Wound complications after distal humerus fracture fixation: incidence, risk factors, and outcome

Risk factors for dysfunctional elbow stiffness following operative fixation of distal humerus fractures

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.

AO/OTA B and C articular fractures of the distal humerus: What are the boundaries between Total Elbow Arthroplasty and ORIF?

BACKGROUND

Nowadays, an increasing number of Total Elbow Arthroplasty (TEA) surgeries have been selected as the primary intervention for distal humerus joint fractures. TEA has demonstrated favorable outcomes in elderly osteoporotic patients and has been associated with fewer complications and reduced stiffness when compared to Open Reduction Internal Fixation (ORIF) surgeries. This retrospective cohort study aimed to analyze differences in terms of functional outcomes, complications, and reoperation rates of distal fractures of the humerus treated with ORIF and TEA.

METHODS

This is a retrospective cohort study.

INCLUSION CRITERIA

Closed intra-articular fractures of the distal humerus (AO/OTA type 13B and 13C); age greater than 50 years; clinical and radiological follow-up of at least 2 years. Patients were divided into two groups according to surgical treatments: ORIF and TEA. The following variables were obtained: age, sex, affected side, AO/OTA classification, follow-up time, approach, surgery duration, Range Of Motions, MEPI (Mayo Elbow Performance Index), QUICK DASH (Disability of the Arm, Shoulder, and Hand), post-operative VAS (Visual Analog Scale), satisfaction rate, complications and reoperation rates. Differences in data averages between the groups were assessed, and a correlation between age and other variables in each group was calculated.

RESULTS

83 subjects (26 men and 57 women) were eligible and selected for the study. Average age and follow-up time were 74.8 years (+-10.6) and 83.6 months (+-42.6). Group TEA consisted of 41 patients (37 female, 4 male), mean age of 78.8 (+-8.6) with follow-up time of 83,6 months (+-42.6). Group ORIF consisted of 42 subjects (20 female, 22 male), mean age of 71.1 (+-11.6) with follow-up time of 70,6 months (+-40,6) The cohorts didn't differ significantly with any variables calculated (p > 0.05) except for complication and reoperation rates, which were significantly lower in the TEA group. Age didn't have a correlation trend associated with the variables in either group assessed independently (p > 0.05).

CONCLUSIONS

The results of the study, may guide in choosing a surgical option for distal humerus fractures in the elderly by considering TEA an alternative that is comparable to ORIF, and in selected cases an alternative that overall provides greater assurance than ORIF.

Clinical outcomes of olecranon sled fixation in patients with Mayo type II olecranon fractures

Background

Tension band wiring and plate fixation are common internal fixation methods used for olecranon fractures, but complications and reoperations are common. The purpose of this study is to investigate the clinical outcomes of displaced olecranon fractures treated with olecranon sled internal fixation.

Methods

The data of 39 patients with olecranon fractures treated with olecranon sled in the Department of Traumatology of Beijing Jishuitan Hospital between May 2018 and April 2020 were retrospectively analyzed. There were 17 males and 22 females; the mean age was 44.0 ± 15.8 (range, 18-68 years). Preoperative olecranon fractures were classified according to the Mayo classification: 24 cases were type IIA and 15 cases were type IIB. Elbow range of motion (extension and flexion) and forearm rotation (protonation and supination) were observed at the last follow-up. The Mayo elbow performance score (MEPS), Disabilities of the arm, shoulder and hand (DASH) and visual analogue scale (VAS) scores were used to evaluate elbow function and pain, and complications were also recorded.

Results

Thirty-nine patients were followed up for 33.6 ± 8.3 months (range, 25-51 months) after the operation. At the last follow-up, the mean flexion-extension arc was 137° ± 15° (range, 60°-160°), and the mean pronation-supination arc was 178° ± 4° (range, 160°-180°). The mean MEPS was 94.9 ± 9.9 (range, 50.0-100.0). The mean DASH score was 5.4 ± 4.3 (range, 0-18.3). The mean VAS score was 0.4 ± 0.8 (range, 0-3). Seven patients developed olecranon skin irritation, and 3 of them had the internal fixation device removed. Two patients developed heterotopic ossification, of whom 1 patient suffered elbow stiffness.

Conclusion

Olecranon sled internal fixation has good clinical outcomes in the treatment of Mayo type II olecranon fractures with a low rate of reoperations.

