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Meyer MA, Leversedge FJ, Catalano LW, Lauder A. Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment. J Am Acad Orthop Surg 2024; 32:669-680. [PMID: 38709855 DOI: 10.5435/jaaos-d-23-00460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 02/20/2024] [Indexed: 05/08/2024] Open
Abstract
Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.
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Affiliation(s)
- Maximilian A Meyer
- From the Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, CO(Dr. Meyer, Dr. Leversedge, Dr. Catalano, and Dr. Lauder), Department of Orthopedic Surgery, Denver Health Medical Center, Denver, CO (Dr. Lauder)
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Masouros P, Christakakis PC, Georgiadou P, Kourtzis D, Moustakalis I, Papazotos N, Garnavos C. Coronoid fractures and complex elbow instability: current concepts. Orthop Rev (Pavia) 2024; 16:118439. [PMID: 38846340 PMCID: PMC11152979 DOI: 10.52965/001c.118439] [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: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 06/09/2024] Open
Abstract
Fractures of the coronoid process typically occur as part of more complex injury patterns, such as terrible triads, trans-olecranon fracture-dislocations, posteromedial rotatory injuries or Monteggia-like lesions. Each pattern is associated with a specific type of coronoid fracture with regard to shape and size and specific soft-tissue lesions. O' Driscoll classification incorporates those associations identifying three major types of fractures: tip, anteromedial facet, and basal fractures. The objective of this study is to review the most common types of complex elbow instability, identify the indications for coronoid fixation and guide the appropriate management. Tip fractures as those seen in terrible triads can conditionally left untreated provided that elbow stability has been restored after radial head fixation and ligaments repair. Anteromedial facet fractures benefit from a buttress plate, while large basilar fractures can be effectively secured with posteroanterior screws. Coronoid reconstruction with a graft should be considered in post-traumatic cases of chronic coronoid deficiency.
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Wang D, Xiong D, Zhang J, Zhang W, Wang S, Tian X, Jia Z, Li H, Xu C, Li J. Finite element analysis of a customized coronoid prosthesis for traumatic coronoid deficiency. J Shoulder Elbow Surg 2024; 33:e248-e260. [PMID: 38182026 DOI: 10.1016/j.jse.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/02/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Traumatic coronoid deficiency with persistent elbow instability is a challenging condition. Autologous bone graft reconstruction is often associated with a range of additional clinical problems and the outcome is often unpredictable. The purpose of this study was to design a prosthetic device that can reconstruct coronoid deficiency of any height and to evaluate its mechanical properties using finite element analysis. MATERIALS AND METHODS A customized coronoid prosthesis was designed based on image registration, automatic measurement, and computer-aided design. After pilot study and sample size calculation, image data collected from 6 patients who underwent bilateral complete upper extremity CT scans were reconstructed. The test was divided into 3 groups: coronoid intact, prosthesis and autograft. Regan-Morrey type II and autologous olecranon osteotomy models were established. The prosthesis and autogenous olecranon were assembled to the coronoid base. Stress was applied axially along the proximal humeral diaphysis and implant micromotion and contact mechanics of the humeroulnar joint were measured at 30°, 45°, 60° and 90° of joint flexion respectively. RESULTS At all flexion angles, the maximum stress on the coronoid articular surface was significantly reduced in the prosthesis and autograft groups, with the reduction being more significant in the latter (P < .001). With increasing flexion, the maximum stress at the coronoid articular surface increased significantly after autograft reconstruction (7.2 to 68 MPa, P < .001), whereas the humeroulnar joint obtained a similar contact mechanics pattern to that of the control group after prosthetic reconstruction. As the flexion angle increased, the relative micromotion of both the prosthesis and autograft increased significantly (0.5-1.6 vs. 0.2-1.2, Pmeasure time < 0.001, Pgroups < 0.001). Contact pressure and center-of-force paths of the humeroulnar joint experience abrupt stress changes at approximately 60° of flexion. CONCLUSION The contact stress pattern in the humeroulnar joint is similar in prosthesis and intact coronoid groups. Autograft reconstruction increases contact stresses at the articular surface and alters the joint center-of-force path. The "stress surge phenomenon" in the humeroulnar joint surface before and after 60° of flexion may be one of the mechanisms of traumatic elbow degeneration.
