Risk factors for posttraumatic heterotopic ossification of the elbow: case-control study

Type of fixation is not associated with range of motion after operative treatment of proximal radius fractures- a systematic review of 519 patients

Background

The aims of this study are 1) to assess whether open reduction internal fixation (ORIF) techniques for fractures of the proximal radius are associated with the range of motion (ROM), 2) to determine the incidence of hardware-related complications and removal following plate and screw fixation of the proximal radius, and 3) to evaluate whether the safe-zone definition is described in the literature and its relation to the ROM.

Methods

A literature search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting ROM in patients undergoing ORIF for radial head or neck fractures were included. Two treatment groups were defined based on ORIF technique: screws only or plates with and without additional screw placement.

Results

A total of 13 articles were included with 519 patients, of which 271 belonged to the screw group and 248 to the plate group. At final follow-up, the screw group reported a mean supination of 79 (95% CI: 74-83), pronation of 76 (95% CI: 69-84), flexion of 131 (95% CI: 124-138), and loss of extension of 4 (95% CI: 1-7). The plate group reported a mean supination of 72 (95% CI: 65-80), pronation of 697 (95% CI: 60-75), flexion of 126 (95% CI: 118-133), and loss of extension of 7 (95% CI: 1-14).

Conclusion

Predominantly retrospective studies show that the ROM seems similar for screw and plate osteosynthesis of proximal radius fractures. Complication rates are similar as well. The safe-zone definition is rarely reported.

Heterotopic ossification of the elbow joint in a child: Successful surgical resection - A case report

Background

This case report describes the occurrence of a rare heterotopic ossification of the elbow joint in a child, caused by inappropriate movement after trauma. A successful operation to remove heterotopic ossification was described in the report with satisfactory results.

Case presentation

A 7-year-old boy suffered a supracondylar fracture of the humerus after an accidental fall, and after immobilization with a cast, improper movement resulted in heterotopic ossification of the elbow joint, which severely affected joint function. The heterotopic ossification was surgically removed and a complete recovery was demonstrated at 18 months follow-up. The heterotopic ossification was successfully removed with good elbow function and no recurrence at 18 months follow-up.

Conclusions

The purpose of this report is to show the good results with surgical treatment of heterotopic ossification of the elbow joint in children,when conservative treatment does not work.

Safety and effectiveness of the three-dimensional-printed guide plate-assisted rotation axis positioning of a hinged external fixator for the elbow

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.

Vegfc-expressing cells form heterotopic bone after musculoskeletal injury

Heterotopic ossification (HO) is a challenging condition that occurs after musculoskeletal injury and is characterized by the formation of bone in non-skeletal tissues. While the effect of HO on blood vessels is well established, little is known about its impact on lymphatic vessels. Here, we use a mouse model of traumatic HO to investigate the relationship between HO and lymphatic vessels. We show that injury triggers lymphangiogenesis at the injury site, which is associated with elevated vascular endothelial growth factor C (VEGF-C) levels. Through single-cell transcriptomic analyses, we identify mesenchymal progenitor cells and tenocytes as sources of Vegfc. We demonstrate by lineage tracing that Vegfc-expressing cells undergo osteochondral differentiation and contribute to the formation of HO. Last, we show that Vegfc haploinsufficiency results in a nearly 50% reduction in lymphangiogenesis and HO formation. These findings shed light on the complex mechanisms underlying HO formation and its impact on lymphatic vessels.

The Internal Joint Stabilizer of the Elbow: A Systematic Review of the Clinical and Biomechanical Evidence

Purpose

The goal of surgical management for unstable elbow injuries is the restoration of joint concentricity and stability. After internal fixation, concerns may exist regarding instability or durability of the fixation construct. Historically, these scenarios were treated with options such as transarticular pinning or external fixation. Recently, an internal joint stabilizer (IJS) that allows postoperative mobilization was introduced. Our objective was to systematically review the literature to aggregate the clinical and biomechanical evidence for the IJS of the elbow.

Methods

A systematic review of the PubMed and Google Scholar databases was performed, following the PRISMA guidelines. The search results were narrowed from 2015 through 2023 to coincide with the inception of the device being reviewed.

Results

A total of nine retrospective reports on the IJS (N = 171) cases at a mean follow-up of 10.8 months were included. The pooled rate of implant failure was 4.4%, and recurrent instability was 4.1%. Additionally, the we included seven case reports and two biomechanical reports.

Conclusions

The aggregate literature describes satisfactory clinical outcomes with low rates of recurrent instability and device failure for the IJS of the elbow. The limited biomechanical investigations conclude efficacy for stability profiles.

Clinical relevance

Across a spectrum of unstable elbow cases, the IJS prevented recurrent instability during the early postoperative period. Notably, the device requires an additional procedure for removal, and the long-term impact of the retained devices is currently unclear.

Postoperative swelling after elbow surgery: influence of a negative pressure application in comparison to manual lymphatic drainage-a randomized controlled trial

PURPOSE

Postoperative soft tissue swelling is a significant factor influencing outcomes after elbow surgery. It can crucially affect important parameters such as postoperative mobilization, pain, and subsequently the range of motion (ROM) of the affected limb. Furthermore, lymphedema is considered a significant risk factor for numerous postoperative complications. Manual lymphatic drainage is nowadays part of the standardized post-treatment concept, basing on the concept of activating the lymphatic tissue to absorb stagnated fluid from the tissue into the lymphatic system. This prospective study aims to investigate the influence of technical device-assisted negative pressure therapy (NP) on early functional outcomes after elbow surgery. NP was therefore compared to manual lymphatic drainage (MLD). Is a technical device-based NP suitable for treatment of lymphedema after elbow surgery?

METHODS

A total of 50 consecutive patients undergoing elbow surgery were enrolled. The patients were randomized into 2 groups. 25 participants per group were either treated by conventional MLD or NP. The primary outcome parameter was defined as the circumference of the affected limb in cm postoperative up to seven days postoperatively. The secondary outcome parameter was a subjective perception of pain (measured via visual analogue scale, VAS). All parameters were measured on each day of postoperative inpatient care.

RESULTS AND CONCLUSION

NP showed an overall equivalent influence compared to MLD in reducing upper limb swelling after surgery. Moreover, the application of NP showed a significant decrease in overall pain perception compared to manual lymphatic drainage on days 2, 4 and 5 after surgery (p <  0.05).

CONCLUSION

Our findings show that NP could be a useful supplementary device in clinical routine treating postoperative swelling after elbow surgery. Its application is easy, effective and comfortable for the patient. Especially due to the shortage of healthcare workers and physical therapists, there is a need for supportive measures which NP could be.