Analysis of the associated factors in postoperative wound infection following open reduction and internal fixation for elbow fracture

Postoperative wound infections (PWIs) following open reduction and internal fixation (ORIF) for elbow fractures can significantly affect patient outcomes. Identifying associated risk factors is crucial for improving clinical practices and patient care. A retrospective analysis (June 2020-June 2023) at our institution involved 90 patients who underwent elbow ORIF. Thirty patients developed PWIs (case group), compared to 60 who did not (control group). Variables like anaemia, operation duration, hospital stay, blood loss, body mass index (BMI), age, hypoalbuminemia, smoking status, diabetes mellitus and open fractures were examined. Univariate and multivariate analyses determined the impact of these variables on PWI incidence, with statistical significance set at p < 0.05. The main pathogens identified were Escherichia coli among Gram-negative bacteria (59.46%) and Staphylococcus aureus among Gram-positive bacteria (40.54%). In the univariate analysis, hypoalbuminemia, anaemia, and lifestyle factors such as smoking showed higher prevalence in patients with PWIs. However, age and length of hospital stay did not significantly influence infection rates. The multivariate analysis further elucidated that anaemia, smoking, diabetes mellitus and open fractures were independent, significant predictors of PWIs. These findings highlight the complexity of factors influencing infection risk post-ORIF, underscoring the importance of both individual health conditions and surgical complications in patient outcomes. Anaemia, smoking, diabetes mellitus and open fractures significantly increase the risk of PWI after elbow ORIF. Early identification and management of these risk factors are imperative to reduce infection rates and improve postoperative recovery.

A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options

Background

Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management.

Methods

A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates.

Results

Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)).

Discussion

Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Surgical flip-dislocation of the bicolumnar approach without olecranon osteotomy versus olecranon osteotomy in type AO 13C3 distal humeral fracture: a matched-cohort study

BACKGROUND

Our experience with the surgical flip-dislocation of the bicolumnar (SFDB) approach for type AO 13C3 humeral fractures indicates that this surgical approach can be performed safely and effectively in appropriately selected patients. We aimed to evaluate the clinical outcomes of the SFDB approach without olecranon osteotomy (OO) for type AO 13C3 distal humeral fractures.

METHODS

We retrospectively reviewed 65 cases of type AO 13C3 distal humeral fractures treated between April 2008 and July 2018; 33 patients were treated with the SFDB approach, and the remaining were treated with OO. Propensity score matching was used to control for sex, age, and the American Society of Anesthesiology score. Elbow pain, range of motion, stability, and function were assessed using the Mayo Elbow Performance Index (MEPI) and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Clinical complications, reoperation rates, and radiographic results were compared between the groups.

RESULTS

Operative time and blood loss were significantly lower in the SFDB group than in the OO group (P = 0.001, P = 0.002, respectively). At the final follow-up, the mean postoperative MEPI did not significantly differ between the groups (P = 0.628). According to Morrey's criteria, a typical functional range of elbow motion was achieved in 12 and 15 patients in the SFDB and OO groups, respectively.

CONCLUSIONS

The SFDB approach achieves superior exposure of the articular surface without injury to the extensor mechanism in type 13C3 articular surface fracture treatment. This approach also results in good early functional recovery and clinical outcomes, with a low risk of complications.

Factors Associated With 30-Day Morbidity and Mortality Following the Surgical Treatment of Olecranon Fractures

The objective of this study was to identify factors independently associated with complications, hospital readmission, reoperation, and death in the 30-day period after surgical treatment of isolated olecranon fractures. A retrospective case-control study was performed using the National Surgical Quality Improvement Program database by querying the Current Procedural Terminology code for patients who underwent surgical treatment of isolated olecranon fractures from 2011 to 2020. A total of 4404 patients were included. The main study outcomes were 30-day medical or wound complications, hospital readmission, reoperation, and death. A bivariate screen was performed for explanatory variables associated with our outcome variables, and variables with P<.1 in the bivariate screen were included in multivariable regression models. Of the 4404 patients in our cohort, 29 patients (0.7%) developed medical or wound complications, 157 patients (3.6%) were readmitted, 123 patients (2.8%) underwent reoperation, and 12 patients (0.3%) died during the 30-day postoperative period. Multivariable logistic regression analysis showed that older age, smoking, bleeding disorders, and higher American Society of Anesthesiologists classification were associated with readmission; that older age, bleeding disorders, and higher American Society of Anesthesiologists classification were associated with reoperation; and that bleeding disorders were associated with mortality. No identifiable factors were independently associated with medical or wound complications. In this National Surgical Quality Improvement Program database study of olecranon fractures treated surgically during a recent 10-year period, we identified demographic and comorbid factors independently associated with 30-day postoperative readmission, reoperation, and mortality. Our findings are relevant for preoperative risk stratification and counseling. [Orthopedics. 2023;46(5):e310-e316.].

Intrawound application of vancomycin reduces the proportion of fracture-related infections in high-risk tibial plateau fractures

INTRODUCTION

Despite the improvements in surgical techniques and the use of prophylactic intravenous antibiotics, the fracture-related infection (FRI) incidence after high-risk tibial plateau fractures remains high. This study aimed to evaluate the clinical effect of the intrawound application of vancomycin on the FRI after high-risk tibial plateau fracture surgery.

