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Heifner JJ, Sandilands SM, Bolano LE, Rubio F, Davis TA, Mercer DM, Araiza ET. Clinical outcomes for linked fixation of distal humerus fractures: a multicenter study. J Shoulder Elbow Surg 2024; 33:2463-2471. [PMID: 39004116 DOI: 10.1016/j.jse.2024.05.029] [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: 03/26/2024] [Revised: 04/26/2024] [Accepted: 05/10/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND O'Driscoll popularized the principle of linked column fixation for distal humerus fractures. Despite the linked column concept being widely accepted, there are few reported techniques to accomplish this goal. A novel device was designed based on the principles of linked columns. An interlocking beam is used to connect the medial and lateral plates, creating a unified fixed angle construct. Our primary objective was to report clinical outcomes across multiple institutions for a linking beam used in distal humerus fracture fixation. METHODS A retrospective series was collected from 5 institutions for the TiBeam (Skeletal Dynamics) with a minimum follow-up of 6 months. Acute and chronic treatment of distal humerus fracture patterns and all plate configurations were included for analysis. RESULTS A total of 36 cases were collected at a mean age of 52 years and a mean follow-up of 19.3 months. AO C-type fractures were 56% of the series. The median Mayo Elbow Performance Score was 85 (interquartile range [IQR] 76.3-90), the median DASH was 21.4 (IQR 15.9-30), and the median score on the visual analog scale for pain during activities of daily living was 3.5 (IQR 2-5). An olecranon osteotomy was used in 86% of cases, and an anatomic plate was used for fixation of the osteotomy in 94% of those cases. There were 3 cases of olecranon plate removal for a rate across the series of 13.7%. DISCUSSION Our short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fracture fixed with a linking beam. Further, the rate of removal for the olecranon osteotomy plate was lower than historical reports for aggregate methods of osteotomy fixation.
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Affiliation(s)
| | | | - Luis E Bolano
- Three Gables Surgical Hospital, Proctorville, OH, USA
| | - Francisco Rubio
- Department of Orthopedic Surgery, Larkin Hospital, Miami, FL, USA
| | - Ty A Davis
- Department of Orthopedic Surgery, Larkin Hospital, Miami, FL, USA
| | - Deana M Mercer
- Department of Orthopedics, University of New Mexico, Albuquerque, NM, USA
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Mihas AK, Reed LA, Patch DA, Cimino A, Davis WT, Young M, Spitler CA. Risk factors for dysfunctional elbow stiffness following operative fixation of distal humerus fractures. J Shoulder Elbow Surg 2024:S1058-2746(24)00542-1. [PMID: 39103087 DOI: 10.1016/j.jse.2024.06.010] [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: 01/20/2024] [Revised: 05/22/2024] [Accepted: 06/17/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Elbow stiffness is 1 of the most common complications after operative fixation of distal humerus fractures; however, there is relatively limited literature assessing which factors are associated with this problem. The purpose of this study is to identify risk factors associated with dysfunctional elbow stiffness in distal humerus fractures after operative fixation. METHODS A retrospective review of all distal humerus fractures that underwent operative fixation (AO/OTA 13A-C) at a single level 1 trauma center from November 2014 to October 2021. A minimum 6-month follow-up was required for inclusion or the outcome of interest. Dysfunctional elbow stiffness was defined as a flexion-extension arc of less than 100° at latest follow-up or any patient requiring surgical treatment for limited elbow range of motion. RESULTS A total of 110 patients with distal humerus fractures were included in the study: 54 patients comprised the elbow stiffness group and 56 patients were in the control group. Average follow-up of 343 (59 to 2079) days. Multiple logistic regression showed that orthogonal plate configuration (adjusted odds ratio [aOR]: 5.70, 95% confidence interval [CI]: 1.91-16.99, P = .002), and longer operative time (aOR: 1.86, 95% CI: 1.11-3.10, P = .017) were independently associated with an increased odds of elbow stiffness. OTA/AO 13A type fractures were significantly associated with a decreased odds of stiffness (aOR: 0.16, 95% CI: 0.03-0.80, P = .026). Among 13C fractures, olecranon osteotomy (aOR: 5.48, 95% CI: 1.08-27.73, P = .040) was also associated with an increased odds of elbow stiffness. There were no significant differences in injury mechanism, Gustilo-Anderson classification, reduction quality, days to surgery from admission, type of fixation, as well as rates of ipsilateral upper extremity fracture, neurovascular injury, nonunion, or infection between the 2 groups. CONCLUSION Dysfunctional elbow stiffness was observed in 49.1% of patients who underwent operative fixation of distal humerus fractures in the present study. Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with increased odds of dysfunctional elbow stiffness; however, 13A type fractures were associated with decreased odds of stiffness. Patients with these injuries should be counseled on their risk of stiffness following surgery and modifiable risk factors like plate positioning and performing an olecranon osteotomy should be considered by surgeons.
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Affiliation(s)
- Alexander K Mihas
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Logan A Reed
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Orthopaedic Surgery, Orlando Health Jewett Orthopaedic Institute, Orlando, FL, USA
| | - David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Addison Cimino
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William T Davis
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew Young
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Sachinis NP, Mitsios N, Baxevanou M, Koukos C, Givissis A, Givissis P. Surgical Challenges and Outcomes in Treating a Floating Upper Arm With Multiple Humerus Fractures and Radial Neck Fractures. Cureus 2024; 16:e66468. [PMID: 39246982 PMCID: PMC11380566 DOI: 10.7759/cureus.66468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2024] [Indexed: 09/10/2024] Open
Abstract
Complex humerus fractures associated with high-energy trauma present significant surgical challenges due to their impact on limb functionality and structural integrity. This case report details the treatment of a floating upper arm injury, characterized by multiple humerus fractures and a radial neck fracture, in a 50-year-old male following a vehicular accident. The patient exhibited fractures at the proximal, mid-shaft, and distal segments of the humerus, necessitating an integrated surgical approach to effectively manage these injuries. Dual surgical approaches and perpendicular plating were employed to address the multifaceted nature of the fractures. The patient achieved satisfactory functional recovery, regaining a significant range of motion, which highlights the efficacy of the chosen surgical strategy. This case contributes to the existing literature by illustrating the benefits of specific surgical techniques in managing complex humerus fractures, emphasizing the necessity for meticulous planning and execution to optimize patient outcomes.
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Affiliation(s)
- Nikolaos P Sachinis
- First Orthopaedic Department, "Georgios Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Nikolaos Mitsios
- First Orthopaedic Department, "Georgios Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Maria Baxevanou
- First Orthopaedic Department, "Georgios Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Christos Koukos
- Sports Trauma and Pain Institute, "Georgios Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Alexandros Givissis
- Orthopaedic Department, School of Medicine, European University of Cyprus, Thessaloniki, GRC
| | - Panagiotis Givissis
- First Orthopaedic Department, "Georgios Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Iwase K, Takegami Y, Tokutake K, Oshika Y, Yokoyama H, Tanaka K, Sakai T, Imagama S. Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly: A multi-center retrospective study (TRON study). Shoulder Elbow 2024; 16:312-320. [PMID: 38818102 PMCID: PMC11135190 DOI: 10.1177/17585732221131923] [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: 04/13/2022] [Revised: 07/16/2022] [Accepted: 09/12/2022] [Indexed: 06/01/2024]
Abstract
Background Distal humerus fracture in the elderly is a challenging fracture for orthopedic surgeons. Non-union is one of the serious complications of distal humerus fracture after surgery. This retrospective multicenter study aimed to estimate the incidence of distal humeral non-union after open reduction and internal fixation, determine factors related to non-union, and compare the postoperative results of cases with non-union to cases with the union. Methods Among 423 patients diagnosed with distal humeral fracture and who were treated by surgical therapy in 2010-2020 from our database called TRON. Only 190 subjects met the inclusion criteria. We performed a logistic regression analysis with the presence of non-union as the response variable to examine risk factors. We compare the Mayo Elbow Performance Scores of cases with non-union to cases with the union. Results Non-union occurred after surgery in 15 patients (7.9%). The logistic regression analysis showed that body mass index<20 kg/m2 and ≥25 kg/m2, and ≤3 screws in the articular segment were significant explanatory factors for non-union (odds ratio 10.4 and 47.8, respectively). The Mayo Elbow Performance Scores were significantly worse in patients with non-union. Discussion Low and high body mass index and three or fewer screws in the articular segment might be risk factors for non-union of distal humerus fracture in the elderly. Non-union is associated with poor clinical outcomes.
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Affiliation(s)
- Kenya Iwase
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasutaka Oshika
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Yokoyama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kohei Tanaka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadahiro Sakai
- Department of Orthopedic Surgery, Toyota Memorial Hospital, Toyota, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Ha C, Choi I, Lee JK, Oh J, Ahn W, Han SH. Anterolateral Dual Plate Fixation for Distal Metaphyseal-Diaphyseal Junction Fractures of the Humerus: Biomechanical Finite Element Analysis with Clinical Results. Clin Orthop Surg 2024; 16:493-505. [PMID: 38827752 PMCID: PMC11130622 DOI: 10.4055/cios23376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 06/04/2024] Open
Abstract
Background Distal metaphyseal-diaphyseal junction fractures of the humerus are a subset of injuries between humeral shaft fractures and distal intra-articular humerus fractures. A lack of space for distal fixation and the unique anatomy of concave curvature create difficulties during operative treatment. The closely lying radial nerve is another major concern. The aim of this study was to determine whether anterolateral dual plate fixation could be effective for a distal junctional fracture of the humerus both biomechanically and clinically. Methods A right humerus 3-dimensional (3D) model was obtained based on plain radiographs and computed tomography data of patients. Two fractures, a spiral type and a spiral wedge type, were constructed. Three-dimensional models of locking compression plates and screws were constructed using materials provided by the manufacturer. The experiment was conducted by using COMSOL Multiphysics, a finite element analysis, solver, and simulation software package. For the clinical study, from July 2008 to March 2021, a total of 72 patients were included. Their medical records were retrospectively reviewed to obtain patient demographics, elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, Mayo Elbow Performance Scores (MEPS), and hand grip strength. Results No fracture fixation construct completely restored stiffness comparable to the intact model in torsion or compression. Combinations of the 7-hole and 5-hole plates and the 8-hole and 6-hole plates showed superior structural stiffness and stress than those with single lateral plates. At least 3 screws (6 cortices) should be inserted into the lateral plate to reduce the load effectively. For the anterior plate, it was sufficient to purchase only the near cortex. Regarding clinical results of the surgery, the range of motion showed satisfactory results in elbow flexion, elbow extension, and forearm rotation. The average DASH score was 4.3 and the average MEPS was 88.2. Conclusions Anterolateral dual plate fixation was biomechanically superior to the single-plate method in the finite element analysis of a distal junctional fracture of the humerus model. Anterolateral dual plate fixation was also clinically effective in a large cohort of patients with distal junctional fractures of the humerus.