The Incidence of Heterotopic Ossification in Surgically and Non-surgically Treated Elbow Fractures at a Municipal Hospital in Japan

Background: Heterotopic ossification (HO) is a well-recognised complication of after elbow trauma. The prevalence and risk factors of HO have been previously reported. However, these reports were based on elbow trauma that had undergone surgical treatment and most of them were from Western countries. This study aimed to assess the incidence of HO in patients with elbow fractures who were treated surgically and non-surgically in Japan. Methods: We retrospectively identified consecutive patients who were treated of elbow fractures and fracture-dislocations at our institution in recent consecutive 3-year periods. We extracted patient demographics, injury mechanisms and treatment details from the medical records. Furthermore, we reviewed radiographs to classify the fracture pattern and identify the presence or absence of HO. Results: HO was identified in 6/97 (6%) patients. Fracture-dislocation was noted in 4/6 patients. The fracture types with HO included terrible triad injury (n = 2), isolated coronoid process fractures (n = 2), distal humerus A-type fractures (n = 1) and radial head fracture (n = 1). According to the Hastings and Graham classification, HO was classified as Class I in five patients and Class II B in one patient who underwent additional surgery for HO resection. Conclusions: The incidence of HO was relatively low in our patients. However, of the 20 conservatively treated elbows, one patient developed clinically relevant HO and required excision of HO. Even patients with elbow fractures treated conservatively should be informed of the potential risk of developing severe HO requiring surgical excision. In addition, surgeons in this region could use these data to inform patients about the risk of HO development after an elbow injury. Level of Evidence: Level IV (Therapeutic).

Association Between Tranexamic Acid Use and Heterotopic Ossification Prevalence After Elbow Trauma Surgery: A Propensity-Score-Matched Cohort Study

BACKGROUND

Heterotopic ossification (HO) is a common complication of elbow trauma that can affect limb mobility. Inflammation is an initiating factor for HO formation. Tranexamic acid (TXA) can reduce the inflammatory response after orthopaedic surgery. However, evidence regarding the effectiveness of TXA use for HO prevention after elbow trauma surgery is lacking.

METHODS

This retrospective observational propensity-score-matched (PSM) cohort study was conducted from July 1, 2019, to June 30, 2021, at the National Orthopedics Clinical Medical Center, Shanghai, People's Republic of China. A total of 640 patients who underwent surgery following elbow trauma were evaluated. The present study excluded patients with an age of <18 years; those with a history of elbow fracture; those with a central nervous system injury, spinal cord injury, burn injury, or destructive injury; and those who had been lost to follow-up. After 1:1 matching on the basis of sex, age, dominant arm, injury type, open injury, comminuted fracture, ipsilateral trauma, time from injury to surgery, and nonsteroidal anti-inflammatory drug use, the TXA group and the no-TXA group comprised 241 patients each.

RESULTS

In the PSM population, the prevalence of HO was 8.71% in the TXA group and 16.18% in the no-TXA group (with rates of 2.07% and 5.80% for clinically important HO, respectively). Logistic regression analyses showed that TXA use was associated with a lower rate of HO (odds ratio [OR], 0.49; 95% CI, 0.28 to 0.86; p = 0.014) than no TXA use, as well as with a lower rate of clinically important HO (OR, 0.34; 95% CI, 0.11 to 0.91; p = 0.044). None of the baseline covariates significantly affected the relationship between TXA use and HO rate (p > 0.05 for all). Sensitivity analyses supported these findings.

CONCLUSIONS

TXA prophylaxis may be an appropriate method for the prevention of HO following elbow trauma.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparison of different treatment approaches for coronoid process fracture in terrible triad injury: a multicenter, randomized controlled study

PURPOSE

The purpose of the study was to compare the functional results of different treatment approaches for the fracture of the coronoid process in terrible triad injury (TTI).

METHODS

This prospective randomized controlled trial included participants from seven level-1 trauma centres in China. All patients were randomly assigned to three groups, wherein different approaches were applied to treat coronoid fracture: group A) internal fixation of the coronoid process without external fixation or splint (ORIF group), B) external fixation using a hinged fixator without internal fixation (Exfix group), and C) long-arm plaster for two to three weeks postoperatively without internal fixation of coronoid process (Plaster group). Early active motion exercises within the limits of pain were started immediately after surgery under the supervision of a physical therapist. Outcomes were evaluated at regular intervals over the subsequent 12 months.

RESULTS

A total of 65 patients (22 patients in Group A, 21 in Group B, and 22 in Group C) were included in this trial from January 2016 to January 2019. The average arc of elbow motion was 114.1° ± 8.92°. The average flexion and flexion contracture were 126.4° ± 11.2° and 12.3° ± 7.7°, respectively. The arcs of forearm rotation of the elbow for each group were 145.41° ± 9.36°, 143.38° ± 9.79°, and 143.86° ± 10.95°, respectively. The MEPS for each group were 86.82 ± 9.7, 86.67 ± 9.92, and 85.23 ± 8.66, respectively. The DASH score for each group were 18.26 ± 19.31, 18.85 ± 15.02, and 20.19 ± 13.59, respectively.

CONCLUSION

All three approaches in our trial showed similar functional results in the long-term survey. Patients treated with external fixation without internal fixation of the coronoid process showed less pain during early mobilization and acquired maximum flexion within a short duration after surgery.

Comparative Study Between the Mini-Open (≤2.5 Cm) Approach and Conventional Open Lateral Approach in the Surgical Treatment of Radial Head Fractures

Purpose

The conventional lateral approach is widely used to treat radial head fractures with screws. However, the traditional incision may have shortcomings, including excessive exposure and significant scarring. We propose an innovative method – a mini-open lateral approach of less than 2.5 cm for surgical treatment of radial head fractures with screws.

Methods

From Jan 2017 to Dec 2020, 34 patients diagnosed with closed radial head fracture were treated with open reduction and internal fixation (ORIF) in this study. The novel group (mini-open group) included 15 patients, and the other 19 patients were in the traditional group. The time of operation and the blood loss during operation were recorded. Postoperative clinical outcomes and radiographic results were recorded and compared between the two groups. The range of motion (ROM) in the elbow, the Visual Analogue Scale (VAS), the Mayo Elbow Performance Score (MEPS), Rating Scale of the American Shoulder and Elbow Surgeons (ASES), and the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH) score and complications, such as wound infection, vascular and nerve damage, and fragment redisplacement were observed in the two groups.

Results

In the comparison between the two groups, there was no significant difference in age, sex, cause of radial head fracture, or other basic information. The operation time, intraoperative blood loss, and VAS score at 3 days postoperation were significantly reduced in the novel group (p < 0.05). The follow-up results showed that there was no significant difference in MEPS, ASES, or Q-DASH scores between the two groups.

Conclusion

The mini-open approach reduced intraoperative blood loss, shortened operation time, relieved patient pain, and achieved a satisfactory postoperative clinical result, which demonstrates that the novel approach is a safe and effective option for treating radial head fractures.

A new prognostic nomogram for heterotopic ossification formation after elbow trauma : the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction (STEHOP) model

AIMS

Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

METHODS

This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation.

RESULTS

Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes.

CONCLUSION

The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963-971.

Comparative study of the functional outcomes of combined medial-lateral approach arthrolysis with or without external fixation for severe elbow stiffness

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.