METHODS

A total of 243 patients who underwent high-risk tibial plateau fracture surgery from May 2013 to June 2021 were retrospectively reviewed. Of these, 233 cases were enrolled. Considering the preoperative patient condition, surgeons applied vancomycin powder directly into the surgical site before wound closure in 105 cases (intrawound application of vancomycin powder with preoperative intravenous cephalosporin). The remaining 128 cases served as the control group (preoperative intravenous cephalosporin alone). Clinical data and surgical details were recorded. The Cox proportional hazards regression analysis was used to assess risk factors for FRI. The Kaplan-Meier method and the log rank test illustrated the infection status of patients based on the application of intrawound vancomycin. The primary outcome was an FRI within one year. Secondary outcomes included bacterial culture and vancomycin-related complications.

RESULTS

Our study demonstrated a significant difference in the incidence of FRI between the vancomycin group and the control group (3.8% versus 10.9%; p=0.041). Multivariable Cox regression showed the intrawound application of vancomycin powder decreased the rate of FRI. There were no complications related to intrawound vancomycin observed during follow-up. The presence of Gram-positive FRI was higher in the control group compared with the vancomycin group.

CONCLUSIONS

Intrawound application of vancomycin was associated with a significant lower rate of FRI after high-risk tibial plateau fracture surgery compared to the control group.

Efficacy and safety of anterior transposition of the ulnar nerve for distal humerus fractures: A systematic review and meta-analysis

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.

Comparison of clinical outcomes of three internal fixation techniques in the treatment of olecranon fracture: a retrospective clinical study

OBJECTIVE

The application of double plating in olecranon fractures is becoming increasingly widespread. There is no research comparing this technique with traditional tension band wiring (TBW) and the single plate technique. The purpose of this study was to compare the efficacy of three fixation techniques in olecranon fractures.

MATERIALS AND METHODS

From March 2016 to May 2020, we collected the clinical data of 95 patients with olecranon fractures who underwent surgical treatment. Thirty-five patients received TBW surgery (TBW Group), 32 patients received a 3.5 mm locking compression plate (LCP, 3.5 mm LCP Group), and 28 patients received double mini-locking plate treatment (DP Group). The operation time, fracture union time, time of return to work, range of motion (ROM), soft tissue stimulation to remove internal fixation, and patient-related functional results (the Weseley score, Mayo Elbow Performance Score [MEPS], and Disabilities of Arm, Shoulder and Hand Score [DASH]) were recorded. The clinical results and complications of the three internal fixation techniques were compared.

RESULTS

The average follow-up time was 15.011.82 months (12-18 months). All patients' fractures healed by first intention. There were no statistically significant differences in the operation time, fracture union time, ROM, Weseley score, MEPS or DASH scores of the three groups of patients. The postoperative return time for patients in the TBW group was 10.002.15 weeks, the 3.5 mm LCP group was 9.561.93 weeks, and the DP group was 8.432.38 weeks (P = 0.014); 12 patients in the TBW group required removal of plant due to soft tissue stimulation, the 3.5 mm LCP group had 8 cases, and the DP group had 2 cases (P = 0.038).

CONCLUSION

The postoperative clinical results and elbow joint function of patients with olecranon fractures fixed by tension band wiring, 3.5 mm LCP and double mini-locking plate are similar, which indicates that double-plate technology can be used as an alternative to the two groups of traditional techniques. In addition, double-plate technology also helps patients return to work earlier and has a lower incidence of soft tissue stimulation.

Bilateral triceps tendon approach is flexible and efficient in the treatment of type C distal humerus fractures

PURPOSE

The purpose of this study was to assess and compare elbow range of motion, triceps extension strength and functional results of type C (AO/OTA) distal humerus fractures treated with bilateral triceps tendon (BTT) approach and olecranon osteotomy (OO). At the same time, we are also trying to know whether BTT approach can provide sufficient vision for comminuted intra-articular fractures of the distal humerus, and whether it is convenient to convert to the treatment to total elbow arthroplasty (TEA) or OO.

METHODS

Patients treated with OO and BTT approaches for type C distal humerus fractures between July 2014 and December 2017 were retrospectively reviewed. Inclusion criteria include: (1) patients' age were more than 18 years old, (2) follow-up was no less than 6 months, and (3) patients were diagnosed with type C fractures (based on the AO/OTA classification). Exclusion criteria include: (1) open fractures (Gustillo type 2 or type 3), (2) treated by other approaches, and (3) presented with combined injuries of ipsilateral upper extremities, such as ulnar nerve. Elbow range of motion and triceps extension strength testing were completely valuated, when the fractures had healed. Assessment of functional results using the Mayo elbow performance score and complications were conducted in final follow-up. The data were compared using the two tailed Student's t-test. All data were presented as mean ± standard deviation.