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Affiliation(s)
- Cheungsoo Ha
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Inrak Choi
- Intuitive Surgical Inc., Sunnyvale, CA, USA
| | - Jun-Ku Lee
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jongbeom Oh
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Wooyeol Ahn
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Soo-Hong Han
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Farzad‐Mohajeri S, Mollaei Z, Sari MM, Rostami A. Surgical stabilization of a distal tibial fracture in a jungle cat (Felis chaus) using orthogonal double plating. Vet Med Sci 2024; 10:e1382. [PMID: 38375978 PMCID: PMC10877987 DOI: 10.1002/vms3.1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 12/20/2023] [Accepted: 01/29/2024] [Indexed: 02/21/2024] Open
Abstract
The jungle cat (Felis chaus) is a member of the genus Felis within the family Felidae, native to south-east Asia, west Asia and north Africa. A 2-year-old male jungle cat was referred with a history of lameness of 3 days duration. At the time of presentation, the animal had non-weight-bearing lameness of the right hindlimb. Examination identified crepitation and instability in the distal diaphyseal region of the right tibial bone. Radiographs confirmed the presence of fractures in the distal diaphyseal region of the right tibia and fibula. Double plating of the tibia was employed for used fixation. The animal was evaluated 2, 4 and 8 weeks post-operatively, and the procedure was considered to have been successful with no observed surgical complications.
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Affiliation(s)
- Saeed Farzad‐Mohajeri
- Department of Surgery and RadiologyFaculty of Veterinary MedicineUniversity of TehranTehranIran
| | - Zahra Mollaei
- Faculty of Veterinary MedicineUniversity of TehranTehranIran
| | | | - Amir Rostami
- Department of Internal MedicineFaculty of Veterinary MedicineUniversity of TehranTehranIran
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7
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Kruszewski A, Piszczatowski S, Piekarczyk P, Cieślik P, Kwiatkowski K. Weak Points of Double-Plate Stabilization Used in the Treatment of Distal Humerus Fracture through Finite Element Analysis. J Clin Med 2024; 13:1034. [PMID: 38398347 PMCID: PMC10888649 DOI: 10.3390/jcm13041034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Multi-comminuted, intra-articular fractures of the distal humerus still pose a challenge to modern orthopedics due to unsatisfactory treatment results and a high percentage (over 50%) of postoperative complications. When surgical treatment is chosen, such fractures are fixed using two plates with locking screws, which can be used in three spatial configurations: either parallel or one of two perpendicular variants (posterolateral and posteromedial). The evaluation of the fracture healing conditions for these plate configurations is unambiguous. The contradictions between the conclusions of biomechanical studies and clinical observations were the motivation to undertake a more in-depth biomechanical analysis aiming to indicate the weak points of two-plate fracture stabilization. METHODS Research was conducted using the finite element method based on an experimentally validated model. Three variants of distal humerus fracture (Y, λ, and H) were fixed using three different plate configurations (parallel, posterolateral, and posteromedial), and they were analyzed under six loading conditions, covering the whole range of flexion in the elbow joint (0-145°). A joint reaction force equal to 150 N was assumed, which corresponds with holding a weight of 1 kg in the hand. The biomechanical conditions of bone union were assessed based on the interfragmentary movement (IFM) and using criteria formulated by Steiner et al. Results: The IFMs were established for particular regions of all of the analyzed types of fracture, with distinction to the normal and tangential components. In general, the tangential component of IFM was greater than normal. A strong influence of the elbow joint's angular position on the IFM was observed, with excessive values occurring for flexion angles greater than 90°. In most cases, the smallest IFM values were obtained for the parallel plaiting, while the greatest values were obtained for the posteromedial plating. Based on IFM values, fracture healing conditions in particular cases (fracture type, plate configuration, loading condition, and fracture gap localization) were classified into one of four groups: optimal bone union (OPT), probable union (PU), probable non-union (PNU), and non-union (NU). CONCLUSIONS No plating configuration is able to ensure distal humerus fracture union when the full elbow flexion is allowed while holding a weight of 1 kg in the hand. However, flexion in the range of 0-90° with such loadings is acceptable when using parallel plating, which is a positive finding in the context of the early rehabilitation process. In general, parallel plating ensures better conditions for fracture healing than perpendicular plate configurations, especially the posteromedial version.
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Affiliation(s)
- Artur Kruszewski
- Faculty of Mechanical Engineering, Institute of Biomedical Engineering, Bialystok University of Technology, 45A Wiejska Street, 15-351 Bialystok, Poland;
| | - Szczepan Piszczatowski
- Faculty of Mechanical Engineering, Institute of Biomedical Engineering, Bialystok University of Technology, 45A Wiejska Street, 15-351 Bialystok, Poland;
| | - Piotr Piekarczyk
- Department of Traumatology and Orthopedics, Military Institute of Medicine—National Research Institute, 128 Szaserów Street, 04-141 Warsaw, Poland; (P.P.); (P.C.); (K.K.)
| | - Piotr Cieślik
- Department of Traumatology and Orthopedics, Military Institute of Medicine—National Research Institute, 128 Szaserów Street, 04-141 Warsaw, Poland; (P.P.); (P.C.); (K.K.)
| | - Krzysztof Kwiatkowski
- Department of Traumatology and Orthopedics, Military Institute of Medicine—National Research Institute, 128 Szaserów Street, 04-141 Warsaw, Poland; (P.P.); (P.C.); (K.K.)
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Loisel F, Amar Y, Rochet S, Obert L. Distal humerus fracture in older patients: ORIF vs. total elbow arthroplasty. Orthop Traumatol Surg Res 2024; 110:103759. [PMID: 37992865 DOI: 10.1016/j.otsr.2023.103759] [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: 10/25/2022] [Accepted: 06/16/2023] [Indexed: 11/24/2023]
Abstract
Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion.
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Affiliation(s)
- François Loisel
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Yassine Amar
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Severin Rochet
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Laurent Obert
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France.
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Same K, Hakiminejad A, Nourani A, Nabian MH, Foruozesh M, Kamrani RS. Cadaveric biomechanical assessment of different configurations for a novel pin and plate fixation method in distal humerus fractures. Sci Rep 2024; 14:242. [PMID: 38168602 PMCID: PMC10762163 DOI: 10.1038/s41598-023-50976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/28/2023] [Indexed: 01/05/2024] Open
Abstract
Use of dual pre-contoured plates has been accepted as the treatment of choice in distal humerus fractures despite challenges especially in very distal or highly fragmented fractures. Aiming to improve results in such instances, our newly proposed method uses several K-wires fixated by a small reconstruction plate. Drawing on the results of previous finite element studies, the current study aims to compare the stiffness of three clinically common variations of this method using biomechanical testing in cadaveric humeri. 24 samples were divided into three groups and fractures were simulated. Groups I and II used 1.5 mm K-wires in differing configurations while 2 mm wires were used in group III. All samples underwent compression, anterior and posterior bending, and torsional testing as well as failure testing. Our results indicated that Group III had significantly higher stiffness in flexion, extension, and torsion (p < 0.05). In failure, group III had the highest mean stiffness in anterior bending and torsion (861.2 N, 30.9 Nm). Based on previous and current results, this new Persian fixation method, especially when implemented using 2 mm K-wires, shows promise in achieving suitable stability and may be useful as an alternative approach in complex distal humerus fractures.
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Affiliation(s)
- Kaveh Same
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Shariati Hospital, Jalal Al Ahmad Highway., Tehran, Iran
| | - Alireza Hakiminejad
- Department of Mechanical Engineering, Sharif University of Technology, Azadi St., Tehran, Iran
| | - Amir Nourani
- Department of Mechanical Engineering, Sharif University of Technology, Azadi St., Tehran, Iran.
| | - Mohammad Hossein Nabian
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Shariati Hospital, Jalal Al Ahmad Highway., Tehran, Iran
| | - Mehdi Foruozesh
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Reza Shahriar Kamrani
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Shariati Hospital, Jalal Al Ahmad Highway., Tehran, Iran.
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10
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Hakiminejad A, Nourani A, Ghias N, Mahmoudi A, Same K, Kamrani RS, Nabian MH. Biomechanical analysis of different osteosynthesis configurations in the pin and plate fixation method for distal humerus fractures. BMC Musculoskelet Disord 2023; 24:579. [PMID: 37460939 DOI: 10.1186/s12891-023-06709-y] [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: 01/30/2023] [Accepted: 07/08/2023] [Indexed: 07/20/2023] Open
Abstract
Distal humerus fractures commonly occur in adults with low bone mineral density causing major technical challenges for orthopedic surgeons. Persian fixation method was introduced as a novel technique to stabilize small fragments in comminuted distal humerus fractures using a set of K-wires and a reconstruction plate. The present study aims to measure this technique's stiffness and stability of this technique and analyze the effect of influential parameters with numerical simulation and biomechanical testing on a cadaveric specimen. Validation of the finite element (FE) model was conducted based on results of experiments. The results indicated that Delta configuration mainly led to a higher stiffness in the case of axial loading and anterior bending compared to L configuration. Analyzing the influential factors of this technique suggests that changes in diameter and number of K-wires have a similarly significant effect on the construct stiffness while the height of plate had a slight influence. Also, the diameter of wires was the most effective parameter for implant failure, particularly in the 3-pin construct, which caused a reduction in failure risk by about 60%. The results revealed that the Persian fixation method would achieve suitable stability compared to the dual-plating technique.
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Affiliation(s)
- Alireza Hakiminejad
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Amir Nourani
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran.
| | - Narges Ghias
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Alireza Mahmoudi
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Kaveh Same
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shahriar Kamrani
- Department of Orthopedic and Trauma Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Nabian
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran.
