contracture release operation will be offered to them. Patients were asked to complete outcome-scoring questionnaires including the Disabilities of the Arm, Shoulder, and hand (DASH) and Mayo Elbow Performance (MEP) score. Complications were monitored for all patients. RESULTS Twenty patients who underwent placement of an IJS for persistent elbow instability were reviewed. Patients with a flexion-extension arc of 70° or less at 12 weeks were offered a staged arthroscopic contracture release. The average MEP score improved from 12.2 ± 12.4 to 82.5 ± 14.3 and the average DASH score improved from 85.3 ± 23.0 to 37.26 ± 29.3. The average postoperative flexion-extension arc at most recent follow-up was 124.3° ± 14.9°, with a median follow-up of 17 months (8 weeks-25 months). CONCLUSIONS Use of an IJS allows for early, congruent, and stable ulnohumeral and radiocapitellar range of motion in instances of persistent elbow instability. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Kristen M Sochol
- Department of Orthopaedic Surgery, Mount Sinai Hospital, Mount Sinai Health System, New York, NY.
| | - Steven M Andelman
- Department of Orthopaedic Surgery, Mount Sinai Hospital, Mount Sinai Health System, New York, NY
| | - Steven M Koehler
- Department of Orthopaedic Surgery, Mount Sinai Hospital, Mount Sinai Health System, New York, NY
| | - Michael R Hausman
- Department of Orthopaedic Surgery, Mount Sinai Hospital, Mount Sinai Health System, New York, NY
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Temporary Bridge Plate Stabilization of Unstable Elbow Fractures and Dislocations. Tech Hand Up Extrem Surg 2018; 22:46-50. [PMID: 29664804 DOI: 10.1097/bth.0000000000000191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Unstable fracture-dislocations of the elbow, and in particular the "terrible triad" injury consisting of an elbow dislocation with a fracture of the radial head and coronoid, are complex injuries that can be plagued and complicated by persistent instability. Acute and chronic instability is a difficult problem and is best managed early by avoidance and restoration of stability. A number of treatment options have been proposed to manage acute postfixation instability of the elbow joint. Traditional stabilization options include immobilization with splinting or casting, cross-articular pinning, and external fixation (hinged or static), followed by early physical therapy. However, each of these approaches can still yield persistent elbow instability. We are proposing a new technique of acute but temporary bridge plate stabilization of the elbow joint to protect the concentrically reduced elbow joint following repair of all injured structures to restore stability followed by staged removal and the delayed initiation of therapy.
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Sukegawa K, Kuniyoshi K, Suzuki T, Matsuura Y, Onuma K, Kenmoku T, Takaso M. Effects of the Elbow Flexion Angle on the Radial Nerve Location around the Humerus: A Cadaver Study for Safe Installation of a Hinged External Fixator. J Hand Surg Asian Pac Vol 2018; 23:388-394. [DOI: 10.1142/s242483551850042x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: This study aimed to investigate whether the distance between the radial nerve and rotational center of the elbow joint when observing from the lateral surface of the humerus changes according to passive elbow joint flexion for safe external fixation with a hinged fixator of the elbow joint. Methods: Twenty fresh-frozen cadaveric arms were dissected. The points where the radial nerve crosses over the posterior aspect of the humerus, crosses through the lateral center, and crosses over the anterior aspect of the humerus were defined in the lateral view of the elbow joint, using fluoroscopy, as R1, R2, and R3, respectively. The distances between the rotational center and each point on the radial nerve were measured when the flexion angle of the elbow joint was 10°, 50°, 90°, and 130°. Results: The distances between the rotational center and R1, R2, and R3 were 118 mm, 94 mm, and 65 mm, respectively, when the flexion angle was 10°; 112 mm, 93 mm, and 74 mm, respectively, for 50°; 108 mm, 93 mm, and 77 mm, respectively, for 90°; and 103 mm, 94 mm, and 83 mm, respectively, for 130°. The distance between the rotational center and R2 was constant regardless of the flexion angle. With elbow joint extension, the distances between R1 and R3 increased; the safe zone, a region where the radial nerve would not be located on the humerus, was the smallest in extension. When the elbow joint was flexed, the distances between R1 and R3 decreased; the safe zone was the largest in flexion. Conclusions: This study showed that the radial nerve location on the humerus varied based on the flexion angle of the elbow joint; the safe zone may change. A half-pin can be likely inserted safely, avoiding the elbow joint extension position.