RESULTS

Eighty-six patients of type C distal humerus fractures, treated by OO and BTT approach were retrospectively reviewed between July 2014 and December 2017. Fifty-five distal humerus fractures (23 males and 32 females, mean age 52.7 years) treated by BTT approach or OO were included in this study. There were 10 fractures of type C1, 16 type C2 and 29 type C3 according to the AO/OTA classification. Patients were divided into two surgical approach groups chosen by the operators: BTT group (28 patients) and OO group (27 patients). And the mean follow-up time of all patients was 15.6 months (range, 6-36 months). Three cases in BTT group were converted to TEA, and one converted to OO. Only one case in BTT group presented poor articular reduction with a step more than 2 mm. There were not significantly different in functional outcomes according to the Mayo elbow performance score, operation time and extension flexion motion are values between BTT group and OO group (p > 0.05). Complications and reoperation rate were also similar in the two groups. Triceps manual muscle testing were no significant difference in the two groups, even subdivided in elder patients (aged >60 years old).

CONCLUSION

BTT is a safe approach to achieve similar functional result comparing with OO. BTT were not suitable for every case with severe comminuted pattern, but it avoids the potential complications related to OO, and has no complications concerning with triceps tendon. It is convenient for open reduction internal fixation and flexible to be converted to OO, as well as available to be converted to TEA in elder patients.

Complications of olecranon osteotomy in the treatment of distal humerus fracture

Distal humerus fractures (DHFs) are challenging to treat due to the locally complex osseous and soft tissue anatomy. Adequate exposure of the articular surface of the distal humerus is crucial when performing an anatomical reconstruction of the elbow. Even though “triceps-on” approaches are gaining popularity, one of the most commonly used surgical treatments for DHF is olecranon osteotomy. The incidence of complications related to this approach is unclear. This review was performed to assess the type and frequency of complications that occur with the olecranon osteotomy approach in the treatment of DHF. A literature search was conducted in the PubMed/Medline, Embase, and Cochrane Library digital databases up to February 2020. Only English articles describing complications of olecranon osteotomy in the treatment of DHF were included. Data on patient and surgical characteristics and complications were extracted. Statistical analysis was performed using SPSS. A total of 41 articles describing 1,700 osteotomies were included, and a total of 447 complications were reported. Of these 447 complications, wound infections occurred in 4.2% of osteotomies, of which 1.4% were deep infections and 2.8% were superficial. Problems related with union occurred in 3.7% of osteotomies, 2% of which represented non-union and 1.7% delayed union. The high risk of complications in olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of DHF.

Proximal Ulna Osteotomy for Complex Fractures of the Distal Humerus: A 3-Dimensional Laser Analysis and Comparison With Olecranon Osteotomy

PURPOSE

The current methods of distal humerus (DH) articular surface visualization only allow a limited view of the joint. This study describes an osteotomy procedure that increases the visualization of and access to the DH articular surface for fixation without compromising ligaments.

METHODS

Eighteen fresh-frozen human elbows (9 matched pairs) underwent proximal ulna osteotomy (PUO) or transverse olecranon osteotomy (OO) contralaterally. The visualized articular surface of the DH was demarcated, and the surface areas of the DH, capitellum, and trochlea were measured using 3-dimensional scanning. The angular arc of the articular surface of the capitellum and trochlea was measured using a goniometer.

RESULTS

The 3-dimensional scans showed that 87.6% of the total DH surface area was visualized using PUO versus 65.6% using OO. When the trochlea and capitellum surface areas were separated, 94.0% versus 75.9% of the trochlea and 74.8% versus 44.7% of the capitellum were visualized using PUO and OO, respectively. The goniometric angles demonstrated that 98.2% versus 70.9% of the trochlea and 75.1% versus 43.5% of the capitellum articular surface arc angles were visualized using PUO and OO, respectively. After PUO with further release of the flexor-pronator mass was performed, 100% of the DH articular surface was visualized.

CONCLUSIONS

Proximal ulnar osteotomy improves the visualization of the DH articular surface.

CLINICAL RELEVANCE

Proximal ulna osteotomy spares ligaments, avoids osteotomizing the greater sigmoid notch, involves more robust metaphyseal bone for potentially better fixation, and may permit DH arthroplasty without compromising primary ligamentous elbow stabilizers. Further clinical studies are needed to assess the utility of this type of osteotomy.

Predictors of reoperation after internal fixation of intra-articular distal humerus fractures

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.

Biomechanical comparison between double-plate fixation and posterior plate fixation for comminuted olecranon fracture using two triceps screws in synthetic bone model

BACKGROUND

Although preventing triceps fragment displacement is essential for treating an olecranon fracture, we frequently encounter situations in which only a few screws can be fixed to the triceps fragment. The aim of this study was to compare the stability of double-plate fixation and posterior plate fixation for olecranon fractures when the triceps fragment was small and only 2 screws could be inserted.