Does posterior configuration have similar strength as parallel configuration for treating comminuted distal humerus fractures? A cadaveric biomechanical study

BACKGROUND

The posterior plating technique could be used as a clinical alternative to parallel plating for treating comminuted distal humerus fractures (DHFs) successfully with good clinical results. However, the biomechanical characteristics for posterior fixation are still unclear. The purpose of this study is to evaluate the biomechanical properties of the posterior fixation and to make comparisons between the parallel and the posterior fixation systems.

MATERIALS AND METHODS

We performed a cadaveric biomechanical testing with two posterior plating systems (a posterior two plating and a single posterior pre-contoured Y plating system) and one parallel two plating system to treat AO/OTA type-C2.3 DHFs. Among three groups, we compared construct stiffness, failure strength, and intercondylar width changes after 5000-cycle fatigue loading and failure loads and failure modes after destructive tests in both the axial compression and (sagittal) posterior bending directions. The correlations between construct failure loads and bone marrow density (BMD) were also compared.

RESULTS

In axial direction, there were no significant differences in the stiffness and failure load between the posterior and the parallel constructs. However, in sagittal direction, the two-plate groups (posterior two plating and parallel plating group) had significant higher stiffness and failure loads than the one-plate group (single posterior Y plating). There was no fixation failure after 5000-cyclic loading in both directions for all groups. Positive correlation was noted between BMD and failure loads on parallel fixation.

CONCLUSIONS

We found that when using two plates for treating comminuted DHFs, there were no significant differences in terms of most biomechanical measurements between posterior and parallel fixation. However, the single pre-contoured posterior Y plate construct was biomechanically weaker in the sagittal plane than the parallel and the posterior two-plate constructs, although there was no fixation failure after the fatigue test for all groups regardless of the fixation methods.

LEVEL OF EVIDENCE

Biomechanical study.

Risk Factors of Elbow Stiffness After Open Reduction and Internal Fixation of the Terrible Triad of the Elbow Joint

OBJECTIVE

To analyze the risk factors of elbow stiffness following open reduction and internal fixation of the terrible triad of the elbow joint.

METHODS

A retrospective study was conducted of 100 patients with the terrible triad of the elbow joint, who had been treated at our hospital from January 2015 to December 2018. All patients were treated with a loop plate to repair the ulnar coronoid process. According to the severity of the injury, the radial head was either fixed or replaced, and the lateral collateral ligament was repaired with an anchor. According to the range of motion of the elbow during the last follow-up, the patients were divided into two groups. The stiffness group (displayed extension-flexion or pronation-supination <100°) consisted of 30 patients. The second group, named the non-stiffness group (exhibited extension-flexion and pronation-supination ≥100°), consisted of 70 patients. Related risk factors included age, gender, smoking, diabetes, whether the fracture is on the dominant side, mechanism of injury, fracture classification, time from injury to surgery, configuration of internal fixation of the radial head, postoperative immobilization time, and use of anti-heterotopic ossification drugs (oral indomethacin). Both t-test and chi squared test were used to analyze any significant differences. Only the variables with a P < 0.05 in the tests were retested into a logistic multiple regression in order to screen risk factors of elbow stiffness.

RESULTS

All patients were followed up for 12-48 months (average, 25.7 months), and all patients exhibited bone healing. Multivariate regression analysis showed that high-energy injury (OR = 3.068, 95% CI 1.134-8.295, P = 0.027), time from injury to surgery > 1 week (OR = 2.714, 95% CI 1.029-7.159, P = 0.044), and postoperative immobilization time (OR = 3.237, 95% CI 1.176-8.908, P = 0.023) were independent risk factors of elbow stiffness after surgery for the terrible triad of the elbow.

CONCLUSION

High-energy injury, the time from injury to surgery > 1 week, and postoperative joint immobilization time > 2 weeks are the independent risk factors of elbow stiffness after surgery of the terrible triad of the elbow, which should be treated carefully in clinical treatment.

Risk Factors for Elbow Joint Contracture After Surgical Repair of Traumatic Elbow Fracture

PURPOSE

The ability to predict contracture development after elbow fracture would benefit patients and physicians. This study aimed to identify factors associated with the development of posttraumatic elbow joint contracture.

METHODS

A retrospective review of elbow fractures (AO/Orthopaedic Trauma Association [OTA] type 13 and 21) treated at one institution between 2011 and 2015 was performed. Data collected included demographics, injury information, treatment, and postoperative elbow range of motion (ROM). Multivariate logistic regression analyses were performed to identify factors associated with contracture development. Notable contracture was defined as an arc of motion less than 100° flexion/extension, which has been associated with reduced ability to perform activities of daily living.

RESULTS

A total of 278 patients at least 1 8 years of age underwent surgical repair of an elbow fracture or fracture-dislocation during the study period and had at least 6 months of postoperative follow-up. Forty-two (15.1%) developed a clinically notable elbow contracture, of whom 29 (69.0%) developed heterotopic ossification (HO). Multivariate analysis of preoperative variables demonstrated that AO/OTA 13-C fracture classification (odds ratio [OR], 13.7, P = 0.025), multiple noncontiguous fractures (OR, 3.7, P = 0.010), and ulnohumeral dislocation at the time of injury (OR, 4.9, P = 0.005) were independently associated with contracture development. At 6 weeks postoperatively, an arc of elbow ROM less than 50° flexion/extension (OR, 23.0, P < 0.0005) and the presence of HO on radiographs (OR, 6.7, P < 0.0005) were found to be independent risk factors for significant elbow stiffness.

DISCUSSION

Ulnohumeral dislocation, multiple noncontiguous fractures, AO/OTA 13-C fracture classification, limited elbow ROM at 6 weeks postoperatively, and the presence of radiographic HO at 6 weeks postoperatively are associated with contracture development after surgical elbow fracture repair. Patients with these risk factors should receive aggressive physical therapy and be counseled as to the possible development of a contracture requiring surgical intervention.

Heterotopic ossification formation after fractures about the elbow

INTRODUCTION

Heterotopic ossification (HO) is a well-known sequela after an elbow injury and is widely studied given the associated morbidity. The anatomic location of HO development for specific elbow injuries has not been reported. The purpose of this study was to describe the precise, anatomic location of HO development after different peri-articular elbow injuries.

METHODS

A retrospective chart review was performed for patients with peri-articular elbow fracture and/or dislocation who underwent an elbow contracture release. The injuries were grouped into coronal shear distal humerus/AO 13.B3 (CSDH), distal humerus/AO 13.A, 13.B1, B2 or 13.C (DH), olecranon/AO 21.B1 (OL), radial head/AO 21.B2 (RH), extra-articular proximal radius and ulna/AO 21.A (EAPRU) fractures and elbow dislocations (DL). The HO location was determined by reviewing elbow radiographs and CT scans and were classified as anterior capsule, medial or lateral collateral ligaments, and posterior capsule/triceps insertion.