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Affiliation(s)
- Daofeng Wang
- Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China; Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
| | - Dou Xiong
- Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Jiabing Zhang
- Graduate School of Medical School of Chinese PLA Hospital Beijing, China; Xidian University, Xi'an, China
| | - Wupeng Zhang
- Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | | | | | - Zhengfeng Jia
- Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Huanyu Li
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, Liaoning, China.
| | - Cheng Xu
- Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
| | - Jiantao Li
- Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
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Foster BK, Ayalon O, Hoyer R, Hoyen HA, Grandizio LC. Postoperative Elbow Instability: Options for Revision Stabilization. J Hand Surg Am 2024; 49:362-371. [PMID: 37999700 DOI: 10.1016/j.jhsa.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/25/2023] [Accepted: 10/01/2023] [Indexed: 11/25/2023]
Abstract
Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.
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Affiliation(s)
- Brian K Foster
- Department of Orthopaedic Surgery, Division of Hand and Upper-Extremity Surgery, Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Omri Ayalon
- Department of Orthopaedic Surgery, Division of Hand & Wrist Surgery, NYU Langone Health, New York City, NY, USA
| | - Reed Hoyer
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA
| | - Harry A Hoyen
- Department of Orthopaedic Surgery, Case Western University, Cleveland, OH, USA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Division of Hand and Upper-Extremity Surgery, Geisinger Commonwealth School of Medicine, Danville, PA, USA.
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Nieboer MJ, Cancio-Bello A, Mallett KE, Velasquez Garcia AR, Hidden KA, Yuan BJ, Morrey ME, Sanchez-Sotelo J, O'Driscoll SW, Barlow JD. Trans-ulnar fracture dislocations of the elbow: a systematic review and clarification of classification systems. J Shoulder Elbow Surg 2024; 33:975-983. [PMID: 38036255 DOI: 10.1016/j.jse.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/24/2023] [Accepted: 10/18/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis. MATERIALS AND METHODS We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II. RESULTS The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13. DISCUSSION Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.
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Affiliation(s)
- Micah J Nieboer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ausberto R Velasquez Garcia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Orthopedic Surgery, Clinica Universidad de los Andes, Santiago, Chile
| | - Krystin A Hidden
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Barlow JD, Nieboer MJ, Cancio-Bello AM, Morrey ME, Hidden KA, Yuan BJ, Sanchez-Sotelo J, O'Driscoll SW. A coronoid-centric classification system of proximal trans-ulnar fracture-dislocations has almost perfect intraobserver and interobserver agreement. J Shoulder Elbow Surg 2023; 32:2561-2566. [PMID: 37479178 DOI: 10.1016/j.jse.2023.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/26/2023] [Accepted: 06/13/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Fracture-dislocations of the elbow, particularly those that involve a fracture through the proximal ulna, are complex and can be difficult to manage. Moreover, current classification systems often cannot discriminate between Monteggia-variant injury patterns and trans-olecranon fracture-dislocations, particularly when the fracture involves the coronoid. The Mayo classification of proximal trans-ulnar fracture-dislocations categorizes these fractures into 3 types according to what the coronoid is still attached to: trans-olecranon fracture-dislocations (the coronoid is still attached to the ulnar metaphysis); Monteggia-variant fracture-dislocations (the coronoid is still attached to the olecranon); and ulnar basal coronoid fracture-dislocations (the coronoid is not attached to either the olecranon or the ulnar metaphysis). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo classification system when assessing elbow fracture-dislocations involving the proximal ulna based on radiographs and computed tomography scans. METHODS Three fellowship-trained shoulder and elbow surgeons and 2 fellowship-trained orthopedic trauma surgeons blindly and independently evaluated the radiographs and computed tomography scans of 90 consecutive proximal trans-ulnar fracture-dislocations treated at a level I trauma center. The inclusion criteria included subluxation or dislocation of the elbow and/or radioulnar joint with a complete fracture through the proximal ulna. Each surgeon classified all fractures according to the Mayo classification, which is based on what the coronoid remains attached to (ulnar metaphysis, olecranon, or neither). Intraobserver reliability was determined by scrambling the order of the fractures and having each observer classify all the fractures again after a washout period ≥ 6 weeks. Interobserver reliability was obtained to assess the overall agreement between observers. κ Values were calculated for both intraobserver reliability and interobserver reliability. RESULTS The average intraobserver agreement was 0.87 (almost perfect agreement; range, 0.76-0.91). Interobserver agreement was 0.80 (substantial agreement; range, 0.70-0.90) for the first reading session and 0.89 (almost perfect agreement; range, 0.85-0.93) for the second reading session. The overall average interobserver agreement was 0.85 (almost perfect agreement; range, 0.79-0.91). CONCLUSION Classifying proximal trans-ulnar fracture-dislocations based on what the coronoid remains attached to (olecranon, ulnar metaphysis, or neither) was associated with almost perfect intraobserver and interobserver agreement, regardless of trauma vs. shoulder and elbow fellowship training. Further research is needed to determine whether the use of this classification system leads to the application of principles specific to the management of these injuries and translates into better outcomes.
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Affiliation(s)
| | - Micah J Nieboer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Krystin A Hidden
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Dirckx M, Phadnis J. Acute and chronic coronoid reconstruction using the olecranon Tip. Shoulder Elbow 2023; 15:664-673. [PMID: 37981964 PMCID: PMC10656967 DOI: 10.1177/17585732221103577] [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: 03/06/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 11/21/2023]
Abstract
Post-traumatic coronoid deficiency in the elbow can lead to chronic pain, instability and arthritis. A variety of osteochondral grafts have been used to reconstruct the coronoid, and restore elbow stability. The radial head and iliac crest grafts are the most common in the literature but have limitations. The olecranon tip is a promising alternative, with both cadaveric and computer models demonstrating superior congruency, without compromising elbow stability or disrupting the extensor mechanism. We present a small, case series demonstrating the technique for contralateral and ipsilateral grafts in both the acute and chronic setting.
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Affiliation(s)
| | - Joideep Phadnis
- University Hospitals Sussex, Brighton, UK
- Brighton & Sussex Medical School, UK
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8
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Bianco JM, Vopat ML, Yang SY, Morris HA, Corrigan CM, Hearon BF. Coronoid Fracture Reconstruction with Ipsilateral Olecranon Osteoarticular Autograft in the Acute Setting: A Case Report. JBJS Case Connect 2023; 13:01709767-202306000-00022. [PMID: 37146170 DOI: 10.2106/jbjs.cc.22.00771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
CASE An 18-year-old male polytrauma patient sustained a high-energy posterior fracture dislocation of his left elbow associated with a comminuted and irreparable O'Driscoll type 2 subtype 3 anteromedial facet coronoid fracture. He underwent early coronoid reconstruction using ipsilateral olecranon osteoarticular autograft with incorporation of the sublime tubercle attachment of the medial collateral ligament and repair of the lateral ulnar collateral ligament. A 3-year follow-up revealed a functional, painless, congruent, and stable elbow. CONCLUSION Early reconstruction of a highly comminuted coronoid fracture may be a useful salvage option for the polytrauma patient, thereby avoiding complications associated with late reconstruction of posttraumatic elbow instability.