METHODS

A composite ulna model was used to simulate olecranon fracture. Four groups were formed consisting of double-plate and posterior plates with cortical and locking screws. The cyclic loading test was conducted for 500 cyclic loads of 5 to 50 N on a specimen to measure micromotion and displacement of the gap caused by light exercise. The load-to-failure test was performed by applying a load until fixation loss, defined as when the fracture gap increased by 2 mm or more or catastrophic failure occurred, to measure the maximum load.

RESULTS

Eight samples per group were tested through the pilot study. All groups were stable with a micromotion of <0.5 mm. However, the mean micromotion showed significant differences between the 4 groups (P < .001, Table 1). In the mean micromotion during exercise, posterior plating with cortical screws was the most stable (0.09 ± 0.02 mm) while double-plating with cortical screws was the most unstable (0.42 ± 0.11 mm). At the maximum load, posterior plating with locking screws was the strongest (205.3 ± 2.8 N) while double-plating with cortical screws was the weakest (143.3 ± 27.1 N). There was no significant difference in displacement after light exercise between the groups.

CONCLUSIONS

This study showed that when 2 triceps screws were used, both groups were stable during light exercise, but posterior-plating was stronger than double-plating.

Low-profile double plating of unstable osteoporotic olecranon fractures: a biomechanical comparative study

BACKGROUND

In the treatment of unstable olecranon fractures, anatomically preshaped locking plates exhibit superior biomechanical results compared with tension band wiring. However, posterior plating (PP) still is accompanied by high rates of plate removal because of soft-tissue irritation and discomfort. Meanwhile, low-profile plates precontoured for collateral double plating (DP) are available and enable muscular soft-tissue coverage combined with angular-stable fixation. The goal of this study was to biomechanically compare PP with collateral DP for osteosynthesis of unstable osteoporotic fractures.

METHODS

A comminuted displaced Mayo type IIB fracture was created in 8 osteoporotic pairs of fresh-frozen human cadaveric elbows. Pair-wise angular stable fixation was performed by either collateral DP or PP. Biomechanical testing was conducted as a pulling force to the triceps tendon in 90° of elbow flexion. Cyclical load changes between 10 and 300 N were applied at 4 Hz for 50,000 cycles. Afterward, the maximum load was raised by 0.02 N/cycle until construct failure, which was defined as displacement > 2 mm. Besides failure cycles and failure loads, modes of failure were analyzed.

RESULTS

Following DP, a median endurance of 65,370 cycles (range, 2-83,121 cycles) was recorded, which showed no significant difference compared with PP, with 69,311 cycles (range, 150-81,938 cycles) (P = .263). Failure load showed comparable results as well, with 601 N (range, 300-949 N) after DP and 663 N (range, 300-933 N) after PP (P = .237). All PP constructs and 3 of 8 DP constructs failed by proximal fragment cutout, whereas 5 of 8 DP constructs failed by bony triceps avulsion.

CONCLUSION

Angular-stable DP showed comparable biomechanical stability to PP in unstable osteoporotic olecranon fractures under high-cycle loading conditions. Failure due to bony triceps avulsion following DP requires further clinical and biomechanical investigation, for example, on suture augmentation or different screw configurations.

Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications

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.

A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty

Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions. In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.

[Sub- and intercondylar fractures of the distal humerus in adults]

Introduction

les fractures articulaires complètes de l’extrémité inférieure de l’humérus de l’adulte sont des lésions rares et graves. Les options thérapeutiques sont nombreuses mais le traitement chirurgical par ostéosynthèse est ardemment défendu. L’objectif de notre travail a été de décrire les caractéristiques épidémiologiques, clinico-radiologiques et thérapeutiques de ces fractures, ainsi que d’évaluer les résultats fonctionnels obtenus chez nos patients.

Méthodes

nous avons mené une étude prospective sur une période de 3 ans, portant sur 38 patients admis pour fracture articulaire complète sus et inter-condylienne de l’humérus distal (classée type C selon la classification de l’AO), traités chirurgicalement par voie postérieure trans-olécranienne avec un recul moyen de 34 mois.

Résultats

nous avons remarqué une distribution bimodale avec une atteinte du sujet jeune de sexe masculin d’une part, et une survenue chez les femmes âgées d’autre part. Les étiologies étaient dominées par les accidents de la voie publique chez 78%. Lors du suivi, nous avons noté un seul cas d’infection superficielle du site opératoire et il n’y a eu aucun cas de démontage du matériel ni de pseudarthrose. De surcroit, aucune complication de l’ostéosynthèse de l’olécrane n’a été enregistrée. Les résultats fonctionnels ont été très satisfaisants avec un score de Mayo-Clinic Elbow Performance Score (MEPS) moyen de 86.