RESULTS

The study consisted of 49 patients, such as 6 CSDH, 13 DH, 6 OL, 21 RH, 4 EAPRU fractures and 20 elbow DL. All CSDH and RH fractures and 19/20 elbow DL developed HO in the collateral ligaments, while 12/13 DH fractures developed an anterior capsule HO. All 6 OL fractures developed HO posteriorly, and 3/4 EAPRU fractures developed a proximal radioulnar synostosis.

CONCLUSIONS

Our findings suggest that the location of HO development is specific to the injury type and is influenced by the soft tissues involved. This is consistent with the understanding that HO is the abnormal ossification of normal structures.

Heterotopic Ossification After Elbow Fractures

Heterotopic ossification (HO), a complication after surgical repair of elbow fractures, can result in pain, decreased range of motion, or complete ankylosis of the joint. This updated systematic review focused on compiling incidence and prevalence rates of HO after surgical repair of various types of elbow fractures. The overall incidence of HO after surgical repair was calculated to be 28.7%, a result comparable with rates in the literature. Further analysis suggested that the odds of having HO may be less after distal humerus fractures than after proximal radius fractures, terrible triad injuries, and elbow fractures/dislocations. [Orthopedics. 2021;44(1):10-16.].

A Case Report of Heterotopic Ossification Caused by High-Voltage Electric Injury

This case report described the diagnosis and treatment of a patient with ectopic bone injury due to high-pressure electric shock. A 24-year-old male patient suffered from burns that covered 50% of TBSA, including on limbs and torso, after coming into contact with 10-kV high-voltage electricity. A repeated Meek micrografting technique (MEEK) was applied for wound healing; skin grafts were cut into micrografts and expanded at a ratio of 1:4 to cover large areas after burn trauma. After the injury, right elbow redness, fever, pains, and joint movement disorder were reported by the patient, which might be attributed to excessive exercises and acute scarring. However, these symptoms were not treated immediately. Six months after the injury, his right elbow joint showed 90° locking and a restricted 5° movement capacity. X-ray examination revealed a new bone formation at the inner tibia shin. In addition, 3D CT showed the formation of right tibia, the ruler bone, and the skull of the humming bridge. Under general anesthesia, the right elbow joint was released, the medial collateral ligament was repaired, and the hinge external fixator was fixed. A large number of hyperplastic bone masses were found at the right elbow joint during surgery, specifically in the foot bone hawk's beak nest. No complications after surgery were observed. X-ray examination in February showed disappearance of the bone bridge and normal relationship of the right elbow joint. This case study revealed that electric shock injury could lead to ectopic bone formation, and much attention should be paid on any changes that indicate aseptic inflammation, such as redness, swelling, fever, and pain during the treatment process. Finally, identification of the scar constriction phase could indicate surgical treatment in order to promote the limb rehabilitation process.

Massive Heterotopic Ossification in the Subdeltoid Space after Shoulder Surgery and Symptomatic Improvement from Conservative Treatment: A Case Report

Background

We herein report a case of heterotopic ossification (HO) in the subdeltoid space after open resection and rotator cuff repair in a patient with refractory calcific tendinitis.

Case

A 56-year-old man was admitted to our hospital because of right shoulder pain and difficulty in raising his arm. The patient was diagnosed with calcific tendinitis with contracture of the right shoulder joint and was scheduled for surgery because of refractory shoulder pain. Calcium removal was performed using a mini-open approach. Postoperative radiographs showed no calcium deposits. There was mild residual pain at 3 months postoperatively, and the range of motion (ROM) had deteriorated when compared to preoperative levels. A massive ossified shadow was observed in the subdeltoid space on radiographs. Etidronate disodium was orally administered, and the patient continued to undergo careful rehabilitation. HO occurred at 3 months postoperatively, matured at 1 year postoperatively, and showed no progression between 1 year and 2 years postoperatively. The clinical symptoms corresponded with the image findings, and restricted ROM and decreased shoulder function scores were observed at 3 months postoperatively. Although the ROM remained restricted and the function score remained low until 1 year postoperatively, a gradual recovery was achieved at 2 years postoperatively, and the patient did not require reoperation.

Discussion

Although early diagnosis, evaluation, and resection are recommended for treating HO, the maturation of bone may lead to symptomatic improvement and the prevention of reoperation, provided that careful rehabilitative measures are performed to avoid ankyloses.

Mid-term outcomes of surgical management of complex, isolated radial head fractures: a multicentre collaboration

OBJECTIVES

The available literature discussing optimal surgical management of Mason II and III radial head (RH) fractures without concomitant bone or ligamentous injuries is limited. We aim to help determine the appropriate management of these functionally significant injuries.

DESIGN

We present our retrospective cohort study of outcomes of surgically managed isolated, displaced RH fractures SETTING: Study from three trauma centres.

PATIENTS/PARTICIPANTS

Adults who underwent surgical treatment for isolated displaced RH fractures.

INTERVENTION

RH open reduction internal fixation (ORIF), replacement or excision MAIN OUTCOME MEASUREMENTS: Elbow range of motion (ROM), pain and function using Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), Patient-Rated Elbow Evaluation (PREE) and QuickDASH (QD).

RESULTS

Of 46 patients included (mean age 47 years and mean follow-up 48 months), 12 type II fractures were treated with ORIF and 34 type III injuries had ORIF (16), replacement (12) or resection (6). ROM was comparable in all groups, with mean arcs of flexion-extension of 131° and pronation-supination of 147°. Mean visual analogue score for pain was 1.3 in those treated with ORIF compared to 1.9 with arthroplasty and 2.5 with excision. Mean functional scores were 41, 92, 14 and 14 for OES, MEPS, PREE and QD, respectively. Complication rates were 39% for ORIF, 33% for arthroplasty and 33% for resection. Overall re-operation rate was 13%.

CONCLUSIONS

Functional outcome is similar in all groups of surgically treated patients with isolated, displaced RH fractures. Complication rates are higher than that reported previously in the literature but with low re-operation rates.

LEVEL OF EVIDENCE

IV.

Prolonged dislocation and delay to surgery are associated with higher rates of heterotopic ossification in operatively treated terrible triad injuries

Background

Heterotopic ossification (HO) formation after complex elbow injuries can significantly impact function. Prior studies have reported a 3%-45% incidence of HO following elbow trauma in a heterogeneous cohort of fracture patterns. The purpose of our study was to evaluate the prevalence of and identify risk factors for HO specifically in patients with terrible triad injuries.

Methods

A total of 61 patients (64 elbows) underwent operative treatment for terrible triad injuries with an average follow-up period of 19.8 months (range, 3-138 months). The medical records were reviewed for demographic data, duration of dislocation, number of reduction attempts, time to surgery, presence of radiographic HO, elbow motion at final follow-up, functional limitations, and need for secondary procedures.

Results

Radiographic HO developed in 77% of patients, and 63% had some level of functional restriction. Thirteen patients (26%) underwent a secondary procedure for HO excision. Patients with HO had a longer time to surgery (4.9 days vs. 2.8 days, P = .02), longer duration of dislocation (21 hours vs. 6 hours, P = .04), and reduced flexion-extension (94° vs. 112°, P = .04) and pronation-supination (109° vs. 163°, P = .002) arcs of motion compared with patients without HO. HO was also more likely to develop in patients who required closed reduction than in those with spontaneous reduction prior to presentation.