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Affiliation(s)
- Koji Sukegawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kazuki Kuniyoshi
- Department of Orthopaedic Surgery and Bioenvironmental Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takane Suzuki
- Department of Bioenvironmental Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yusuke Matsuura
- Department of Orthopaedic Surgery and Bioenvironmental Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenji Onuma
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomonori Kenmoku
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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Gottlieb M, Schiebout J. Elbow Dislocations in the Emergency Department: A Review of Reduction Techniques. J Emerg Med 2018; 54:849-854. [DOI: 10.1016/j.jemermed.2018.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/04/2018] [Accepted: 02/07/2018] [Indexed: 01/13/2023]
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Song J, Ding H, Han W, Wang J, Wang G. An X-ray-free method to accurately identify the elbow flexion-extension axis for the placement of a hinged external fixator. Int J Comput Assist Radiol Surg 2017; 13:375-387. [PMID: 29101641 DOI: 10.1007/s11548-017-1680-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 10/19/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Identifying the elbow flexion-extension (F-E) movement axis is important for placing a hinged elbow external fixator. An X-ray fluoroscopy-based method is widely used in clinical practice, exposing the patient and surgeons to high doses of radiation. Additionally, the accuracy and repeatability of the fluoroscopy-based method are very low and affected by subjective factors. METHODS To solve this problem, an X-ray-free method based on kinematics analysis was proposed to identify the elbow F-E movement axis, and a navigation system was built to guide the placement of the elbow external fixator. RESULTS Our X-ray-free navigation method is more repeatable than the current X-ray fluoroscopy method used clinically. Both our algorithm and the NIST (National Institute of Standards and Technology) algorithm showed high accuracy and repeatability to identify the axis. CONCLUSIONS The method proposed in this study is very promising to avoid a large dose of X-ray radiation and increases the repeatability and performance of identifying the elbow F-E movement axis for the placement of the hinged elbow external fixator.
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Affiliation(s)
- Jian Song
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Room C249, Beijing, 100084, People's Republic of China
| | - Hui Ding
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Room C249, Beijing, 100084, People's Republic of China
| | - Wei Han
- Beijing Jishuitan Hospital, 4th Medical College of Peking University, 31st East Xinjiekou Street, Beijing, 100035, People's Republic of China
| | - Junqiang Wang
- Beijing Jishuitan Hospital, 4th Medical College of Peking University, 31st East Xinjiekou Street, Beijing, 100035, People's Republic of China
| | - Guangzhi Wang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Room C249, Beijing, 100084, People's Republic of China.
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Wiggers JK, Snijders RM, Dobbe JGG, Streekstra GJ, den Hartog D, Schep NWL. Accuracy in identifying the elbow rotation axis on simulated fluoroscopic images using a new anatomical landmark. Strategies Trauma Limb Reconstr 2017; 12:133-139. [PMID: 28593358 PMCID: PMC5653598 DOI: 10.1007/s11751-017-0289-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/07/2017] [Indexed: 11/28/2022] Open
Abstract
External fixation of the elbow requires identification of the elbow rotation axis, but the accuracy of traditional landmarks (capitellum and trochlea) on fluoroscopy is limited. The relative distance (RD) of the humerus may be helpful as additional landmark. The first aim of this study was to determine the optimal RD that corresponds to an on-axis lateral image of the elbow. The second aim was to assess whether the use of the optimal RD improves the surgical accuracy to identify the elbow rotation axis on fluoroscopy. CT scans of elbows from five volunteers were used to simulate fluoroscopy; the actual rotation axis was calculated with CT-based flexion–extension analysis. First, three observers measured the optimal RD on simulated fluoroscopy. The RD is defined as the distance between the dorsal part of the humerus and the projection of the posteromedial cortex of the distal humerus, divided by the anteroposterior diameter of the humerus. Second, eight trauma surgeons assessed the elbow rotation axis on simulated fluoroscopy. In a preteaching session, surgeons used traditional landmarks. The surgeons were then instructed how to use the optimal RD as additional landmark in a postteaching session. The deviation from the actual rotation axis was expressed as rotational and translational error (±SD). Measurement of the RD was robust and easily reproducible; the optimal RD was 45%. The surgeons identified the elbow rotation axis with a mean rotational error decreasing from 7.6° ± 3.4° to 6.7° ± 3.3° after teaching how to use the RD. The mean translational error decreased from 4.2 ± 2.0 to 3.7 ± 2.0 mm after teaching. The humeral RD as additional landmark yielded small but relevant improvements. Although fluoroscopy-based external fixator alignment to the elbow remains prone to error, it is recommended to use the RD as additional landmark.