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11
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Fouladpour A, Asadi K, Aris A, Mollaei A, Vajargah PG, Karkhah S, Salari A. Massive bone defects due to infection at the surgical site associated with a distal humeral fracture that was treated using fibula autograft: a case report. Ann Med Surg (Lond) 2023; 85:955-959. [PMID: 37113880 PMCID: PMC10129282 DOI: 10.1097/ms9.0000000000000183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/24/2022] [Indexed: 03/31/2023] Open
Abstract
Distal humerus fractures comprise between 2 and 5% of all fractures, and approximately one-third of all humerus fractures are of this type. In the present report, the authors described the massive bone defects due to infection at the surgical site associated with a distal humeral fracture that was treated using fibula autograft. Case presentation A 28-year-old female patient experienced a fall from a height of 4 m and was referred to Poursina Educational and Medical Center. Clinical examinations and radiological imaging showed an open fracture of the right distal humerus. In the postoperative 50-day follow-up, the complication of infection at the surgical site causes bone loss of up to 8 cm. The posterior triceps-split approach (Campbell) to the distal humerus was used in this surgery. To evaluate the quality of surgery, standard radiographs of anteroposterior and lateral of the elbow joint and humeral shaft were performed after surgery. Clinical discussion At 5 months postoperatively, the patient's initial results are good, and the range of motion of the elbow joint is ~10-120°. Conclusion Based on the results of the present study, fibular transplantation in distal humerus fractures is considered one of the bone treatment options for repair.
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Affiliation(s)
- Amin Fouladpour
- Department of Orthopedics, Orthopedic Research Center, Poorsina Hospital, Faculty of Medicine, Guilan University of Medical Sciences
| | - Kamran Asadi
- Department of Orthopedics, Orthopedic Research Center, Poorsina Hospital, Faculty of Medicine, Guilan University of Medical Sciences
| | - Arash Aris
- Department of Orthopedics, Orthopedic Research Center, Poorsina Hospital, Faculty of Medicine, Guilan University of Medical Sciences
| | - Amirabbas Mollaei
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Pooyan Ghorbani Vajargah
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Samad Karkhah
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Amir Salari
- Department of Orthopedics, Orthopedic Research Center, Poorsina Hospital, Faculty of Medicine, Guilan University of Medical Sciences
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Low Transcondylar Fractures of the Distal Humerus: A Multicenter Cohort Study. J Orthop Trauma 2023; 37:e57-e62. [PMID: 36084238 DOI: 10.1097/bot.0000000000002486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the demographic characteristics and clinical and radiologic results of low transcondylar fractures and compare them with those of other types of distal humerus fractures using multicenter data and to suggest an optimal method for their treatment. DESIGN Retrospective cohort study. SETTING Tertiary-care university hospital. PATIENTS Between 2009 and 2019, 581 patients who underwent surgery for distal humerus fractures (OTA/AO classification A1 to C3) were enrolled at 7 university-affiliated hospitals. INTERVENTION Internal fixation of low transcondylar fractures. MAIN OUTCOME MEASURES Demographic characteristics, including sex, age, mechanism of injury, fixation methods, and complications, were compared between low transcondylar (group A) and other distal humerus (group B) fractures. Clinical outcomes assessed included pain, stability, and range of motion. Radiographs obtained at the latest follow-up were assessed for union, delayed union, nonunion, and implant failure. RESULTS Mean age was 62.1 ± 19.1 (range, 20-95) years, and it was higher in group A (n = 100) than in group B (n = 376). Patients in group A were predominantly women. Low-energy trauma, such as that from a simple fall, was the most common cause of fracture in group A. Both column fixation, including parallel and orthogonal double plating, was performed more commonly in group A than in group B (87.4% vs. 66.4%, P < 0.001). The nonunion rate was higher in group A, but the difference was not significant. The incidence of ulnar nerve-related symptoms was higher in group A after surgery (6.3% vs. 2.0%, P = 0.003). No significant difference in clinical outcomes was found between the groups. CONCLUSIONS Low transcondylar fractures occurred more frequently than other distal humerus fractures in older female patients and accounted for 21% of distal humerus fractures. The incidence of ulnar nerve-related symptoms was higher in patients with low transcondylar fractures after surgery. Clinical outcomes were not inferior in patients with low transcondylar fractures. The nonunion rate in patients with low transcondylar fractures treated with double plating was 3.6%. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Li T, Yan J, Ren Q, Hu J, Wang F, Xiao C, Liu X. Efficacy and safety of anterior transposition of the ulnar nerve for distal humerus fractures: A systematic review and meta-analysis. Front Surg 2023; 9:1005200. [PMID: 36684340 PMCID: PMC9853443 DOI: 10.3389/fsurg.2022.1005200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/14/2022] [Indexed: 01/08/2023] Open
Abstract
Background This systematic review and meta-analysis was performed to summarize available evidence of anterior transposition of the ulnar nerve for patients with distal humerus fractures. Materials and Methods The databases were searched from PubMed, Cochrane, Embase, Scopus, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database up to June 2022. The clinical outcome included operation time, fracture healing time, hospital stays, elbow joint function, and ulnar neuritis rate. Statistical analysis was performed with Review Manager 5.3 (Cochrane Collaboration). Results A total of 17 studies were included (8 RCTs and 9 retrospective studies), and 1280 patients were analyzed. The results of this meta-analysis showed anterior transposition group had longer operation time (MD = 20.35 min, 95%CI: 12.56-28.14, P < 0.00001). There was no significant difference in fracture healing time (SMD = -0.50, 95%CI: -1.50-0.50, P = 0.33), hospital stays (MD = -1.23 days, 95%CI: -2.72--0.27, P = 0.11), blood loss (MD = 2.66 ml, 95%CI: -2.45-7.76, P = 0.31), and ulnar neuritis rate (OR = 1.23, 95%CI: 0.63-2.42, P = 0.54) between two groups. Finally, elbow joint motion, elbow joint function, fracture nonunion, and post-operative infection (P > 0.05) between two groups were not significantly statistic difference. Conclusion This meta-analysis showed that anterior transposition group is not superior to non-transposition group for patients with distal humerus fractures without ulnar nerve injury. On the contrary, non-transposition group have shorter operation time than that of anterior transposition group. Non-transposition group did not increase the post-operative ulnar neuritis rate. Therefore, both anterior transposition group and non- transposition group are the treatment options for patients with distal humerus fractures without ulnar nerve injury. Besides, these findings need to be further verified by multi-center, double-blind, and large sample RCTs.
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Affiliation(s)
- Ting Li
- Department of Orthopedics, Sichuan Provincial People's Hospital, Chengdu, China,Department of Postgraduate, Chengdu Medical College, Chengdu, China
| | - Jingxin Yan
- Department of Interventional Therapy, Affiliated Hospital of Qinghai University, Xining, China,Department of Postgraduate, Qinghai University, Xining, China
| | - Qiuyu Ren
- Department of Orthopedics, Sichuan Provincial People's Hospital, Chengdu, China,Department of Postgraduate, Chengdu Medical College, Chengdu, China
| | - Jiang Hu
- Department of Orthopedics, Sichuan Provincial People's Hospital, Chengdu, China
| | - Fei Wang
- Department of Orthopedics, Sichuan Provincial People's Hospital, Chengdu, China
| | - Chengwei Xiao
- Department of Orthopedics, Sichuan Provincial People's Hospital, Chengdu, China,Correspondence: Xilin Liu Chengwei Xiao
| | - Xilin Liu
- Department of Orthopedics, Sichuan Provincial People's Hospital, Chengdu, China,Correspondence: Xilin Liu Chengwei Xiao
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Comparison of the Complications, Reoperations, and Clinical Outcomes between Open Reduction and Internal Fixation and Total Elbow Arthroplasty for Distal Humeral Fractures in the Elderly: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11195775. [PMID: 36233648 PMCID: PMC9571352 DOI: 10.3390/jcm11195775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
Distal humeral fractures are challenging injuries seen in the elderly. Open reduction and internal fixation (ORIF) are the gold standard treatments. Total elbow arthroplasty (TEA) is an alternative to ORIF. This study aimed to pool and analyze the outcomes and complications in elderly patients with distal humeral fractures treated with either ORIF or TEA by performing a meta-analysis. We searched the PubMed, Embase, Google Scholar, and Cochrane Library databases for studies that compared the clinical and functional outcomes of ORIF and TEA in patients aged 60 years or older. After screening and performing a quality assessment of the articles, we obtained one randomized control study and nine retrospective comparative studies. The odds ratio and standardized mean difference were used to analyze the differences in outcomes between the two surgical options. In terms of the flexion/extension arc, TEA produced significantly better outcomes than ORIF (p = 0.02). The rates of reoperation and elbow stiffness were significantly lower in the TEA group than in the ORIF group (p = 0.003 and p = 0.04, respectively). However, the functional scores and other ranges of motion (flexion, loss of extension, pronation, supination) after surgery were similar between the two groups. The outcomes from the present meta-analysis can provide guidance when selecting a surgical option for distal humeral fractures in the elderly.
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Athanaselis ED, Komnos G, Deligeorgis D, Hantes M, Karachalios T, Malizos KN, Varitimidis S. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022; 17:7-13. [PMID: 35734034 PMCID: PMC9166263 DOI: 10.5005/jp-journals-10080-1546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options. Materials and methods Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus. Results The mean follow-up time was 8.7 years [range 2–15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6–10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0–49) and 83.3 (range 25–100), respectively. Conclusion In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function. How to cite this article Athanaselis ED, Komnos G, Deligeorgis D, et al. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022;17(1):7–13.