Conclusion

The prevalence of radiographic and clinically relevant HO after terrible triad injuries was higher than previously reported. Persistent dislocation necessitating a closed reduction, a longer duration of dislocation, and a delay to surgery were associated with the development of HO. Providers should consider earlier surgical stabilization or urgent referral to a specialist for patients with unstable injuries.

Serum uric acid level is associated with the incidence of heterotopic ossification following elbow trauma surgery

BACKGROUND

Heterotopic ossification (HO) is a common complication after surgery for elbow trauma. Uric acid is the end product of purine metabolism and has several physiological and pathogenic roles. However, the relationship between HO and uric acid has not been explored. This retrospective study aimed to assess the relationship between HO and serum uric acid (SUA).

MATERIAL AND METHODS

We retrospectively reviewed data from 155 patients undergoing elbow trauma surgery in our hospital between January 2013 and December 2018. One hundred patients were included according to the inclusion criteria. They were divided into 2 groups according to the presence or absence of HO, and the SUA level was compared between groups using the independent samples t test. The optimal prognostic cutoff value was obtained using the maximum value of the Youden index.

RESULTS

The SUA level was significantly higher in the HO group than in the non-HO group (362.0 ± 87.4 μmol/L vs. 318.3 ± 87.0 μmol/L; P < .05). Using the maximum value of Youden index, 317.5 μmol/L was determined to be the optimal SUA cutoff value for the prediction of HO, with a sensitivity of 68.75% (95% confidence interval [CI], 54.67%-80.05%) and specificity of 55.77% (95% CI, 42.34%-68.40%).

CONCLUSIONS

Our study was the first to find that the high SUA level is a risk factor for HO of the elbow joint after trauma. Moreover, 317.5 μmol/L is the SUA threshold predicting the occurrence and development of HO of the elbow, with high sensitivity and specificity.

Global Excision of Severe Heterotopic Ossification of the Shoulder: A Case Report

CASE

A 21-year-old man sustained a closed glenohumeral fracture/dislocation as a pedestrian struck by a motor vehicle. He was treated nonoperatively and developed severe post-traumatic heterotopic ossification (HO) with near-complete shoulder ankylosis. We present our technique for safe surgical excision.

CONCLUSIONS

Excision led to improvements in motion and quality of life at 1 year postoperatively. Recommendations for successful HO excision around the shoulder include excision after at least 180 days, appropriate preoperative imaging to include cross-sectional imaging and a 3D model, intraoperative fluoroscopy, well-serviced instruments, preparation for iatrogenic fracture and/or neurovascular injury, meticulous hemostasis, postoperative HO prophylaxis, immediate postoperative therapy, and involvement of a multidisciplinary team.

Incidence of and risk factors for the development of asymptomatic heterotopic ossification after elbow fracture fixation

OBJECTIVE

This study was performed to investigate the incidence of and risk factors for asymptomatic heterotopic ossification (HO) after open reduction and internal fixation of elbow fractures.

METHODS

This retrospective analysis involved 197 patients with elbow fractures treated operatively from 2014 to 2017 at our institution. Patient-related and clinical variables were recorded. Univariate analysis and multivariate logistic regression were performed to reveal independent risk factors for postoperative HO. In addition, a receiver operating characteristic (ROC) curve was performed to assess the ability of risk factors to predict the development of postoperative HO.

RESULTS

The overall rate of asymptomatic HO after surgery was 18.78%. The incidence was highest in terrible triad injuries and lowest in capitellum fractures. Independent predictors of asymptomatic HO identified by the multivariate analysis were underlying diseases, fracture dislocation, and a prolonged operative time. The area under the ROC curve for underlying diseases, fracture dislocation, and a prolonged operative time were 0.593, 0.596, and 0.694, respectively.

CONCLUSIONS

The incidence of postoperative asymptomatic HO in patients with elbow fractures is high. Clinicians should employ prophylaxis to avoid HO when treating patients with elbow fractures who have underlying diseases, fracture dislocation, or a prolonged operative time.

Severity of heterotopic ossification in patients following surgery for hip fracture: a retrospective observational study

BACKGROUND

Heterotopic ossification (HO) is a relatively common complication following hip surgery treated with open reduction and internal fixation, total arthroplasty or hemiarthroplasty. Development of HO after hip surgery is an important clinical issue as it can affect functional status. We aimed to determine whether there was association between severity of heterotopic ossification about the hip and the interval between the time of hip fracture and surgery.

MATERIALS AND METHODS

Our retrospective study included 151 patients (age range 33-95 years) treated for hip fractures by hemiarthroplasty. Medical records were reviewed for time interval to surgery, laterality, surgical approach, and patient age. Patients who had any post-operative complications were excluded. Radiographs were semiquantitatively assessed for the degree of heterotopic ossification based on Brooker Classification (5-point scale). Statistical analysis was performed utilizing Chi-square, Kruskal-Wallis, and Score tests, and also a proportional odds model (significance level set at 0.05).

RESULTS

Thirty eight patients had no heterotopic ossification, 43 had class 1, 55 had class 2, and 15 had class 3 or greater heterotopic ossification. The majority of patients (59.6%) had surgery within 2 days of acute injury. Severe heterotopic ossification (HO 3+) was associated with the longer interval between the time of acute hip fracture and surgery (median 6 days) vs. median 2 days in all other groups (HO classes 0-2) (p = 0.0015). The odds ratio and 95% CI for one level higher HO class was 1.296 (1.152, 1.459), which meant that the odds of having HO class one level higher increased by about 29.6% for every one-day increase in the days to surgery. No significant association was found for other variables.

CONCLUSION

Class 3 or greater HO was associated with longer time interval between time of acute hip fracture and surgery compared to all other groups (HO class 0-2).

Complications of open reduction and internal fixation of distal humerus fractures

Treatment of distal humerus fractures is demanding. Surgery is the optimal treatment and preoperative planning is based on fracture type and degree of comminution.

Fixation with two precontoured anatomical locking plates at 90^o:90^o orthogonal or 180^o parallel is the optimal treatment.

The main goal of surgical treatment is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness.

Despite evolution of plates and surgical techniques, complications such as mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, infection, and complications from olecranon osteotomy are quite common.

Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Cite this article: EFORT Open Rev 2018;3:558-567. DOI: 10.1302/2058-5241.3.180009

Post-traumatic stiff elbow

Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.The following presentation reviews the recent literature on pathomechanisms and treatment alternatives. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062.