Conclusion

nous considérons que la voie postérieure trans-olécranienne semble être la meilleure voie d’abord de ces fractures puisqu’elle permet une bonne exposition articulaire, condition sine qua non pour une restitution anatomique parfaite et une ostéosynthèse stable afin d’entreprendre une rééducation précoce et adaptée.

Analysis of Factors Affecting Return to Work After Surgical Treatment in Patients with AO Type C Distal Humerus Fractures

BACKGROUND

The purpose of this study is to evaluate the functional results of distal humerus fractures which were treated by open reduction and fixation with pre-contoured angular stable plates in young patients, and investigate whether the patients could return to their pre-injury work and patients' financial conditions while they were not working.

MATERIALS AND METHODS

The data of 48 patients, ages between 18 and 55 years, working in a job and having AO/OTA type C distal humerus fracture were retrospectively evaluated. Mayo Elbow Performance Score (MEPS) was used to determine functional results. Postoperative radiographs were evaluated to determine the rate of union, degenerative changes, malunion and heterotopic ossification. Financial outcome form was constituted by the authors and the patients asked whether she/he could return to their pre-injury works after treatment finished and the financial status of the patients during the treatment and after the treatment.

RESULTS

The mean flexion-extension arc was 114° ± 12°(range 85°-135°) and the mean MEPS score was 85 ± 11(range 65-100). The average time to return to work was 6.5 ± 2.4 months (3-12 months). AO type C2 and C3 fractures and heterotopic ossification negatively affected the functional results and also adversely affected the patients' return to their pre-injury works. 38 (79%) patients returned to pre-injury work and 29 (76%) of them started to work at the same position before the fracture occured. Nine of 38 patients (24%) had to change their positions. Among the 48 patients, 10 patients (21%) could not return to the same work, 7 of them found light duty and 3 of them had not been to work.

CONCLUSION

Although the functional results of surgical treatment of intra-articular distal humerus fractures are good, at the end of the treatment, especially heavy workers may have difficulties in returning to their former works.

Correlation between modified trochleocapitellar index and post-traumatic elbow stiffness in type C2-3 distal humeral fractures among adults

BACKGROUND

The purpose of this study was to propose the modified trochleocapitellar index (mTCI), assess its reliability, and evaluate its correlation with post-traumatic elbow stiffness in type C2-3 distal humeral fractures among adults.

METHODS

From January 2013 to June 2017, a total of 141 patients with type C2-3 distal humeral fractures were included. The mTCI was calculated as the ratio between the modified trochlear and capitellar angles relative to the humeral axis (mTCI-HA), lateral humeral line (mTCI-LHL), and medial humeral line (mTCI-MHL) from anteroposterior radiographs taken immediately after the operation. The patients were divided into group A (with elbow stiffness) and group B (without elbow stiffness) based on follow-up results. To determine risk factors for elbow stiffness, univariate and logistic regression analyses were performed on each radiographic parameter separately, together with other clinical variables. Interrater reliability was assessed for all measurements.

RESULTS

Specific optimal ranges of value were identified for mTCI-HA (0.750-0.875), mTCI-LHL (0.640-1.060), and mTCI-MHL (0.740-0.900), beyond which the likelihood of elbow stiffness significantly increased (P < .001). By multivariate analysis, mTCI-HA (odds ratio [OR] 26.22, 95% confidence interval [CI] 3.39-203.07, P = .002), mTCI-LHL (OR 5.37, 95% CI 2.17-13.28, P < .001), and mTCI-MHL (OR 5.95, 95% CI 1.91-18.56, P = .002) values beyond the optimal ranges were identified as the independent risk factors for elbow stiffness. The interrater reliability of mTCI-HA, mTCI-LHL, and mTCI-MHL was 0.986, 0.983, and 0.987, respectively.

CONCLUSION

The mTCI measurement method is reliable. Either too small or too large mTCI values were associated with post-traumatic elbow stiffness among adult patients with type C2-3 distal humeral fractures. The mTCI-HA showed a better predictive value than mTCI-LHL and mTCI-MHL.

Elbow Fractures

The elbow joint consists of the humeroulnar, humeroradial, and proximal radioulnar joints. Elbow stability is maintained by a combination of static and dynamic constraints. Elbow fractures are challenging to treat because the articular surfaces must be restored perfectly and associated soft tissue injuries must be recognized and appropriately managed. Most elbow fractures are best treated operatively with restoration of normal bony anatomy and rigid internal fixation and repair and/or reconstruction of the collateral ligaments. Advanced imaging, improved understanding of the complex anatomy of the elbow joint, and improved fixation techniques have contributed to improved elbow fracture outcomes.