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Affiliation(s)
- Efstratios D Athanaselis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Georgios Komnos
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Dimitrios Deligeorgis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Michael Hantes
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Theofilos Karachalios
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Konstantinos N Malizos
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
| | - Sokratis Varitimidis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece
- Sokratis Varitimidis, Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, Greece, e-mail:
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Haglin JM, Kugelman DN, Lott A, Belayneh R, Konda SR, Egol KA. Intra-articular Distal Humerus Fractures: Parallel Versus Orthogonal Plating. HSS J 2022; 18:256-263. [PMID: 35645650 PMCID: PMC9096995 DOI: 10.1177/15563316211009810] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
Background: Dual-plating osteosynthesis is the standard treatment for Orthopedic Trauma Association (OTA)-type 13-C distal humerus fractures. However, optimal plate position is debated. Purpose: The purpose of this study was to evaluate dual-plate positioning following intra-articular distal humerus fracture repair by comparing outcomes between patients plated in parallel and those plated orthogonally following open-reduction, internal-fixation (ORIF) of intra-articular distal humerus fractures. Methods: All OTA-type 13-C intra-articular distal humerus fractures treated operatively at our institution over a 10-year period were reviewed. Clinical outcomes and complications were compared between those plated in parallel and those plated orthogonally. Data were analyzed using independent-samples t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests. Results: A total of 69 patients met inclusion criteria. Mean follow-up among this cohort was 19.3 months; 45 (64.8%) patients had orthogonal dual plating, and 24 (35.2%) had parallel plating. Groups did not differ with respect to demographics or duration of follow-up. Clinically, there were no significant differences in time to union, elbow arc of motion at any time point, or patient Mayo Elbow Performance Index (MEPI) scores at final follow-up. Furthermore, there were no differences in complications. Conclusion: Parallel and orthogonal plating following ORIF of distal humerus fractures with modern, contoured locking compression plates had similar outcomes in this study. This study represents the largest comparative series in the literature at the time of its writing. Both techniques may be considered when deciding on dual-plating technique for treating intra-articular distal humerus fractures.
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Affiliation(s)
- Jack M. Haglin
- Department of Orthopedic Surgery, NYU
Langone Orthopedic Hospital, New York, NY, USA
| | - David N. Kugelman
- Department of Orthopedic Surgery, NYU
Langone Orthopedic Hospital, New York, NY, USA
| | - Ariana Lott
- Department of Orthopedic Surgery, NYU
Langone Orthopedic Hospital, New York, NY, USA
| | - Rebekah Belayneh
- Department of Orthopedic Surgery, NYU
Langone Orthopedic Hospital, New York, NY, USA
| | - Sanjit R. Konda
- Department of Orthopedic Surgery, NYU
Langone Orthopedic Hospital, New York, NY, USA
| | - Kenneth A. Egol
- Department of Orthopedic Surgery, NYU
Langone Orthopedic Hospital, New York, NY, USA,Kenneth A. Egol, MD, Department of
Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10003, USA.
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Somerson JS, Morrey ME, Sanchez-Sotelo J, Morrey BF. Predictors of reoperation after internal fixation of intra-articular distal humerus fractures. Shoulder Elbow 2022; 14:76-83. [PMID: 35154407 PMCID: PMC8832696 DOI: 10.1177/1758573219895972] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/19/2019] [Accepted: 11/27/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite good reported outcomes with open reduction and internal fixation of intra-articular distal humerus fractures, complication rates remain high. The objective of this work is to identify factors associated with reoperation. METHODS Sixty-three patients treated with open reduction and internal fixation for intra-articular (Arbeitsgemeinschaft für Osteosynthesefragen type C) distal humerus fractures between 2004 and 2010 were identified using an institutional trauma registry, 62 of which were followed for a minimum of six months. Age, gender, fracture subclassification, open fracture presence, Injury Severity Score, time to definitive surgery, length of postoperative immobilization, and type of approach were recorded. Multivariate analysis was utilized to identify factors independently associated with reoperation. RESULTS Complications requiring reoperation developed in 25 (40.3%) elbows. The most common reasons were wound dehiscence or infection in nine elbows (14.5%) and symptomatic hardware in six (9.6%). During multivariate analysis, only olecranon osteotomy remained an independent predictor for reoperation (P = 0.043). DISCUSSION Despite improved internal fixation techniques, a high proportion of elbows require reoperation after open reduction and internal fixation for distal humerus fractures. Higher complication rates in fractures fixed through an olecranon osteotomy may reflect additional reoperations due to nonunion of the osteotomy or need to remove hardware from the ulna. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Jeremy S Somerson
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, USA,Jeremy S Somerson, Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 2.316 Rebecca Sealy, 301 University Blvd Route 0165, Galveston, TX 77555-0165, USA.
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18
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Lee S, Baek E, Kim M, Kim J, Lee H, Kim DK, Jang Y, Han SH. Are Outcomes Comparable for Repair of AO/OTA Type 13C1 and Type 13C2 Distal Humeral Fractures Using the Paratricipital Approach? Clin Orthop Surg 2022; 14:169-177. [PMID: 35685971 PMCID: PMC9152886 DOI: 10.4055/cios21126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/17/2021] [Accepted: 01/29/2022] [Indexed: 11/29/2022] Open
Abstract
Background Studies have reported favorable outcomes using the paratricipital approach for fixation of distal humeral intra-articular fractures. However, literature evaluating the clinical results of the approach remains limited. The objective of this study was to compare clinical outcomes between type 13C2 and type 13C1 distal humeral fractures after open reduction and internal fixation performed using the same approach and same type of plate. Methods A total of 52 adults with type 13C1 or 13C2 distal humeral fractures were treated surgically at our institution during 2006 to 2018. We retrospectively analyzed data from 29 of these patients (19 with type 13C1 fractures and 10 with 13C2 fractures) who met the inclusion criteria. All subjects were followed for a minimum of 2 years postoperatively. Clinical and radiologic results were analyzed to determine differences in outcomes between the two types of fractures. Clinical results were evaluated using elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), and Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score. Alignment, fracture union, and presence of posttraumatic arthritis were evaluated radiologically. Results The patients’ mean age was 51 years, and the mean duration of follow-up was 29 months. Mean ROM was 129.5° ± 21.5° in the type 13C1 group and 123.0° ± 20.6° in the 13C2 group (p = 0.20). Mean Q-DASH score was 12.6 ± 11.7 in the 13C1 group and 16.2 ± 19.8 in the 13C2 group (p = 0.60). Mean MEPS was 92.9 ± 8.5 in the 13C1 group and 85.0 ± 14.1 in the 13C2 group (p = 0.09). Carrying angle did not differ significantly between the 13C1 and 13C2 groups. No patient in either group exhibited nonunion or posttraumatic arthritis. Conclusions Although the paratricipital approach has the disadvantage of limited visualization of articular surfaces, there were no differences in surgical outcomes between type 13C1 and type 13C2 distal humeral fractures after fixation using this approach. Thus, surgeons may need to consider using the paratricipital approach for open reduction and internal fixation of 13C2 distal humeral fractures.
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Affiliation(s)
- Soonchul Lee
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Eugene Baek
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Minwook Kim
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Junhan Kim
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyunil Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | | | - Yoon Jang
- CHA Graduate School of Medicine, Pocheon, Korea
| | - Soo-Hong Han
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Moursy M, Wegmann K, Wichlas F, Tauber M. Distal humerus fracture in patients over 70 years of age: results of open reduction and internal fixation. Arch Orthop Trauma Surg 2022; 142:157-164. [PMID: 33151362 PMCID: PMC8732916 DOI: 10.1007/s00402-020-03664-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 10/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Due to the complexity of distal humerusfractures and often poor bone quality in elderly patients, these entities remain a challenge. However, because of a high rate of complications related to total elbow prostheses, reconstruction of distal humerus fractures should still be considered a therapeutic option, also in the elderly patient. The purpose of the present study was to investigate the clinical outcomes after open reduction and internal fixation and to evaluate whether the results justify reconstruction even in elderly patients. We hypothesized that despite advanced age, reasonable clinical results can be achieved, using a standardized surgical technique and aftertreatment protocol for the treatment of distal humerus fractures in elderly patients. METHODS Between 2004 and 2012, 30 patients with a mean age of 78 years at the time of injury with a recent distal humerus fracture were evaluated. All patients underwent the identical aftertreatment protocol with no weight bearing for 6 weeks and weekly increasing range of motion. Follow-up rate was 90%. 22 patients were treated with double plate, 4 with single plate, and 1 with screw fixation only. Patients were evaluated based on clinical criteria. Primary outcome measures were Mayo Elbow Performance Score, VAS and joint range of motion, secondary was radiological evaluation. RESULTS After a mean follow-up period of 3.8 years (min. 1 year, max. 9 years, SD ± 2), the average range of motion was flexion of 127° (min. 100°; max. 150°; SD ± 16.5) and average loss of extension of 20.9° (min. 5°; max. 40°; SD ± 11). Average pronation and supination was 68.3° (min. 0°; max. 90°; SD ± 25.3) and 75.3° (min. 0°; max. 90°; SD ± 19.7), respectively. Average Mayo Elbow Performance (MEPS) score was 88.7 (min. 60; max. 100; SD ± 12.1). 6 patients developed heterotopic ossification without significant effect on the clinical outcome. 7 patients had radiological evidence of at least partial non-union with one requiring revision, 2 discrete hardware dislocations were treated conservatively. There were no infections in the presented cohort. Our results regarding the surgical approach showed significantly higher patient satisfaction scores in the osteotomy group, compared to the group with Triceps-On Approach (PTOA). CONCLUSION The present data support indication for open reduction internal fixation (ORIF) even in the elderly patient. Advanced age should not be seen as a contraindication for ORIF of fractures of the distal humerus. Although the rate of complications is higher than in younger patients, complications such as non-union are often asymptomatic, patient satisfaction scores are high, and the possible devastating complications of failed elbow replacement can be evaded. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Mohamed Moursy
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Kilian Wegmann
- University of Cologne, Faculty of Medicine, Cologne, Germany
- University Hospital Cologne, Center of Orthopedic and Trauma Surgery, Cologne, Germany
| | - Florian Wichlas
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Mark Tauber
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
- Shoulder and Elbow Surgery, ATOS Clinic, Munich, Germany
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Abstract
Distal humerus fractures in the elderly population can be difficult to manage because of substantial articular comminution, poor bone quality, and soft tissue compromise. Important patient considerations for treatment include physiologic age, mental status, activity level, and independence with activities of daily living. Elderly patients may be reliant on their upper extremity as a weight-bearing limb when using a walker or rising to stand which creates additional demand. The goal of surgical treatment is to recreate a stable, painless elbow with a functional range of motion to preserve independence for daily activities and mobilization. The main surgical treatment options are open reduction and internal fixation and arthroplasty. Here, we discuss indications and operative goals in each clinical scenario.