Is heterotopic ossification getting nervous?: The role of the peripheral nervous system in heterotopic ossification

Heterotopic ossification (HO), or de novo bone formation in soft tissue, is often observed following traumatic injury. Recent studies suggest that peripheral nerves may play a key functional role in this process. The results supporting a neurological basis for HO are examined in this article. Evidence supports the fact that BMPs released from bone matrix possess the capacity to induce HO. However, the process cannot be recapitulated using recombinant proteins without extremely high doses suggesting other components are required for this process. Study of injuries that increase risk for HO, i.e. amputation, hip replacement, elbow fracture, burn, and CNS injury suggests that a likely candidate is traumatic injury of adjacent peripheral nerves. Recent studies suggest neuroinflammation may play a key functional role, by its ability to open the blood-nerve barrier (BNB). Barrier opening is characterized by a change in permeability and is experimentally assessed by the ability of Evans blue dye to enter the endoneurium of peripheral nerves. A combination of BMP and barrier opening is required to activate bone progenitors in the endoneurial compartment. This process is referred to as "neurogenic HO".

Risk factors for development of severe post-traumatic elbow stiffness

PURPOSE

The purpose of this study was to compare different grades of elbow stiffness and investigate demographic, injury, and treatment factors potentially associated with the development of severe elbow stiffness.

METHODS

We performed a retrospective study involving 169 patients with post-traumatic elbow stiffness between June 2014 and June 2016. Patient demographics, injury, and treatment details were reviewed. Patients were classified into three groups according to the elbow motion. Ordinal regression analyses were performed to examine the independent factors.

RESULTS

Patients were classified into: mild (49 patients), moderate (59 patients), and severe (61 patients) groups. Patients with severe stiffness had a significantly worse elbow functional performance. Univariate ordinal regression revealed that severe elbow stiffness was associated with high-energy injury (odds ratio [OR] 4.73), olecranon fracture (OR 1.92), fracture-dislocation (OR 2.28), and open fracture (OR 3.24). Multivariate regression showed that higher-energy injuries were associated with severe stiffness (OR 4.45, p = 0.003).

CONCLUSIONS

Elbow stiffness after fracture surgery often results in joint stiffness. Severe stiffness often resulted in more significant functional impairment. Our study suggested that high-energy injuries were associated with the development of severe elbow stiffness.

Heterotopic Ossification Following Upper Extremity Injury

Heterotopic ossification (HO) presents a substantial barrier to rehabilitation for patients with severe burns or trauma. Although surgical excision is a mainstay of management for this condition, this is unable to address the chronic sequelae of HO, including chronic pain, joint contractures, nerve dysfunction, and open wounds. Current therapeutic modalities are aimed at excision and the prevention of recurrence using nonsteroidal antiinflammatory drugs (NSAIDs) or radiation therapy. Research is now focused on identifying alternative strategies to prevent the initial occurrence of HO through NSAIDs and novel inhibitors of the bone morphogenetic protein signaling pathway.

Mason type III radial head fractures treated by anatomic radial head arthroplasty: Is this a safe treatment option?

BACKGROUND

Radial head fractures make up approximately 3% of all fractures and they are the most common elbow fracture in adults. Replacement through arthroplasty is the recommended treatment in the context of unstable elbow injury and comminuted radial head fracture. The midterm clinical, functional, and radiographic results in patients treated with anatomic radial head arthroplasty for a Mason type III radial head fracture are presented.

MATERIAL AND METHODS

We performed a retrospective search of our facility's prospective trauma database to identify all skeletally mature patients who were treated by primary radial head replacement or open reduction and internal fixation following an acute radial head fracture. Inclusion criteria were Mason type III fractures and anatomic radial head arthroplasty (RHA). All the patients included were evaluated using a standard postoperative protocol including clinical and radiographic evaluation at 1, 3 and 12 months of follow-up. All the patients were reviewed clinically at an average of 30 months' follow-up.

RESULTS

Forty-one subjects (32 Mason type III and 9 Mason IV fractures) were treated with anatomic RHA (Acumed, Hillsboro, OR, USA). Of these, two patients (1 Mason type III and 1 Mason type IV) were excluded from the analysis because severe cognitive impairment. Moreover, we decided to exclude the subjects with a Mason type IV fracture to obtain a more homogeneous sample. Therefore, 31 patients with a Mason type III fracture were included in this study. Based on the Mayo Elbow Performance Score, excellent results were obtained in 24 (77%) patients, good in 3 (10%) and fair in 4 (13%) patients. Heterotopic ossification was reported in 8 patients (26% of cases). The final elbow flexion-extension range of motion was of 112°, with a mean flexion of 125°. The final forearm rotational range of motion was 134° with a mean pronation of 68° and a mean supination of 66°.

DISCUSSION

Anatomic radial head replacement leads to a good functional recovery, even in the presence of severe instability, such as coronoid fractures and LUCL injury. However, patients should be informed of the high number of adverse events (mainly heterotopic ossification) following this treatment.

LEVEL OF EVIDENCE

Therapeutic IV.

Bicolumnar 90-90 plating of AO 13C type fractures

Objective

The aim of this study was to evaluate functional results and complication rate of patients who underwent medial-dorsolateral plating for intra-articular distal humeral fracture (Müller AO type 13C).

Methods

Twenty-four patients (14 men, 10 women; mean age: 47 years) with AO type 13C distal humerus fracture were included in the study. Mean follow-up time was 28 months. Nine patients were in 13C1 subgroup, according to AO classification system, 11 patients were categorized as 13C2, and 4 patients were 13C3. Final follow-up assessment of outcomes included Broberg and Morrey radiological criteria; Mayo Elbow Performance Score, disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure, score based on Jupiter criteria; and range of motion (ROM) values.

Results

The mean carrying angle of operated elbows was 11.37° (range: 0-20°). According to Broberg and Morrey radiological criteria, 14 patients, had radiologically normal elbow, 4 patients had mild change, 3 patients had moderate change, and 3 patients had severe radiological change. Mean DASH score was 21.91 (range: 0-50), and mean Mayo rating was 83.37 (range: 55-100). Jupiter criteria evaluation revealed excellent results in 10 cases, good in 12, and fair results in 2. One patient with fair result had open fracture, and the other had previous hemiparesis in the same extremity. There was no instance of nonunion observed at follow-up.

Conclusion

Osteosynthesis with medial-dorsolateral plating is a safe and effective method for the treatment of intra-articular fractures of distal humerus.

Level of evidence

Level IV, Therapeutic study.

Posttraumatic stiff elbow

Posttraumatic stiff elbow is a frequent and disabling complication and poses serious challenges for its management. In this review forty studies were included to know about the magnitude of the problem, causes, pathology, prevention, and treatment of posttraumatic stiff elbow. These studies show that simple measures such as internal fixation, immobilization in extension, and early motion of elbow joint are the most important steps that can prevent elbow stiffness. It also supports conservative treatment in selected cases. There are no clear guidelines about the choice between the numerous procedures described in literature. However, this review article disproves two major beliefs-heterotopic ossification is a bad prognostic feature, and passive mobilization of elbow causes elbow stiffness.