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Affiliation(s)
- J K Wiggers
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - R M Snijders
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J G G Dobbe
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - G J Streekstra
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - D den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - N W L Schep
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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Elbow fractures: current concepts. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zhou Y, Cai JY, Chen S, Liu S, Wang W, Fan CY. Application of distal radius-positioned hinged external fixator in complete open release for severe elbow stiffness. J Shoulder Elbow Surg 2017; 26:e44-e51. [PMID: 28104095 DOI: 10.1016/j.jse.2016.09.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/31/2016] [Accepted: 09/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Radical release for severe stiff elbows may lead to instability. Hinged external fixation is used to treat unstable elbows. We hypothesized that extensive open release combined with a distal radius-positioned hinged external fixator would have good performance and low complications rate in treating severe elbow stiffness. Thus, the efficacy and security of this technique were assessed in this study. METHODS We retrospectively reviewed 38 post-traumatic elbows with severe stiffness that underwent arthrolysis between February 2011 and February 2014. All patients were assessed as having elbow instability after complete arthrolysis. Ligament repair was combined with implantation of a hinged external fixator (fixed to the humerus and distal radius) to maintain elbow stability. Flexion arc, forearm rotation, Mayo Elbow Performance Score, elbow stability, and radiographs were evaluated preoperatively and postoperatively, and complications were documented. RESULTS Mean follow-up was 31 months. Significant improvement was noted in flexion-extension arc (from 27° to 126°), forearm rotation (from 148° to 153°), and mean Mayo Elbow Performance Score (from 68 points to 96 points). Mean pronation arc decreased from 66° preoperatively to 6° at 1.5 months of follow-up and showed a transient reduction during first 6 months postoperatively. Pin-related infection occurred in 2 patients, which was cured with conservative treatment. Two patients had moderate instability after removal of the fixator and regained stability at the 12-month follow-up. At the last follow-up, complications included ulnar nerve paralysis in 3, recurrence of heterotopic ossification in 1, and moderate pain in 1. CONCLUSIONS Complete open release combined with a distal radius-positioned hinged external fixator is an effective treatment for severe stiff elbows. This technique had a low complication rate.
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Affiliation(s)
- Yi Zhou
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China; Department of Orthopaedics, Capital Medical University, Affiliated Beijing ChaoYang Hospital, Beijing, China
| | - Jiang-Yu Cai
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China; Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuai Chen
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Shen Liu
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Cun-Yi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China.
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Orbay JL, Ring D, Kachooei AR, Santiago-Figueroa J, Bolano L, Pirela-Cruz M, Hausman M, Papandrea RF. Multicenter trial of an internal joint stabilizer for the elbow. J Shoulder Elbow Surg 2017; 26:125-132. [PMID: 27939280 DOI: 10.1016/j.jse.2016.09.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/26/2016] [Accepted: 09/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our primary efficacy objective was to evaluate the effectiveness of the internal joint stabilizer of the elbow (IJS-E) in maintaining concentric location of the elbow during and after removal of the device in the treatment of persistent or recurrent instability after elbow fracture or dislocations, or both. The secondary study objectives were to assess range of motion, Broberg-Morrey functional score, Broberg-Morrey categorical rating, the Disabilities of the Arm, Shoulder and Hand score, and the rate of complications and adverse events after the use of IJS-E. METHODS Twenty-four patients were studied in a multicenter, nonrandomized, prospective, single-arm study. The IJS-E was used to provide temporary stabilization of the elbow joint and allow a functional range of motion while ligaments and fractures healed. RESULTS The elbow remained concentrically aligned in 23 of 24 patients. One coronoid-deficient elbow did not maintain concentric reduction. At the last evaluation a minimum of 6 months after device removal, the mean arc of elbow flexion was 119° (range, 80°-150°; standard deviation [SD], 18°), and the mean arc of forearm rotation was 151° (range, 90°-190°; SD, 24°). The mean and median Broberg-Morrey scores were 93 and 97, respectively. Categorically the results were excellent in 14, good in 8, fair in 1, and poor in 1. The mean Disabilities of the Arm, Shoulder and Hand score was 16 (range, 0-68; SD, 18). CONCLUSION The IJS-E maintains concentric reduction, allows elbow motion, and avoids the inconveniences and pin problems of percutaneous fixation.