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Kataoka T, Yasui Y, Kuriyama K, Namba J, Murase T. Parallel plate fixation for distal humeral fracture: Computer simulation to determine the appropriate screw insertion sequence. J Orthop Sci 2021; 26:860-864. [PMID: 33309403 DOI: 10.1016/j.jos.2020.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/02/2020] [Accepted: 07/24/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Parallel plate fixation for distal humeral fractures provides good clinical outcomes. However, few studies have investigated the insertion sequence of the distal screws, although long screw insertion into the distal fragment is technically demanding. The purpose of this study was to investigate a correlation between the insertion sequence of the distal screws and the screw insertion difficulty. METHODS Medial and lateral anatomical locking plates were closely fitted to the medial and lateral sides of the 10 intact humerus bone models on the computer. Most distal screws have 2 patterns: the screw was inserted from the lateral side first followed by insertion from the medial side (group 1) or from the medial side first followed by insertion from the lateral side (group 2). We calculated the target area wherein the second screw can be inserted. RESULTS The length of the first most distal screw in group 2 was significantly longer than that in group 1 (58.4 vs. 49.8 mm, p < 0.05). The target areas in both groups were divided into the distal and proximal areas. The distal and proximal areas in group 1 were 91.6 and 61.6 mm2, respectively, and those in group 2 were 191.1 and 11.3 mm2, respectively. The distal area in group 2 was significantly greater than in the other areas (p < 0.05). CONCLUSIONS In parallel plate fixation for distal humeral fracture, most distal screws could be more easily inserted from the medial side first followed by insertion from the lateral side than from the lateral side first followed by insertion from the medial side.
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Affiliation(s)
- Toshiyuki Kataoka
- Department of Orthopedic Surgery, JCHO Hoshigaoka Medical Center, 4-8-1, Hoshigaoka, Hirakata, Osaka, 573-8511, Japan.
| | - Yukihiko Yasui
- Department of Orthopedic Surgery, JCHO Hoshigaoka Medical Center, 4-8-1, Hoshigaoka, Hirakata, Osaka, 573-8511, Japan
| | - Kohji Kuriyama
- Department of Orthopedic Surgery, Toyonaka Municipal Hospital, 4-14-1, Sibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Jiro Namba
- Department of Orthopedic Surgery, JCHO Hoshigaoka Medical Center, 4-8-1, Hoshigaoka, Hirakata, Osaka, 573-8511, Japan
| | - Tsuyoshi Murase
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
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Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis. J Shoulder Elbow Surg 2021; 30:1957-1967. [PMID: 33711499 DOI: 10.1016/j.jse.2021.02.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years. METHODS We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating. RESULTS Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01). CONCLUSIONS This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.
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Wilson ES, Buckwalter JA, Henning G, Davison J, Fleury IG, Willey MC. Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications. J Orthop Trauma 2021; 35:e223-e227. [PMID: 33208714 DOI: 10.1097/bot.0000000000002006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13). DESIGN Retrospective comparative cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy). INTERVENTION Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy. MAIN OUTCOME MEASURE Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI). RESULTS Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001). CONCLUSIONS Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Erin S Wilson
- University of Iowa, Carver College of Medicine, Iowa City, IA; and
| | - Joseph A Buckwalter
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Grant Henning
- University of Iowa, Carver College of Medicine, Iowa City, IA; and
| | - John Davison
- University of Iowa, Carver College of Medicine, Iowa City, IA; and
| | - Ignacio G Fleury
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael C Willey
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
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24
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Shih CA, Kuan FC, Hsu KL, Hong CK, Lin CL, Yeh ML, Su WR. Does posterior configuration have similar strength as parallel configuration for treating comminuted distal humerus fractures? A cadaveric biomechanical study. BMC Musculoskelet Disord 2021; 22:440. [PMID: 33990212 PMCID: PMC8122534 DOI: 10.1186/s12891-021-04302-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/22/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Chien-An Shih
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Fa-Chuan Kuan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Orthopedics, National Cheng Kung University Hospital Dou-Liou Branch, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Cheng-Li Lin
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan. .,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan.
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25
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Grogan BF, Danford NC, Lopez CD, Maier SP, Kongmalai P, Kovacevic D, Levine WN, Jobin CM. Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate. SICOT J 2021; 7:25. [PMID: 33812466 PMCID: PMC8019548 DOI: 10.1051/sicotj/2021006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 01/31/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. Methods: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. Results: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). Conclusion: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.
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Affiliation(s)
- Brian F Grogan
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA - Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UW Health at The American Center, 4602 Eastpark Boulevard, Madison, 53718 WI, USA
| | - Nicholas C Danford
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Cesar D Lopez
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Stephen P Maier
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Pinkawas Kongmalai
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - David Kovacevic
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
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Tarallo L, Novi M, Porcellini G, Giorgini A, Micheloni G, Catani F. Surgical tips and tricks for coronal shear fractures of the elbow. Arch Orthop Trauma Surg 2021; 141:261-270. [PMID: 32495117 DOI: 10.1007/s00402-020-03500-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/31/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Coronal shear fractures of the distal humerus represent an uncommon lesion and could be burdened by high complications. This complex lesion requires an accurate reduction and surgical fixation for a better outcome. Different techniques have been described, however no standard protocol have been proposed. Purpose of this retrospective study, is to evaluate the clinical and radiological outcome with posterior cannulated self-tapping headless screws followed by an early-active-motion protocol and to outline the surgical tips and tricks for different fracture patterns. MATERIALS AND METHODS From 2013 to 2019, a consecutive series of 24 patients with coronal shear fracture undergoing ORIF were included in the study. Fractures were classified according to Dubberley's classification. Cannulated self-tapping headless screws were used to fix the fragments. When necessary, additional cannulated half-threaded screws on the lateral edge of the humerus were used, as well as bone chips and fibrin sealant on severe comminution. All patients underwent an assisted early-active-motion rehabilitation protocol. Mean follow-up was 30 months; patients underwent standard X-rays and clinical outcome assessment with range of motion, Broberg and Morrey score and MEPI score. RESULTS Surgical fixation with headless screw guaranteed complete healing of all shear fractures examined, no loss of reduction were reported. ROM assessment showed good results with an average arc of 113.1°. Excellent to good Broberg-Morrey and MEPI score were reported. No cases of avascular necrosis nor post-traumatic osteoarthritis resulted in our series. Complications occurred in 16.6% of the patients. CONCLUSION Coronal shear fracture represents a challenging injury to treat. Anatomical reduction and the use of cannulated self-tapping headless screws from posterior provide a stable fixation, high union rates and good elbow function, with a low cartilage damage and risks of necrosis over 2 years of follow-up. LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Luigi Tarallo
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy.
| | - Michele Novi
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Giuseppe Porcellini
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Andrea Giorgini
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Gianmario Micheloni
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Fabio Catani
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
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27
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Olson JJ, Dyer GS. Skinny wire and locking plate fixation for comminuted intra-articular distal humerus fractures: a technical trick and case series. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:34-40. [PMID: 37588629 PMCID: PMC10426594 DOI: 10.1016/j.xrrt.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Introduction Intra-articular distal humerus fractures present a challenge to orthopedic surgeons. Stable fixation is difficult to achieve in fractures with articular and metaphyseal comminution and osteoporotic bone. Hence, these fractures are more commonly being managed with total elbow arthroplasty. We describe a novel surgical technique that confers stable fixation, allowing for early range of motion resulting in a high rate of union, a functional range of motion, and excellent patient reported outcome scores without the activity restrictions of total elbow arthroplasty. Methods Retrospective case series of 30 patients with AO/OTA type B and C intra-articular distal humerus fractures who underwent ORIF from 2014-2019 utilizing a novel surgical technique that focuses on reconstructing a comminuted articular surface through meticulous, transverse fixation of the tiny articular fragments with long, thin Kirchner wires, which are then bent over and trapped under locking compression plates to create a fixed angle support to the metadiaphysis. Results Patient mean age of 59 (19-90) years and 61% were female. Median follow up was 1.2 years. Twenty-seven (87%) were type C fractures and 3 (13%) were type B. Five patients (16%) suffered a concurrent ipsilateral upper extremity injury and four (13%) had an open fracture. Two were polytrauma patients. All fractures healed with an average time to union of 11 weeks. Over 80% patients reported no or mild pain at final follow up. Mean arc of elbow motion was 102 degrees, mean QuickDASH score 25.2. Post-operative complications included ulnar nerve paresthesias (38%), wound infection (3.2%), heterotopic ossification (3.2%), and olecranon nonunion (3.2%). Eight patients underwent secondary procedures: 7 (23%) removal hardware, 3(9.6%) capsular release, 2 (6.4%) ulnar nerve transpositions, and 1 (3.2%) total elbow arthroplasty. Conclusion We describe a novel surgical technique that we believe results in strong, stable fixation of complex intra-articular distal humerus fractures irrespective of bone quality. In our series, all fractures healed and post-operatively patients reported low levels of pain, achieved excellent elbow range of motion, high patient reported outcome scores. Patients should be counseled about high rates of post-operative ulnar nerve paresthesias that can be expected to improve over time and high reoperation rates for symptomatic hardware.
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Affiliation(s)
- Jeffrey J. Olson
- Harvard Combined Orthopaedic Surgery Program, Boston, MA, USA
- Orthopaedic Trauma Initiative at Harvard Medical School, Boston, MA, USA
| | - George S.M. Dyer
- Harvard Combined Orthopaedic Surgery Program, Boston, MA, USA
- Orthopaedic Trauma Initiative at Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA
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28
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Herman ZJ, Edelman DG, Ilyas AM. Heterotopic Ossification After Elbow Fractures. Orthopedics 2021; 44:10-16. [PMID: 33238018 DOI: 10.3928/01477447-20201119-03] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/10/2020] [Indexed: 02/03/2023]
Abstract
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.].