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Affiliation(s)
- Jake M Bianco
- Department of Orthopaedic Surgery, University of Kansas School of Medicine Wichita, Wichita, Kansas
| | - Matthew L Vopat
- Department of Orthopaedic Surgery, University of Kansas School of Medicine Wichita, Wichita, Kansas
| | - Shang-You Yang
- Department of Orthopaedic Surgery, University of Kansas School of Medicine Wichita, Wichita, Kansas
| | - Harry A Morris
- Department of Orthopaedic Surgery, University of Kansas School of Medicine Wichita, Wichita, Kansas
- Advanced Orthopaedic Associates, PA, Wichita, Kansas
| | - Chad M Corrigan
- Department of Orthopaedic Surgery, University of Kansas School of Medicine Wichita, Wichita, Kansas
- Advanced Orthopaedic Associates, PA, Wichita, Kansas
| | - Bernard F Hearon
- Department of Orthopaedic Surgery, University of Kansas School of Medicine Wichita, Wichita, Kansas
- Advanced Orthopaedic Associates, PA, Wichita, Kansas
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Jiang Y, Qi L, Peng C, Li Q, Zhang P, Wang Y, Wu D. Reconstruction of the coronoid process with the olecranon tip for chronic elbow dislocation in children: A rare case report and literature review. Front Pediatr 2022; 10:977866. [PMID: 36507138 PMCID: PMC9730028 DOI: 10.3389/fped.2022.977866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/31/2022] [Indexed: 11/25/2022] Open
Abstract
The coronoid process of the ulna, as a key part of the elbow joint, plays an important role in maintaining elbow joint stability. Reconstruction of the coronoid process is necessary in both acute and chronic coronoid defects to restore elbow stability and avoid early joint degeneration. The olecranon tip may be a useful autologous osteochondral graft for reconstructing the same shape of the ulna coronoid process. The purpose of this report was to verify if reconstruction of the coronoid process with the olecranon tip can restore elbow stability and kinematics. Here, we report a 13-year-old boy who had undergone Kirschner-wire fixation for a left supracondylar fracture of the left humerus 9 years previously. After that, the right elbow dislocation and varus deformity gradually appeared. Imaging revealed posterolateral dislocation of the left elbow due to the absence of the coronoid process of the ulna. We reconstructed the ulnar coronoid process by intercepting the ipsilateral olecranon tip. After 22 months of follow-up, the range of motion of the left elbow joint was normal, and the cubitus varus deformity disappeared. The results of this report suggest that olecranon tip autografts are suitable to replace transverse coronoid defects. Given the patient's satisfactory clinical results, this reconstruction technique is safe and effective for the treatment of chronic elbow instability due to coronoid process defects of the ulna.
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Affiliation(s)
- Yikun Jiang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Le Qi
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Chuangang Peng
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Qiwei Li
- Department of Pediatric Orthopaedics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Zhang
- Department of Radiology, The Second Hospital of Jilin University, Changchun, China
| | - Yanbing Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Dankai Wu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
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Walch A, Garcia-Maya B, Knowles NK, Athwal GS, King GJW. Computed tomography analysis of the relationship between the coronoid and the radial head. J Shoulder Elbow Surg 2021; 30:2824-2831. [PMID: 34216785 DOI: 10.1016/j.jse.2021.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 05/17/2021] [Accepted: 05/23/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The coronoid process is an important stabilizer of the elbow, and its anatomy has been extensively studied. However, data documenting the relationship of the coronoid relative to the radial head (RH) are limited. The latter is a good landmark for the surgeon when débriding or reconstructing the coronoid. This imaging-based study quantified the anatomic relationship between the coronoid and the proximal radius and ulna. METHODS We investigated 80 cadaveric upper extremities (18 paired elbows) by 3-dimensional digital analysis of computed tomography data. After construction of a standardized coordinate system, the relationships between the coronoid, the anterior-most point of the RH, the deepest point of the articular surface of the RH, the top of the lesser sigmoid notch, and the deepest point of the guiding ridge of the trochlear notch were analyzed. RESULTS The mean height of the tip of the coronoid was 36 ± 4 mm (range, 26-43 mm). The mean height of the anterior-most point of the RH was 40 ± 4 mm (range, 28-47 mm). The mean distance between the tip of the coronoid and the anterior-most point of the RH was 4.5 ± 1 mm (range, 2-10 mm). For paired elbows, the heights of the tip of the coronoid and the anterior-most point of the RH were similar between sides. CONCLUSION This study described the relationship between the coronoid and RH. This information should prove useful when reconstructing a coronoid from a medial approach in the case of an intact RH. The difference in radiographic height between the tip of the coronoid and anterior RH in the normal elbow averages 5 mm. However, when we account for the normal cartilage thickness of the RH and coronoid, a 3- to 6-mm difference in height would be seen at surgery depending on whether the cartilage of the coronoid process is intact or removed. The distance between the tip of the coronoid and the anterior-most point of the RH is similar to the size of shavers used when débriding osteophytes during arthroscopy.