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Affiliation(s)
- Jorge L Orbay
- The Miami Hand & Upper Extremity Institute, Miami, FL, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Amir R Kachooei
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - Luis Bolano
- Department of Orthopedics, Three Gables Surgical Hospital, Proctorville, OH, USA
| | - Miguel Pirela-Cruz
- Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University of Health Science, El Paso, TX, USA
| | - Michael Hausman
- Department of Orthopedics, The Mount Sinai Medical Center, New York, NY, USA
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Dos Santos A, Creze M, Begin M, Laemmel E, Assabah B, Soubeyrand M. Cadaveric assessment of a 3D-printed aiming device for implantation of a hinged elbow external fixator. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:405-414. [PMID: 27942933 DOI: 10.1007/s00590-016-1889-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Proper implantation of a hinged external elbow fixator (HEEF) is demanding since it requires precise alignment between the flexion-extension's and HEEF's axis. In order to optimize this alignment, we have developed a 3D-printed aiming device. The primary goal of the study was to compare the aiming device-based technique with the conventional pin technique. The secondary goal was to determine whether it is possible to share the aiming device with the surgical community. MATERIALS AND METHODS A HEEF was implanted in cadavers with either the aiming device (n = 6) or the conventional pin technique (n = 6). For both techniques the duration of the procedure, the radiation exposure as well as the offset and angular divergence between the HEEF's and flexion-extension's axis were compared. To achieve the secondary goal, two surgeons used aiming devices 3D-printed from files sent by email in order to implant HEEF on cadaveric specimens (n = 6). RESULTS Duration of the procedure was not significantly different between both techniques. However, the aiming device allowed for reduction of the number of image intensifier shots (p = 0.005), angular divergence (p = 0.02) and offset between both axes (p = 0.05). The aiming devices have been delivered less than 15 days after ordering, and they have allowed proper implantation of six HEEF. CONCLUSION The 3D-printed aiming device allowed less irradiant and more accurate implantation of HEEF. It is possible to share it with other surgeons.
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Affiliation(s)
- Alexandre Dos Santos
- Department of Orthopaedic Surgery, Universitary Hospital of Bicêtre, Public Assistance Hospital of Paris, 78 Rue General Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Maud Creze
- Department of Radiology, Universitary Hospital of Bicetre, Public Assistance Hospital of Paris, 78 Rue General Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Matthieu Begin
- Clinique de l'Yvette, 67 Route de Corbeil, 91160, Longjumeau, France
| | - Elisabeth Laemmel
- Laboratoire de Microcirculation, Faculté de Médecine de Lariboisière, Université Paris-Diderot, 10 Avenue de Verdun, 75010, Paris, France
| | - Bouchra Assabah
- Faculty of Medicine, University Paris Sud-XI, 63 rue Gabiel Peri, 94270, Le Kremlin-Bicêtre, France
| | - Marc Soubeyrand
- Department of Orthopaedic Surgery, Universitary Hospital of Bicêtre, Public Assistance Hospital of Paris, 78 Rue General Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Faculty of Medicine, University Paris Sud-XI, 63 rue Gabiel Peri, 94270, Le Kremlin-Bicêtre, France.
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Poglia P, Wehrli L, Steinmetz S, Zermatten P. Radial nerve palsy after the use of an adjuvant hinged external fixator in a complex fracture-dislocation of the elbow: a case report and review of the literature. J Med Case Rep 2016; 10:121. [PMID: 27170152 PMCID: PMC4866299 DOI: 10.1186/s13256-016-0904-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/19/2016] [Indexed: 11/13/2022] Open
Abstract
Background The combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture is known as “terrible triad” injury of the elbow. This injury is one of the most challenging injuries of the musculoskeletal system and almost always causes instability of the elbow. The use of an adjuvant hinged external fixator in such injuries is still debated. Case presentation In this case report we present a case of radial nerve palsy after setting up an adjuvant hinged external fixator in a complex fracture–dislocation of the elbow. The patient was a 39-year-old white man. A revision of his radial nerve was undertaken at 7 weeks. A radial nerve injury at two levels facing the humeral apex pins was found intraoperatively; the pins were carefully removed and partial nerve grafts done. The functional outcome at 18 months was excellent. Conclusion This case report highlights that the use of an adjuvant hinged external fixator in complex fracture –dislocation of the elbow is technically demanding and not without risk.