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29
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Shah NV, Hayes WT, Wang H, Hordines JC, Karakostas JE, Paxinos O, Koehler SM. A pilot biomechanical study comparing a novel, intramedullary Nail/Plate construct to standard Dual-Plate fixation of intra-articular C2.3 distal humerus fractures. Injury 2020; 51:2148-2157. [PMID: 32605784 DOI: 10.1016/j.injury.2020.06.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The gold-standard treatment for intra-articular distal humerus fractures (DHFs) is dual-plate/dual-column fixation, though optimal orientation is not yet established. With a superior method not yet identified, we propose a load-sharing construct, combining absolute stability (extramedullary plate fixation) for distal articular fragments and relative stability (load-sharing intramedullary nail) for the metaphyseal segment. The purpose of this pilot study was to evaluate the biomechanical performance of a novel implant compared to orthogonal dual-plating. MATERIALS AND METHODS Ten fresh-frozen matched-pairs of human cadaveric upper extremities with no prior elbow pathology/surgery were used. Pairs were randomized into two groups: Dual-Plate (medial and posterolateral) or novel Nail/Plate (cross-locked medial nail and posterolateral plate). AO/ASIF type 13-C2.3 multifragmentary fractures with simulated metaphyseal comminution. Biomechanical testing included stiffness (MPa) and load to failure (Newtons) in axial (100 cycles at 3 Hz at 20 N increments from 20 to 100 N) and coronal (varus/valgus; 4,000 cycles from 50N-100 N at 3 Hz) planes. Failed specimens were not analyzed and mechanisms were identified. For all failures, mechanisms were identified and reviewed by three consultant surgeons for revision vs. immobilization, to attempt to recreate a real-world scenario. All outcomes were compared between groups. RESULTS During stiffness testing, zero Nail/Plate specimens failed, but two (20%) Dual-Plate specimens failed (mechanisms: fracture diastasis; bone collapse and intussusception into osteotomy, yielding articular congruency loss). For remaining samples, Nail/Plate (n = 10) coronal (varus/valgus) stiffness was comparable to Dual-Plate (n = 8) constructs (41.5 vs. 39.0 MPa, p = 0.440). Remaining Dual-Plate constructs had greater axial overall stiffness than Nail/Plate (118.3 ± 48.3 vs. 95.6 ± 34.7 MPa, p = 0.020). Failure loads were comparable between Nail/Plate and Dual-Plate constructs (1,327.8 vs. 1,032.4 N, p = 0.170). Individual nail yield strength ranged from 1,101.1-1,124.4 N (n = 2). In review of all failures, the most common overall mechanism was fracture/osteotomy site posterolateral plate bending. Revision recommendation rate was comparable between constructs (Nail/Plate, 22.2% vs. Dual-Plate, 44.4%, p>0.05). CONCLUSIONS The novel Nail/Plate construct demonstrated non-inferior coronal (varus/valgus) stiffness, despite producing lower axial stiffness than orthogonal dual-plating, potentially due to the load-sharing cross-locked design. Considering comparable biomechanical performance, with no failures and comparable recommendations for revision, this novel construct warrants further evaluation as an alternative to the gold-standard, dual-plate fixation method for intra-articular distal humerus fractures. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Westley T Hayes
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Hanbin Wang
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - John C Hordines
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Jonathan E Karakostas
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Odysseas Paxinos
- Orthopaedic Department, 251 Hellenic Air Force Hospital, Athens, Greece
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA.
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30
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Sur YJ, Kim Y, Park HY. Results of plate fixation for transcondylar fracture of the distal humerus: a rare pattern of fractures. JSES Int 2020; 4:478-484. [PMID: 32939471 PMCID: PMC7478994 DOI: 10.1016/j.jseint.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The pattern of transcondylar fracture of the humerus is unique and the incidence rate is very low. Stable internal fixation may be difficult to achieve, and complications have been reported at a higher rate. The purpose was to report the outcomes of open reduction and internal fixation (ORIF) for transcondylar fractures of the humerus. Methods Seventeen patients were included between January 2014 and December 2017. ORIF was performed using anatomic distal humerus plates. Results were evaluated by range of motion, Mayo Elbow Performance Score (MEPS), and complications. We analyzed the results according to ulnar nerve transposition status and fixation pattern. Results The mean range of elbow motion was 117° flexion and 20° extension. The MEPS was excellent in 12, good in 3, fair in 1, and poor in 1. There were in total 5 cases of complications among 17 patients: 1 with nonunion, 1 with ulnar neuropathy, 2 with delayed union, and 1 with heterotopic ossification. The results according to ulna nerve transposition and fixation pattern showed no difference. Conclusions For reliable and good results, rigid fixation using anatomic plates and appropriate immobilization of the fracture site are key factors in the treatment. In our case series, the overall outcome was good and there were 2 major complications. The ORIF using anatomic plates can be a reliable treatment option for transcondylar humeral fractures.
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Affiliation(s)
- Yoo Joon Sur
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University, Gyeonggi-do, Republic of Korea
| | - Yoochang Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University, Gyeonggi-do, Republic of Korea
| | - Ho Youn Park
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University, Gyeonggi-do, Republic of Korea
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Cho JW, Kim BS, Yeo DH, Kang SH, Lim EJ, Sakong S, Cho WT, Oh JK. Clinical outcome of AO/OTA type C fracture of the distal humerus using the expanded paratricipital approach and cadaveric comparison of the exposure of the paratricipital and expanded paratricipital approaches to the distal humerus. J Shoulder Elbow Surg 2020; 29:1554-1563. [PMID: 32713465 DOI: 10.1016/j.jse.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/20/2020] [Accepted: 03/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach. METHODS Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows. RESULTS The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection. CONCLUSIONS The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.
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Affiliation(s)
- Jae-Woo Cho
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Do-Hyun Yeo
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Seong Hyun Kang
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Seungyeob Sakong
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Won-Tae Cho
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea.
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea.
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Wang X, Liu G. A comparison between perpendicular and parallel plating methods for distal humerus fractures: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020; 99:e19602. [PMID: 32501964 PMCID: PMC7306383 DOI: 10.1097/md.0000000000019602] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To compare the clinical outcomes of perpendicular and parallel plating for the treatment of distal humerus fractures. METHODS Two investigators independently searched PubMed, OVID, and ScienceDirect databases prior to April 2019, without any limitations on language or publication status. The outcomes were union time, range of motion of elbow, Mayo Elbow Performance Score, and postoperative complications. Two authors independently performed a methodological quality and risk of bias assessment using Cochrane collaboration's tool. Data analysis was performed with STATA version 13.0. RESULTS Six randomized controlled trials with 305 participants were included. The present meta-analysis indicated that orthogonal plating was associated with a longer union time compared with parallel plating. There were no significant differences between the 2 groups regarding Elbow function, Mayo Elbow Performance Score, operation time, reduction quality, or postoperative complications. CONCLUSION Both parallel plating and orthogonal plating are considered to be effective methods when treating distal humerus fractures. The results of this study found that parallel plating is superior to orthogonal plating in humerus fracture healing.
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Affiliation(s)
- Xiaohan Wang
- Department of Orthopedics, Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing
| | - Guoyan Liu
- Department of Orthopedics, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Shandong, China
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Baik JS, Lee SH, Kang HT, Song TH, Kim JW. Comparison of open reduction and internal fixation with total elbow arthroplasty for intra-articular distal humeral fractures in older age: a retrospective study. Clin Shoulder Elb 2020; 23:94-99. [PMID: 33330240 PMCID: PMC7714334 DOI: 10.5397/cise.2020.00052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 11/25/2022] Open
Abstract
Background Intra-articular distal humeral fractures can be surgically challenging. It remains under discussion whether open reduction and internal fixation (ORIF) or total elbow arthroplasty (TEA) is more beneficial for treatment of the elderly. This study aimed to compare the clinical and functional outcomes of ORIF and TEA for managing intra-articular distal humerus fractures in patients aged 65 years or older. Methods Patients who underwent ORIF (n=28) or TEA (n=43) for in intra-articular distal humerus fracture between May 2008 and December 2018 were reviewed. Range of motion, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiologic outcomes, and surgical complications were evaluated at the final follow-up visit. Results The ORIF and TEA groups showed a mean arc of flexion–extension of 97°±21° and 101°±12°, respectively. The mean MEPS and DASH scores were 94±15 and 27±12 points, respectively, in the ORIF group and 81±27 and 47±28 points in the TEA group. This difference was statistically significant. The incidence of total complications was similar between the groups. Conclusions In patients older than 65 years with intra-articular distal humerus fracture, ORIF had better outcomes than TEA.
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Affiliation(s)
- Jong Seok Baik
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyun Tak Kang
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Tae Hyun Song
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
| | - Jeong Woo Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Korea
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Lauder A, Richard MJ. Management of distal humerus fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:745-762. [DOI: 10.1007/s00590-020-02626-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
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Yu X, Xie L, Wang J, Chen C, Zhang C, Zheng W. Orthogonal plating method versus parallel plating method in the treatment of distal humerus fracture: A systematic review and meta-analysis. Int J Surg 2019; 69:49-60. [PMID: 31362124 DOI: 10.1016/j.ijsu.2019.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/23/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This systematic review and meta-analysis was performed to investigate the outcomes of orthogonal plating method and parallel plating method in the treatment of distal humerus fracture from the current literatures. METHODS The electronic literature database of Pubmed, Embase, and Cochrane library were searched in November 2018. The data operation time, union time, Mayo Elbow Performance Score (MEPS), range of motion (ROM) of elbow, arc of elbow flexion, arc of elbow extension, rate of excellent and good results and complications (including heterotopic ossification, transient ulnar nerve neuropathy and ankylosis) were extracted. Stata 14.0 software was used for our meta-analysis. RESULTS A total of 8 studies including 6 RCTs and 2 cohort studies met our inclusion criteria. This meta-analysis showed that there was no significant difference between the two groups regarding operation time, MEPS, ROM of elbow, arc of elbow flexion, arc of elbow extension and rate of excellent and good results at final follow-up (P = 0.50, P = 0.39, P = 0.87, P = 0.18, P = 0.58 and P = 0.59 respectively). However, the present meta-analysis demostrated that parallel plating method had significantly shorter union time than orthogonal plating method (P = 0.018). As for the complications (heterotopic ossification, transient ulnar nerve neuropathy and ankylosis), there was no significant difference between the two groups (P = 0.89, P = 0.08 and P = 0.29 respectively). CONCLUSION Our meta-analysis suggested that both orthogonal plating and parallel plating method could achieve satisfactory outcomes with the similarly low complications in the treatment of distal humerus fracture. More RCTs are required for further research.