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Affiliation(s)
- Arnaud Walch
- Service de Chirurgie de la Main et du Membre Superieur, Hopital Edouard Herriot, Lyon, France.
| | | | - Nikolas K Knowles
- Roth/McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada
| | - Georges S Athwal
- Roth/McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada
| | - Graham J W King
- Roth/McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada
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11
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Hackl M, Knowles NK, Wegmann K, Müller LP, Athwal GS, King GJW. Coronoid process reconstruction with a distal clavicle autograft: an in silico analysis of fitting accuracy. J Shoulder Elbow Surg 2021; 30:1282-1287. [PMID: 33045331 DOI: 10.1016/j.jse.2020.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/01/2020] [Accepted: 09/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The coronoid process plays a vital role in preserving elbow stability. In cases of acute or chronic deficiency of the coronoid process, reconstruction is warranted to restore stability and to avoid early joint degeneration. The distal clavicle might be a useful osteochondral autograft for coronoid reconstruction with low donor-site morbidity. This study evaluated the fitting accuracy of the distal clavicle as an autograft for coronoid process reconstruction. METHODS One hundred upper-extremity computed tomography scans of 85 body donors were available for this study (mean age, 69 ± 17 years; 46 male and 39 female donors; 15 bilateral specimens). Standardized 40% transverse defects of the coronoid process were digitally created; the distal clavicles were digitally harvested and placed onto the defects by a best-fit technique in 2 different orientations using commercially available software: (1) with the superior aspect of the articular surface of the graft oriented toward the coronoid tip and (2) with the inferior aspect of the articular surface of the graft oriented toward the coronoid tip. The fitting accuracy of the grafts to the native coronoid process was evaluated from lateral to medial using custom code. RESULTS Regardless of the orientation of the graft, the distal clavicle provided a good fit in the central portion of the coronoid process. In the lateral and medial aspects of the defect, however, the fitting accuracy of the graft declined significantly (P ≤ .044). No significant differences were observed between ipsilateral and contralateral grafts (P ≥ .199). The intrarater reliability was excellent. CONCLUSION The results of this study suggest that a distal clavicle autograft may be suitable to replace a transverse defect of the coronoid process; however, it may not fully reconstruct the anteromedial and anterolateral aspects of the coronoid.
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Affiliation(s)
- Michael Hackl
- Faculty of Medicine, University of Cologne, Cologne, Germany; Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany; Roth
- McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada.
| | - Nikolas K Knowles
- Roth
- McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada
| | - Kilian Wegmann
- Faculty of Medicine, University of Cologne, Cologne, Germany; Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - Lars Peter Müller
- Faculty of Medicine, University of Cologne, Cologne, Germany; Center of Orthopedic and Trauma Surgery, University Hospital Cologne, Cologne, Germany
| | - George S Athwal
- Roth
- McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada
| | - Graham J W King
- Roth
- McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada
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12
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Zhao S, Zeng C, Yuan S, Li R. Reconstruction of coronoid process of the ulna: a literature review. J Int Med Res 2021; 49:3000605211008323. [PMID: 33858252 PMCID: PMC8053771 DOI: 10.1177/03000605211008323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022] Open
Abstract
As a pivotal part of the elbow joint structure, the coronoid process of the ulna plays a vital role in maintaining elbow joint stability. Loss of coronoid process height causes instability of the elbow joint depending on the fracture characteristics and size. The diagnosis and treatment of coronoid process fractures has gained widespread attention from orthopedic surgeons. Nevertheless, few reports have described reconstruction of coronoid process fractures and defects that affect elbow joint stability. Treatment of elbow joint instability induced by coronoid process defects is challenging because most cases are complicated by other elbow joint injuries. Moreover, the clinical efficacy remains unclear. The present narrative review was performed to examine the research progress on reconstruction of the coronoid process. The findings of this review provide evidence for clinical repair and reconstruction of coronoid process defects and contribute to the published literature on this topic.