Predrilled locking compression plate is more accurate than tension band wiring in restoring articular geometry of the ulnar greater sigmoid notch after olecranon Chevron osteotomy

INTRODUCTION

The olecranon Chevron osteotomy (OCO) is commonly used to approach complex intra-articular fractures of the distal humerus. Predrilled tension band wiring (TBW) has historically been used to fix OCO. However, clinical outcomes are burdened by secondary loss of reduction and up to 21.3% non-union rates. The biomechanical stability of anatomic locking compression plate (LCP) was reported to be superior to TBW in olecranon fracture fixation. We hypothesised that this implant may also be superior to TBW in the anatomic reconstruction of the articular surfaces of the ulnar greater sigmoid notch after OCO by predrilling the holes of the angular stable plate with the threaded drill guide prior to osteotomy.

MATERIALS AND METHODS

Lateral standardised and calibrated radiographs of twenty synthetic ulnar bones were obtained using a custom-made holder prior to preparation by a senior orthopaedic trauma surgeon. Ten specimens were then predrilled using the threaded drill bit guide of an olecranon LCP, while the other ten samples were predrilled with two 1.6 mm Kirschner wires. A distal "V" OCO was performed using a 0.6 mm oscillating saw. After repositioning and fixation with the corresponding device, lateral radiographs were repeated. Two independent observers used the TraumaCad planning software to document the articular geometry of the ulnar greater sigmoid notch pre- and postoperatively. The diameter of the best-fitting circle (diameter), the distance between the tip of the coronoid and the olecranon processes (distance) and the maximum articular depth were measured.

RESULTS

With the TBW technique, after OCO and fixation, all three postoperative measurements were significantly (p≤0.001) different from preoperative measurements. The diameter and distance increased by a mean of 1.5±0.5 mm and 0.9±0.3 mm, respectively, while the depth decreased by a mean of 0.2±0.1 mm. In contrast, no significant differences between pre- and postoperative measurements were observed with the LCP technique (p≥0.13). Inter and intra-observer measurement reliability was strong to very strong (intraclass correlation coefficients≥0.793) for all three variables.

CONCLUSION

Our study reveals that the predrilled LCP technique is more accurate than the predrilled TBW in restoring the anatomic articular geometry of the ulnar greater sigmoid notch after OCO.

Surgical Approach and Internal Fixation Techniques for Intra-Articular Distal Humerus Fracture With Coronal Shear Capitellar Fracture

Intra-articular distal humerus fractures with an associated coronal shear capitellar fragment present a challenge for stable internal fixation. Adequate visualization and fixation of the capitellar shear fragment are difficult to achieve with conventional exposures, including the olecranon osteotomy. The capitellar fragment often translates anterior and proximally and is challenging to visualize with intact soft tissue attachments from a posterior approach. We describe a surgical exposure that releases the lateral ulnar collateral ligament in addition to an olecranon osteotomy to allow complete visualization of the entire articular surface. In contrast to an isolated capitellar fracture, the column stability and the posterior cortex are frequently disrupted with distal humerus fractures. Depending on the comminution of the posterior cortex, a supplemental posterolateral plate or headless compression screws can provide fixation to the coronal fracture plane. The lateral ulnar collateral ligament is repaired at the conclusion of fracture stabilization through a bone tunnel or to the plate to restore lateral stability. Despite the release of the ligament and additional soft tissue stripping, there were no cases of elbow instability or avascular necrosis in our case series of 9 patients.

Brachioradialis muscle flap for posterior elbow defects: a simple and effective solution for the upper limb surgeon

BACKGROUND

Trauma, infection, and posterior surgical approach are the most frequent causes of soft tissue defects of posterior elbow. The brachioradialis (BR) muscle flap is a rotational muscular pedicled flap, and the dominant vascular pedicle arises from the radial recurrent artery in the proximal portion of the muscle. The aim of the study was to present the BR muscle flap as a simple, safe, and effective solution for the treatment of soft tissue defects of the posterior elbow.

METHODS

Five patients (3 males; mean age, 61.4 years; range, 40-73 years) with soft tissue defects of the posterior elbow underwent surgical treatment with the BR muscle flap. The causes of the defects were total elbow arthroplasty and postsurgical infection (n = 2), 1 patient with elbow arthrodesis due to neuropathic arthropathy, and postsurgical infection after open reduction and internal fixation of olecranon fractures (n = 2). All patients had a BR muscle flap and skin grafting. Orthopedic hardware was removed in 3 cases.

RESULTS

At the mean follow-up of 45 months (range, 26-61 months), all patients had viable and functional soft tissue coverage. All patients were free of infection, whereas 1 patient had a posterior elbow discomfort in daily activities. None of the patients reported wrist problems.

CONCLUSIONS

The BR muscle flap is a reliable solution, easy to harvest without requiring microsurgical expertise for small-size posterior elbow defects. It is a 1-stage procedure with no morbidity to the harvest site that provides stable and adequate coverage even in cases with postoperative infection.

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

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.