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Affiliation(s)
- Xianbin Yu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Linzhen Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jinwu Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chunhui Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chuanxu Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Wenhao Zheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
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Atif M, Hasan O, Mohib Y, Rashid RH, Hashmi P. Does surgical approach affect outcome after fixation of intra-articular fractures of distal humerus? Retrospective cohort study from a level-1 trauma centre in a metropolitan city. Ann Med Surg (Lond) 2019; 43:48-51. [PMID: 31198551 PMCID: PMC6556481 DOI: 10.1016/j.amsu.2019.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction Fractures around the distal humerus fractures make up to 2% of all fractures. Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint. Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction. Conflict still persists regarding the choice of ideal approach. In this study we compare the effect of surgical approach triceps lifting vs olecranon osteotomy on the functional outcome after fixation of distal humerus fractures. Methods Non-funded, non-commercial, retrospective cohort study was conducted on patients with closed distal humerus intra-articular fractures between 2010 and 2015 at our tertiary care level-1 trauma and university hospital. Patients >18 years of age with closed complex intra-articular distal humerus fracture were operated using one of the two surgical approaches, either triceps lifting approach (Group1) or with olecranon osteotomy (Group 2). Functional evaluation using quick DASH scores at 1 year of follow-up. Study is registered with ID:NCT03833414 and work has been reported in line with the STROCSS criteria. Results Out of 43 patients 16 were treated with triceps lifting approach and 27 with olecranon osteotomy. The difference between the mean quick DASH score for both groups was not statistically significant (p = 0.52) although higher for group 1. Complications were comparable for both groups but 2 patients suffered delayed union of osteotomy site in group 2. Conclusion Triceps lifting approach can be used equally efficiently for exposure of these complex distal humerus injuries with no comprise in visibility of articular fragments. Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint. Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction. For long time, olecranon osteotomy approach was utilized to provide clear access to the joint. This is at the cost of creating osteotomy and the risk of its delayed/nonunion. Triceps lifting approach avoids this catastrophic complication.
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Affiliation(s)
| | - Obada Hasan
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
| | - Yasir Mohib
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
| | - Rizwan Haroon Rashid
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
| | - Pervaiz Hashmi
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
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Lee HJ. Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures. Clin Shoulder Elb 2019; 22:113-117. [PMID: 33330205 PMCID: PMC7714297 DOI: 10.5397/cise.2019.22.2.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/01/2019] [Accepted: 04/07/2019] [Indexed: 12/02/2022] Open
Abstract
Treating distal humerus fractures, especially those involving intra-articular lesions, is complex and often technically demanding. Although there still exist many controversial issues, the goal of treatment is to establish anatomical stable fixation by restoring the two columns and the articular surface. Universally, a posterior midline incision is applied, and the approach varies according to the further management of the triceps or olecranon. Evidence supports dual plate fixation as the optimal fixation method, and debates regarding appropriate plating configuration are still ongoing. As multiple clinical studies comparing results of parallel and perpendicular plate fixation have shown no actual difference, it is important to place the plates according to the fracture configuration.
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Affiliation(s)
- Hyo-Jin Lee
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Lustenberger T, Leonardy R, Marzi I, Frank J. Outcome after surgical treatment of complex elbow fractures: a single-center follow-up study. Eur J Trauma Emerg Surg 2019; 46:1445-1449. [PMID: 31115614 DOI: 10.1007/s00068-019-01157-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/16/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Elbow injuries present particular challenges for the treating surgeons. The aim of the present study was to evaluate the postoperative outcome after surgical treatment of complex elbow fractures. PATIENTS AND METHODS Retrospective analysis with subsequent clinical follow-up examination of all patients with complex elbow fractures admitted to our level I trauma center over a 6-year period. The patients were stratified into three groups: single fractures of the proximal forearm (olecranon fractures type Mayo IIB, radial head fractures type Mason II-IV), distal humerus fractures (AO type C1-3), and combined injures. The clinical examination included the range of motion, grip strength measured with a Jamar dynamometer, DASH and MEP score. RESULTS Overall, 39 patients with complex elbow fractures were included in the study. Twelve patients presented with a distal, intra-articular humerus fracture, 16 patients had an isolated proximal forearm fracture and 11 patients suffered multiple fractures. The functional scores showed good overall results, with a median DASH score of 6.7 points and median MEP score of 85.0 points. The median extension deficit in the elbow joint was 15.0° (mean 16.2° ± 12.8°), the median flexion deficit was 5.0° (9.8° ± 12.3°) and the median pronation/supination (overall rotation) deficit was 5.0° (16.7° ± 23.6°). Patients with intra-articular distal humerus fractures showed a significantly increased extension and flexion deficit compared to the other groups. CONCLUSION The surgical treatment of complex elbow fractures was associated with good to excellent clinical results. However, distal intra-articular humerus fractures presented the most prominent loss of elbow motion in the follow-up examination.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| | - Raphael Leonardy
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Johannes Frank
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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Wei L, Ling M, An Z. Biomechanical analysis of a novel plating for intra-articular distal humerus fractures: combined anteromedial and anterolateral plating. J Orthop Surg Res 2019; 14:132. [PMID: 31088497 PMCID: PMC6518756 DOI: 10.1186/s13018-019-1181-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/30/2019] [Indexed: 12/03/2022] Open
Abstract
Purpose The traditional strategy for fixing intra-articular distal humerus fractures is double plating placed in an orthogonal or parallel configuration, based on posterior approach. With a combined medial and lateral approach, a novel configuration of plating (combined anteromedial and anterolateral plating) has been used. In this study, we investigated the biomechanical properties of the novel plating by comparing it with orthogonal plating. Methods Based on the 3D morphology of a healthy subject’s humerus, the models of simple intra-articular distal humerus fractures were simulated. Two configurations of plating were applied to fix the models: the novel plating (with one plate anteromedially and the other anterolaterally on distal humerus), and orthogonal plating. Stresses, displacement, and stiffness were simulated and calculated under the conditions of axial compression, rotation torsion, bending torsion, and valgus torsion by using finite element analysis. Results In all the conditions, the maximal von Mises stresses of the novel plating are similar to those of orthogonal plating, and the patterns of stress distribution are similar between these two configurations. However, the impact of high stresses was weaker on the novel plating. The maximal displacement of the novel plating is smaller than that of orthogonal plating. The stiffness of the novel plating is superior to that of orthogonal plating, with the improvements of 19.4%, 122.7%, 25.0%, and 54.2% in axial compression, rotation torsion, bending torsion, and valgus torsion, respectively. Conclusions The novel plating is stronger than orthogonal plating without increasing stress magnitude when fixing simple intra-articular distal humerus fractures, which makes it a feasible alternative. Further biomechanical and clinical studies are needed for a decisive conclusion.
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Affiliation(s)
- Libiao Wei
- Department of Traumatic Orthopedics Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Ming Ling
- Orthopedic Biomechanical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Zhiquan An
- Department of Traumatic Orthopedics Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600 Yishan Road, Shanghai, 200233, People's Republic of China.
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Nestorson J, Rahme H, Adolfsson L. Arthroplasty as primary treatment for distal humeral fractures produces reliable results with regards to revisions and adverse events: a registry-based study. J Shoulder Elbow Surg 2019; 28:e104-e110. [PMID: 30342824 DOI: 10.1016/j.jse.2018.07.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/22/2018] [Accepted: 07/25/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Primary prosthetic replacement has become an accepted method for the treatment of complex distal humeral fractures. The present study investigated implant survival and adverse events related to this procedure based on available Swedish registries and examined the completeness of the Swedish Elbow Arthroplasty register. MATERIALS AND METHODS Patients treated in Sweden with a primary elbow replacement due to a distal humeral fracture between 1999 and 2014 were identified through 3 different registries: The Swedish Elbow Arthroplasty Register, National Board of Health and Welfare inpatient register, and local registries of all orthopedic departments. Prosthetic survival was examined using Cox regression analysis with Kaplan-Meier plots. Adverse events, defined as medical treatment of the affected elbow besides revision, were analyzed separately. The study included 406 elbows in 405 patients, and no register was complete. RESULTS Implant survival at 10 years was 90% (95% confidence interval, 85%-96%), but only 45 patients had an observation time of 10 years or more because 46% of the patients had died, resulting in a mean observation time of 67 (standard deviation, 47) months. An increase in the use of hemiarthroplasties and a proportional decrease of total elbow arthroplasties was detected. There were 18 revisions (4%), and 26 patients (6%) experienced an adverse event, of whom 16 (4%) required surgery. The completeness of the Swedish Elbow Arthroplasty Register regarding primary arthroplasty was 81%. CONCLUSION Primary arthroplasty as treatment of distal humeral fractures produces reliable results with regards to revisions and other adverse events.
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Affiliation(s)
- Jens Nestorson
- Department of Experimental and Clinical Medicine, Linköping University, Linköping, Sweden.
| | - Hans Rahme
- Department of Orthopedics, Elisabeth Hospital, Uppsala, Sweden
| | - Lars Adolfsson
- Department of Experimental and Clinical Medicine, Linköping University, Linköping, Sweden
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Hara A, Kudo T, Ichihara S, Iwase H, Nagao M, Maruyama Y, Kaneko K. Biomechanical evaluation of a transcondylar screw from the dorsolateral plate support on the stabilization of orthogonal plate configuration in distal humeral fracture. Injury 2019; 50:256-262. [PMID: 30579588 DOI: 10.1016/j.injury.2018.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/14/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intra-articular distal humeral fractures involving both columns require double-plate fixation. In orthogonal plate fixation, screws from the medial plate reach the radial column, while screws from the dorsolateral plate run posterior-anterior, not creating interdigitation. The Synthes LCP-DHP system has an orthogonal plate configuration that enables dorsolateral plating with support, as the radial and ulnar columns are linked via interdigitation of the distal screws. We hypothesized that the transcondylar screw from the posterolateral plate, which interdigitates with screws from the medial plate, enables more rigid stabilization of orthogonal plating in distal humeral AO type C fractures. METHODS A previous study reported the biomechanical properties of orthogonal plate fixation using an AO type 13-C2.3 intra-articular fracture model with a 1-cm supracondylar gap using artificial bones (Kudo et al., Injury, 2016). We performed a biomechanical study of the dorsolateral plate with support, and inserted one 2.7-mm locking screw through the support in the lateral-to-medial direction, creating interdigitation of the distal screws. A 0-200 N axial load was applied separately to the radial and ulnar columns. We calculated the stiffness of both columns, and the anterior displacement of the condylar fragment. We compared the biomechanical properties of orthogonal plating with versus without interdigitation. RESULTS There were no significant differences between the two groups in radial or ulnar axial compression. The ulnar column was stiffer than the radial column in both groups. There were no significant differences between groups in the angular displacements of the capitellum or trochlea. The capitellum moved more anteriorly than the trochlea during axial compression in both groups. DISCUSSION The radial and ulnar columns were linked via interdigitation of the distal screws by adding one transcondylar screw from the dorsolateral plate, which did not affect radial column stiffness or capitellar anterior movement under axial compression. In the orthogonal configuration, axial compression induced more anterior displacement of the capitellum than the trochlea, which may induce secondary fragment or screw dislocation on the dorsolateral plate or nonunion at the supracondylar level. CONCLUSIONS The transcondylar screw from the dorsolateral plate did not affect axial compression of the radial column or capitellar anterior displacement.