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Affiliation(s)
- Shanwen Zhao
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Orthopaedic Hospital of Guangdong Province, Guangzhou, China
- Academy of Orthopaedics, Guangdong Province, Guangzhou, China
| | - Canjun Zeng
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Orthopaedic Hospital of Guangdong Province, Guangzhou, China
- Academy of Orthopaedics, Guangdong Province, Guangzhou, China
| | - Song Yuan
- Department of Orthopedics, Linzhi People’s Hospital, Linzhi, China
| | - Runguang Li
- Department of Foot and Ankle Surgery, Center for Orthopaedic Surgery, the Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- Orthopaedic Hospital of Guangdong Province, Guangzhou, China
- Academy of Orthopaedics, Guangdong Province, Guangzhou, China
- Department of Orthopedics, Linzhi People’s Hospital, Linzhi, China
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Wallace WA. CORR Insights®: What Factors Are Associated with Reoperation after Operative Treatment of Terrible Triad Injuries? Clin Orthop Relat Res 2021; 479:126-128. [PMID: 33369587 PMCID: PMC7899491 DOI: 10.1097/corr.0000000000001446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 01/31/2023]
Affiliation(s)
- W Angus Wallace
- W. A. Wallace, University of Nottingham, Division of Orthopaedic and Accident Surgery, Queen's Medical Centre, Nottingham, UK
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Giannicola G, Sessa P, Calella P, Gumina S, Cinotti G. Chronic complex persistent elbow instability: a consecutive and prospective case series and review of recent literature. J Shoulder Elbow Surg 2020; 29:e103-e117. [PMID: 32197771 DOI: 10.1016/j.jse.2019.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 11/10/2019] [Accepted: 11/16/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic complex persistent elbow instability (CCPEI) is a condition that even expert elbow surgeons find challenging to treat. The results of the few studies that have dealt with the treatment of this condition are conflicting. We describe the surgical results of a consecutive prospective series of patients with CCPEI and provide a review of the recent literature. METHODS We assessed 21 patients with previous failed surgical or conservative treatment, with a terrible-triad injury in 13, Monteggia-like lesion in 6, humeral shear fracture-dislocation in 1, and radial head fracture-dislocation in 1. Overall, 21 open débridement procedures, 15 ulnar nerve transpositions, 6 ulnar in situ neurolysis procedures, 7 total elbow arthroplasties, 8 radial head arthroplasties, 1 radial head resection with humeroradial anconeus interpositional arthroplasty, 4 coronoid graft reconstructions, 14 ligament retensioning procedures, 3 ulnar nonunion treatments, and 2 ulnar osteotomies were performed. Two dynamic external fixators were applied. The Mayo Elbow Performance Score, quick Disabilities of the Arm, Shoulder and Hand score, and modified American Shoulder and Elbow Surgeons score were used preoperatively and postoperatively. RESULTS The mean follow-up period was 29.4 months. A significant improvement was found between preoperative and postoperative clinical scores and range-of-motion values. The reintervention and major complication rates were 19% and 23%, respectively. Arthritic evolution was observed in 71% of the cases. CONCLUSIONS CCPEI is a challenging condition with an uncertain prognosis. The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. The time interval between the initial trauma and index surgical procedure significantly affects the feasibility of reconstructive procedures.
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Affiliation(s)
- Giuseppe Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome-Policlinico Umberto I, Rome, Italy
| | - Pasquale Sessa
- Department of Orthopedics and Traumatology, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy.
| | - Piergiorgio Calella
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome-Policlinico Umberto I, Rome, Italy
| | - Stefano Gumina
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Polo Pontino, Latina, Italy
| | - Gianluca Cinotti
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome-Policlinico Umberto I, Rome, Italy
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