Osificación heterotópica en codo: resultados tras tratamiento quirúrgico

Introducción y objetivos: Se entiende osificación heterotópica (OH) como la formación ectópica de hueso maduro en los tejidos blandos adyacentes a zonas previamente lesionadas. La OH es una de las causas de rigidez articular del codo postraumática, con una prevalencia que oscila según series entre el 3 y el 45%. En su patogénesis se postula la diferenciación de células mesenquimales pluripotenciales en osteoblastos, siendo estos los causantes de la formación de hueso ectópico; sin embargo, se desconocen las causas que provocan esta reacción. Recientemente, diversos estudios de series de casos retrospectivos mediante análisis uni y multivariante han intentado encontrar factores de riesgo (FR) y parámetros predictores de la formación de OH, así como de su repercusión clínica.

Material y métodos: Presentamos un análisis retrospectivo de los casos de OH en codo tratados quirúrgicamente en nuestro centro entre los años 2005 y 2015. Se recogieron variables demográficas, antecedentes personales, evento traumático inicial, clínica, tiempo desde el traumatismo hasta el diagnóstico de la OH, tiempo desde el diagnóstico de OH hasta la cirugía escisional, seguimiento, recurrencia, y grados de movilidad en precirugía escisional y al final del seguimiento. Con ello pretendemos mostrar nuestra experiencia en el tratamiento quirúrgico de esta patología.

Resultados: Obtuvimos 4 casos con un tiempo medio de seguimiento de 40 meses. En 2 casos el evento traumático fue la luxación de codo, y en los otros 2, la ruptura del tendón del bíceps en su inserció n distal. Tres de ellos debutaron clínicamente con limitación en la movilidad articular, y uno con déficit motor a nivel radial. Todos los casos fueron varones con una edad media de 48 años. El tiempo medio transcurrido desde el evento traumático hasta el diagnóstico de OH fue de 4 meses, realizándose el tratamiento quirúrgico escisional tras el diagnóstico igualmente a los 4 meses aproximadamente como media. Tres de los 4 casos recidivaron, apareciendo nuevas calcificaciones con repercusión clínica y funcional.

Conclusión: Nuestros resultados convergen con los de la literatura en cuanto a FR y resultados funcionales; sin embargo, llama la atención el alto índice de recidiva en nuestra serie, con una tasa del 75% frente al 10-24% descrito en la literatura.

The posttraumatic stiff elbow: an update

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.

Risk factors predicting revision surgery after medial epicondylectomy for primary cubital tunnel syndrome

BACKGROUND

Medial epicondylectomy (ME) is one of several accepted surgical options for the treatment of cubital tunnel syndrome (CuTS). Although reported outcomes after ME are generally favorable, few data exist regarding which patients are prone to poorer outcomes requiring revision surgery. The goal of this study was to identify risk factors predicting the need for revision surgery after ME for the treatment of CuTS.

METHODS

We conducted a retrospective chart review of all patients treated at our institution with ME for CuTS from 2006 through 2011. We identified patients who underwent additional operations for recurrent or persistent ulnar nerve symptoms as the revision cohort. We performed bivariate analysis to determine which variables had a significant influence on the need for revision surgery. We examined qualitative factors associated with revision, including the degree of bony resection performed during the index ME, and intraoperative findings at the time of revision surgery.

RESULTS

Revision surgery was required in 13.3% of cases (11 of 83). On bivariate analysis, younger age, associated workers' compensation claims, lesser disease severity, and preoperative opioid use were all significant predictors of the need for revision surgery. Perineural scarring and heterotopic bone formation about the elbow were the 2 most common findings at the time of revision.

CONCLUSIONS

For patients with CuTS, the risk of revision surgery after ME is higher in younger patients, patients with less severe disease, patients taking opioid medications preoperatively, and patients with associated workers' compensation claims.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Terrible triad of the elbow: is it still a troublesome injury?

BACKGROUND

Terrible triad injury (TTI), one of the main patterns of complex elbow instability, is difficult to treat and yields conflicting surgical results. We analyzed prospectively a series of patient affected by TTI and treated according to the current diagnostic and surgical protocols to investigate whether their application allow to obtain more predictable outcomes.

MATERIAL AND METHODS

We analyzed 26 patients with a mean age of 52 years. Preoperative X-rays and CT were performed; all patients were operated by the same elbow surgeon and underwent the same surgical and rehabilitation treatment. Final functional outcome was assessed by the Mayo Elbow Performance Score (MEPS), Quick-Disability of the Arm Shoulder and Hand-score (Q-DASH) and the modified-American Shoulder and Elbow Surgeons score (m-Ases). A radiographic evaluation was also performed.

RESULTS

Mean follow-up was 31 months. At final evaluation, mean flexion, extension, supination and pronation were 137°, 10°, 77° and 79°, respectively; mean MEPS, m-ASES and Q-DASH scores were respectively 96, 91 and 8 points. Complications observed after first surgery were: elbow stiffness in 5 cases, mild posterolateral instability in 3 cases, chronic subluxation in 1 case. Radiographic evaluation showed secondary arthritis in 9 cases, symptomatic HO in 3 cases and late hardware displacement in 2 cases. Six out of 26 patient underwent reoperation with final satisfactory results.

CONCLUSION

The current diagnostic and therapeutic protocols allow obtaining satisfactory clinical outcomes in majority of cases but a high number of major and minor unpredictable complications persist yet. In this series, low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery. On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon's inexperience.

LEVEL OF EVIDENCE

Level IV, Case series, Treatment study.

Distal Humerus Fractures: Open Reduction Internal Fixation

Distal humerus fractures are challenging injuries for the upper extremity surgeon. However, recent techniques in open reduction internal fixation have been powerful tools in getting positive outcomes. To get such results, the surgeon must be aware of how to properly use these techniques in their respective practices. The method of fixation depends on the fracture, taking the degree of comminution and the restoration of the columns and articular surface into account. This article helps surgeons understand the concepts behind open reduction internal fixation of the distal humerus and makes them aware of pitfalls that may lead to negative results.

Complications of Open Elbow Arthrolysis in Post-Traumatic Elbow Stiffness: A Systematic Review

Objective

The objective of this study was to systematically review the literature for a more comprehensive understanding of the complications of open elbow arthrolysis in patients with post-traumatic elbow stiffness and provide a reference for better prevention and treatment of them.

Methods

The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were searched for therapeutic studies with a set of inclusion and exclusion criteria. Data were extracted from selected articles, and a statistical analysis was performed to evaluate related factors and management of the complications.

Results

Twenty-eight articles published between 1989 and 2013, involving 810 patients, were included. Most of the complications included in the selected articles were nerve complications, heterotopic ossification, elbow instability, infection, pin-related complications and repeat elbow contracture. The total complication rate was 24.3% ± 3.0%, and the reoperation rate was 34.0%. Furthermore, the statistical analysis revealed that preoperative range of motion (β = -0.004, P = 0.01) and proportion of female (β = 0.336, P = 0.04) were the independent factors affecting the total complication rate.