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Affiliation(s)
- Akira Hara
- Department of Orthopedic Surgery, Juntendo University Urayasu Hospital, Chiba, Japan.
| | - Toshiya Kudo
- Department of Orthopedic Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Satoshi Ichihara
- Department of Orthopedic Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hideaki Iwase
- Department of Mechanical Engineering, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Masashi Nagao
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
| | - Yuichiro Maruyama
- Department of Orthopedic Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kazuo Kaneko
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan
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Savvidou OD, Zampeli F, Koutsouradis P, Chloros GD, Kaspiris A, Sourmelis S, Papagelopoulos PJ. Complications of open reduction and internal fixation of distal humerus fractures. EFORT Open Rev 2018; 3:558-567. [PMID: 30662764 PMCID: PMC6335604 DOI: 10.1302/2058-5241.3.180009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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 90o:90o orthogonal or 180o 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
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Affiliation(s)
- Olga D Savvidou
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Frantzeska Zampeli
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | | | - George D Chloros
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Aggelos Kaspiris
- Department of Trauma and Orthopaedics, Thriasio General Hospital-NHS, Athens, Greece
| | - Savas Sourmelis
- First Department of Orthopaedics, Hygeia Hospital, Athens, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
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Total elbow arthroplasty versus plate fixation for distal humeral fractures in elderly patients: a systematic review and meta-analysis. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Parallel versus orthogonal plate osteosynthesis of adult distal humerus fractures: a meta-analysis of biomechanical studies. INTERNATIONAL ORTHOPAEDICS 2018; 43:449-460. [PMID: 29679109 DOI: 10.1007/s00264-018-3937-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 04/05/2018] [Indexed: 01/23/2023]
Abstract
PURPOSE There are two widely used distal humerus fracture (DHF) fixation methods with either orthogonal or parallel double-plate osteosynthesis. However, biomechanical studies have shown inconsistent results on which technique is more effective. We performed a meta-analysis to compare these two fixation methods for adult DHF fixation. METHODS We searched the literature for entries discussing the biomechanical testing of orthogonal and parallel fixation techniques for DHFs. We then performed a meta-analysis of the following biomechanical outcome measures: axial/sagittal/coronal/torsional stiffness, load to failure, and torque to failure. RESULTS Seventeen studies comparing both constructs were included. The parallel configuration exhibited greater mechanical strength with respect to axial stiffness/load to failure, torsional stiffness, and posterior bending load to failure than the orthogonal constructs. Subgroup analysis revealed that parallel constructs also had higher torsional stiffness in supracondylar fractures. CONCLUSIONS This meta-analysis shows that parallel constructs provide greater axial stiffness, axial strength, and torsional stiffness than orthogonal plate for DHF fixation. A subgroup analysis revealed that parallel constructs had better torsional stiffness in supracondylar fracture fixation. LEVEL OF EVIDENCE IA.
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Intra-articular fractures of the distal humerus-a review of the current practice. INTERNATIONAL ORTHOPAEDICS 2018; 42:2653-2662. [PMID: 29404666 DOI: 10.1007/s00264-017-3719-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Abstract
Intra-articular fractures of the distal humerus are complex injuries that can considerably limit elbow function if not treated appropriately. Surgical management is indicated for most intra-articular distal humerus fractures with the goal of restoring elbow range of motion and function. Open reduction and internal fixation (ORIF) with plates and screws has been the preferred surgical option. Double plating is recommended for bicolumnar fractures and plates can be applied either parallel or orthogonal to each other. Surgical approach for ORIF of the distal humerus can be performed through an olecranon osteotomy, but other approaches that preserve the olecranon are also in use, such as the triceps-reflecting, triceps-splitting, paratricipital, and triceps-reflecting anconeus pedicle approach. The ulnar nerve is identified during the approach, followed by either in situ decompression or anterior transposition. Elbow arthroplasty has also emerged as a viable alternative to ORIF for fixation of these fractures in elderly patients with poor bone quality.
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Evaluation of risk factors for stiffness after distal humerus plating. INTERNATIONAL ORTHOPAEDICS 2018; 42:921-926. [PMID: 29392385 DOI: 10.1007/s00264-018-3792-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE In distal humerus fractures, the goal is to achieve a functional range of motion of 30°-130° which is not always possible. The aims of the study were to evaluate the functional results after distal humerus fracture operation and to investigate the risk factors for stiffness. METHODS Between 2005 and 2014, 75 patients with the mean age of 37.8 years (17-80) underwent open reduction and plate fixation for distal humerus fractures. Range of motion (ROM), Mayo elbow performance scores, and quick DASH scores were used for functional evaluation. Patients were divided into two groups according their ROM. Group 1 had > 100° of extension-flexion ROM and group 2 had < 100°. Older age (> 60), AO type C2-3 fracture, open fracture, longer injury-surgery interval, type of plating, and presence of olecranon osteotomy were investigated as risk factors for poor outcome. RESULTS At a mean follow-up of 25 months (6-80), 40 patients were in group 1 and 35 patients were in group 2. Group 1 had significantly better functional scores than group 2. AO type C2 and C3 fracture (odds ratio (OR) 16.6, p < 0.0001) and injury-surgery interval longer than 7 days (OR 2.59, p 0.047) were found as significant risk factors for stiffness. CONCLUSIONS Patients who had distal humerus fracture should be informed about the risk of elbow stiffness especially in AO type C2-C3 fractures and surgical treatment should be planned without any delay.
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Beazley JC, Baraza N, Jordan R, Modi CS. Distal Humeral Fractures-Current Concepts. Open Orthop J 2017; 11:1353-1363. [PMID: 29290875 PMCID: PMC5721312 DOI: 10.2174/1874325001711011353] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 11/22/2022] Open
Abstract
Background: Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation. Methods: A literature search was performed and the authors’ personal experiences are reported. Results: This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate orientation, transposition of the ulnar nerve and the role of elbow arthroplasty. Conclusion: Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes.
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Affiliation(s)
- James C Beazley
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Njalalle Baraza
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Robert Jordan
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Chetan S Modi
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
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Ul Islam S, Glover AW, Waseem M. Challenges and Solutions in Management of Distal Humerus Fractures. Open Orthop J 2017; 11:1292-1307. [PMID: 29290867 PMCID: PMC5721336 DOI: 10.2174/1874325001711011292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/02/2017] [Accepted: 10/05/2017] [Indexed: 11/22/2022] Open
Abstract
Background Management of distal humerus fractures remains a challenge for trauma surgeons and advancements in treatment options continue to be made to achieve the best results for patients presenting with these complex fractures. Our aim in this article is to provide the surgeons with a detailed review of current literature to help them make an evidence based decision when faced with managing such complex injuries in their surgical practice. Methods This is a comprehensive review of the current literature that details various aspects of distal distal humerus fractures such as classification, surgical anatomy, surgical approaches, treatment options, choices of devices, outcomes and complications. Results With the advancements in techniques and equipment, there has been improvement in patients' outcomes following surgical management of these fractures and a large proportion of these patients are able to achieve pre-injury level of function. The contoured locking plates have enabled successful fixation of many of these fractures that were previously considered unfixable. For those not amenable to surgical fixation, total elbow arthroplasty and elbow hemiarthroplasty are considered as good alternatives. Conclusion Since the days where the 'bag of bones' technique was the preferred method of treating these complex injuries, techniques and outcomes have advanced greatly. However, they still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.
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Affiliation(s)
- Saif Ul Islam
- Macclesfield District General Hospital, Cheshire, United Kingdom
| | | | - Mohammad Waseem
- Macclesfield District General Hospital, Cheshire, United Kingdom
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Pantalone A, Vanni D, Guelfi M, Belluati A, Salini V. Double plating for bicolumnar distal humerus fractures in the elderly. Injury 2017; 48 Suppl 3:S20-S23. [PMID: 29025604 DOI: 10.1016/s0020-1383(17)30652-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Distal humerus fractures are uncommon injuries requiring specific clinical and radiographic analysis in order to plan the optimal therapeutic strategy. In particular, bicolumnar distal humerus fractures (Type A2, A3 and C) are complex fractures. In the last years, double plating fixation became the standard treatment: this procedure helped surgeons to obtain a stable and anatomical fixation and an early mobilization, which is the main outcome for obtaining valuable functional results. In this retrospective study, we evaluated the use of open bicolumnar 90-90 plating for fixation of acute fragility fractures of the distal humerus in elderly patients, using the olecranon osteotomy as surgical approach.
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Affiliation(s)
- Andrea Pantalone
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy
| | - Daniele Vanni
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy
| | - Matteo Guelfi
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy
| | | | - Vincenzo Salini
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy.
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Abstract
Distal humerus fractures present complex challenges in the elderly patient. These fractures often occur in patients who are living independently but have poor bone quality and low physiologic reserve, thus complicating management decisions and treatment. The goal is a painless, functional, stable elbow that allows completion of the activities of daily living. Nonsurgical management is reserved for those who cannot tolerate surgery. Open reduction and internal fixation is the preferred choice in fractures amenable to rigid fixation and early motion. Although total elbow arthroplasty provides improved early function and similar overall outcomes in appropriately selected patients, it has the potential to cause devastating complications. With modern technology and treatment principles, as well as early definitive treatment by an experienced specialist, predictable return to function can be expected.
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