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Affiliation(s)
- Pietro Poglia
- Department of Surgery, Division of Orthopaedic Surgery and Traumatology, Centre Hospitalier du Centre du Valais, avenue Gd-Champsec 80, 1950, Sion, Switzerland
| | - Laurent Wehrli
- Department of Surgery, Division of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, University of Lausanne, rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sylvain Steinmetz
- Department of Surgery, Division of Orthopaedic Surgery and Traumatology, Centre Hospitalier du Centre du Valais, avenue Gd-Champsec 80, 1950, Sion, Switzerland
| | - Philippe Zermatten
- Department of Surgery, Division of Orthopaedic Surgery and Traumatology, Centre Hospitalier du Centre du Valais, avenue Gd-Champsec 80, 1950, Sion, Switzerland.
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Jennings JD, Hahn A, Rehman S, Haydel C. Management of Adult Elbow Fracture Dislocations. Orthop Clin North Am 2016; 47:97-113. [PMID: 26614925 DOI: 10.1016/j.ocl.2015.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.
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Affiliation(s)
- John D Jennings
- Department of Orthopedic Surgery and Sports Medicine, Temple University Hospital, 3501 North Broad Street, Philadelphia, PA 19140, USA.
| | - Alexander Hahn
- Department of Orthopedic Surgery and Sports Medicine, Temple University School of Medicine, 3501 N. Broad St, Philadelphia, PA 19102, USA
| | - Saqib Rehman
- Department of Orthopedic Surgery and Sports Medicine, Temple University Hospital, 3501 North Broad Street, Philadelphia, PA 19140, USA
| | - Christopher Haydel
- Department of Orthopedic Surgery and Sports Medicine, Temple University Hospital, 3501 North Broad Street, Philadelphia, PA 19140, USA
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Bigazzi P, Biondi M, Corvi A, Pfanner S, Checcucci G, Ceruso M. A new autocentering hinged external fixator of the elbow: a device that stabilizes the elbow axis without use of the articular pin. J Shoulder Elbow Surg 2015; 24:1197-205. [PMID: 26189805 DOI: 10.1016/j.jse.2015.05.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hinged external fixation of the elbow is an important tool for the orthopedic surgeon. It enables early postoperative mobilization that may result in better outcomes. All models require correct alignment with the elbow axis of rotation. There is a long learning curve to this procedure, it may be time-consuming, and it can be associated with a high dose of x-ray exposure. An axial pin can interfere with bone-ligament suture anchors and bone reconstruction plates. MATERIALS AND METHODS A new external fixator has been designed and mechanically tested. The hinge has a special gear able to freely align itself with the center of elbow rotation during passive flexion-extension movements. It has been clinically tested on 7 patients affected by traumatic and post-traumatic elbow disorders. The maintenance of the correct position has been tested clinically with computed tomography scans and radiographs. RESULTS All patients had correct alignment of the axis of rotation of the external fixator with the axis of elbow rotation. No cases of misalignment, loss of fixation, pin loosening, or instability were found. CONCLUSION A new self-centering hinged external fixator correctly aligns itself with the axis of elbow rotation. It does not interfere with ligamentous reconstruction anchors, distal plates, or screw fixation. The surgical technique is easy to learn and relatively quick. It can also be positioned without performing an arthrotomy to maintain reduction of simple dislocations of the elbow.
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Affiliation(s)
- Prospero Bigazzi
- Department of Hand Surgery and Reconstructive Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Marco Biondi
- Department of Hand Surgery and Reconstructive Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Corvi
- Department of Engineering, Università degli Studi di Firenze, Florence, Italy
| | - Sandra Pfanner
- Department of Hand Surgery and Reconstructive Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Checcucci
- Department of Hand Surgery and Reconstructive Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Massimo Ceruso
- Department of Hand Surgery and Reconstructive Microsurgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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CORR Insights ®: Good functional recovery of complex elbow dislocations treated with hinged external fixation: a multicenter prospective study. Clin Orthop Relat Res 2015; 473:1462-3. [PMID: 25377136 PMCID: PMC4353559 DOI: 10.1007/s11999-014-4050-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/30/2014] [Indexed: 01/31/2023]
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