Conclusions

Various risk factors are related to each of the complications, and we found that patients with less preoperative ROM and a higher proportion of female gender may point to a higher total complication rate. Therefore, to further improve the overall outcomes of this procedure, more and larger prospective studies should be performed to further elucidate the effects of prophylactic interventions targeting the risk factors, thus improving the methods of prevention and treatment of complications.

The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise

BACKGROUND

Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary.

METHODS

We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated.

RESULTS

Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively.

CONCLUSIONS

Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.

Clinically relevant heterotopic ossification after elbow fracture surgery: a risk factors study

BACKGROUND

Heterotopic ossification (HO) is a common complication of elbow fracture surgery that can significantly impair function and range of motion (ROM). Whereas numerous studies have assessed HO after hip trauma or replacement surgery, few data have been reported on the prevalence and risk factors of HO after elbow fractures.

HYPOTHESIS

Our objective was to investigate the prevalence and risk factors of clinically relevant HO after elbow fracture surgery under the hypothesis that the ability to identify high-risk patients would improve treatment tailoring and assist in meeting patient expectations.

MATERIALS AND METHODS

We retrospectively included consecutive patients who had surgery for elbow injuries between January 2007 and December 2011. Patient demographics, operative details, and radiographs were reviewed.

RESULTS

Of 124 elbows in 122 patients, 38 (30.6%) had HO and 26 (21%) clinically relevant HO. The prevalence of clinically relevant HO was highest in floating elbow injury, followed by combined olecranon and radial head fractures, types A and B distal humerus fractures, and terrible triad injury. By multiple logistic regression, factors that independently predicted clinically relevant HO were fracture-dislocation (OR, 4.87; 95%CI, 1.78-13.29; P=0.002) and longer time to surgery (P<0.05). Of the 26 patients with clinically relevant HO, 6 (23%) eventually required revision elbow surgery to improve ROM.

DISCUSSION

HO of the elbow occurred in almost one-third of our patients with surgically treated elbow fractures. Fracture-dislocation of the elbow and longer time to surgery independently predicted HO responsible for ROM loss. Clinically relevant HO was associated with significant morbidity.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Heterotopic ossification formation after fracture-dislocations of the elbow

BACKGROUND

Heterotopic ossification (HO) is a serious complication of traumatic elbow injuries, particularly fracture-dislocations. Limited data exist in the literature regarding the risk factors associated with HO formation in these injuries. The purpose of this study was to review the incidence of HO after fracture-dislocation of the elbow and to identify potential risk factors associated with its formation.

METHODS

Twenty-seven patients (28 elbows) were surgically treated for elbow fracture-dislocations during 8 years, with an average follow-up of 14 months. Records were reviewed with attention paid to several factors: demographic data, comorbidities, time interval from injury to surgical intervention, number of closed reductions attempted before surgery, surgical approach, management of the radial head, treatment of the anterior capsular injury, and coronoid fixation.

RESULTS

Of the 28 elbows, 12 (43%) developed HO postoperatively; 9 of 28 elbows underwent multiple attempted closed reductions before definitive surgical stabilization, with HO formation in 7 of the 9 (77%). Time to surgery, age, gender, radial head fixation or replacement, coronoid open reduction and internal fixation, capsular repair, and medical comorbidities were not found to influence HO formation, although the performance of multiple reductions was identified as a risk factor.

DISCUSSION

HO developed in 77% of patients with multiple attempted closed reductions. We found a 43% incidence of HO in patients surgically treated for elbow fracture-dislocations. Neither time to surgery after the injury nor demographic or other factors relating to the manner in which associated osseous or soft tissue injuries were managed influenced the formation of HO.

Injury complexity factors predict heterotopic ossification restricting motion after elbow trauma

BACKGROUND

Heterotopic ossification (HO) is a common extrinsic cause of elbow stiffness after trauma. However, factors associated with the development of HO are incompletely understood.

QUESTIONS/PURPOSES

We retrospectively identified (1) patient-related demographic factors, (2) injury-related factors, and (3) treatment-related factors associated with the development of HO severe enough to restrict motion after surgery for elbow trauma. We also determined what percentage of the variation in HO restricting motion was explained by the variables studied.

METHODS

Between 2001 and 2007, we performed surgery on 417 adult patients for elbow fractures; of these, 284 (68%) were available for radiographs at a minimum of 4 months and clinical review at a minimum of 6 months after surgery (mean, 7.9 months; range, 6–31 months). HO was classified according to the Hastings and Graham system. Patients with HO restricting motion (defined as a Hastings and Graham Class II or III) were compared with patients without HO restricting motion in terms of demographics, fracture location, elbow dislocation, open wound, mechanism of injury, ipsilateral fracture, head trauma, time from injury to surgery, number of surgeries within 4 weeks, total number of surgeries, bone graft, and infection, using bivariate and multivariable analyses. A total of 96 patients had radiographic HO, and in 27 (10% of those available for followup), it restricted motion.

RESULTS

There were no patient-related demographic factors that predicted the formation of symptomatic HO. Ulnohumeral dislocation in addition to fracture (odds ratio, 2.38; 95% CI, 1.01–5.64; p = 0.048) but not fracture location was associated with HO. Longer time from injury to definitive surgery and number of surgical procedures in the first 4 weeks were also independent predictors of HO (p = 0.01 and 0.004, respectively). These factors explained 20% of the variance in risk for HO restricting motion.

CONCLUSIONS

HO restricting motion after operative elbow fracture treatment associates with factors that seem related to injury complexity, in particular, ulnohumeral dislocation, delay, and number of early surgeries; however, a substantial portion of the variation among patients with elbow fracture who develop restrictive HO remains unexplained.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Low transcondylar fractures of the distal humerus: results of open reduction and internal fixation

BACKGROUND

This study presents the outcomes of low transcondylar fractures of the distal humerus treated by open reduction and internal fixation.

METHODS

Between 1996 and 2010, 263 distal humeral fractures were managed at our institution. Patients with a true low transcondylar fracture treated by open reduction and internal fixation were included. Fourteen patients form the basis of this study. Fracture fixation was achieved through a triceps-sparing approach, a triceps tongue, or an olecranon osteotomy. Internal fixation was performed with parallel plates, orthogonal plates, a single lateral plate, or a single medial plate. The clinical outcome was measured with pain levels, range of motion, and the Mayo Elbow Performance Score. Radiographs at latest follow-up were assessed for union, delayed union, nonunion, and hardware failure.

RESULTS

At most recent follow-up, 11 patients had no pain, 2 had mild pain, and 1 had moderate pain. The mean Mayo Elbow Performance Score was 85. The mean arch of motion was 95°. Complications included nonunion, delayed union, wound complications, deep infection, and heterotopic ossification.

DISCUSSION

Stable internal fixation of low transcondylar fractures is perceived as difficult to achieve because of the very small size of the distal fragment. However, the results of our study indicate that internal fixation of low transcondylar fractures of the distal humerus is associated with a high union rate and satisfactory clinical results. Elbow arthroplasty does not need to be considered for most patients with a low transcondylar distal humeral fracture.