Olecranon Osteotomy Approach for Complex AO-13C Fractures of Distal Humerus: A Prospective Analysis of 24 Cases

Introduction: Olecranon osteotomy is well described approach for complex intra-articular distal humeral fractures. In this study, we investigated the usefulness and complications of olecranon osteotomy approach for such fractures. We hypothesise that outcome is comparable in young adults and middle age group and also functional outcome is independent of fracture subtype following surgical fixation.

Materials and Methods: Between December 2012 and September 2015, twenty-four adult patients (male: 15, female: 9) having mean age of 41.4 years with closed intra-articular fracture (AO-13C) were surgically managed using olecranon osteotomy approach and were followed-up for a mean of 28.5 months (range: 22-35 months). Functional outcome was measured using Mayo Elbow Performance Score (MEPS) and complications were observed. Statistical analysis was done using Student t-test and Kruskal Wallis test.

Results: All fractures united by the end of three months. Mean elbow flexion achieved was 123°, mean extension lag was 9° and mean active arc of motion was 114°. Mean MEPS was 87 (excellent: 8, good: 14, fair: 1 and poor: 1). Post-operative transient ulnar nerve palsy was noted in two cases, heterotopic ossification (HO) was in one case, infection in two cases, implant prominence in five and elbow stiffness in three cases. Motion arc was higher in young adults and MEPS was comparable in both age group. Functional outcome was also dependent on fracture subtype. Conclusion: The olecranon osteotomy approach for distal humerus fractures had good functional outcome with fewer complications. Joint congruity and fixation could easily be assessed intraoperatively.

Comparison of biomechanical characteristics in treatment of distal humerus fracture using different fixation plates: A finite element study

With the development of digital technology of orthopedics, personalized plate has been applied to treat different kinds of fractures. However, no studies of personalized implants in the treatment of distal humeral fractures have been reported. Therefore, we design a personalized anatomical locking plate (DPALP) to treat distal humerus fracture of adult. The model of humerus and personalized plate and traditional Y-shaped compression plate (YCP) was built and analyzed by finite element method. We found that peak value of stress of humerus fixed by YCP is higher than that of DPALP, and the peak value of stress of screws used in DPALP group is higher than that of YCP. Meanwhile, peak of displacement of YCP is higher than that of DPALP, and the peak value of displacement of humerus bone is higher than that of YCP. The patient with DPALP had a good clinical outcome (83) evaluated with Broberg and Morrey Score. Our results show that DPALP and YCP could get similar mechanical and clinical results for distal humorous intra-articular fractures, and stress distribution of DPALP group is more balanced, and it takes less time in the operation. Furthermore, DPALP can perfectly fit the humeri and achieve the anatomical reduction. In general, DPALP is more suitable for patients with intra-articular complicated fractures. Our findings will benefit clinicians treating distal humeral fractures and provide an alternative option.

Complications of open reduction and internal fixation of distal humerus fractures

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

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

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

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

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

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

A new local muscle flap for elbow coverage-the medial triceps brachii flap: anatomy, surgical technique, and preliminary outcomes

BACKGROUND

The medial triceps brachii is vascularized by the middle collateral artery and the arterial circle of the elbow. This vascularization allows a distal pedicled use to cover soft tissue defects of the elbow. We report our experience using this flap to cover traumatic and postsurgical wounds.

METHODS

Patients who underwent a pedicled medial triceps brachii flap procedure between 2008 and 2015 were included. Data concerning characteristics of the patients, wound size, surgical technique, and complications were retrospectively reviewed. An independent observer examined patients and assessed outcome of the coverage procedure: wound healing, scar length, range of elbow motion, and patient satisfaction.

RESULTS

Eight patients were included (70.6 ± 17.7 years old at the time of surgery). All patients had serious comorbidities and risk factors of poor wound healing. Defects were due to postoperative healing complications (5 patients), skin necrosis secondary to an underlying olecranon fracture (1 patient), and direct open fractures (2 patients). Soft tissue defects had a median surface of 17 (14-22) cm². The olecranon was exposed in 7 cases and the medial humeral epicondyle in 1 case. Mean procedure duration was 83 ± 14 minutes. There was no intraoperative or postoperative complication. All patients healed properly at 3 weeks of follow-up. No wound recurrence or surgery-related complication was reported after a median follow-up of 40.5 (21.5-69.5) months.

CONCLUSION

Favorable outcomes in all of our 8 patients make this flap an interesting option to cover small to medium-sized defects of the posterior aspect of the elbow.

Evaluation of risk factors for stiffness after distal humerus plating

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.

The challenging surgical treatment of closed distal humerus fractures in elderly and octogenarian patients: radiographic and functional outcomes with a minimum follow-up of 24 months

INTRODUCTION

The main purpose of this retrospective, non-randomized, case series study was to evaluate the clinical and radiographic outcomes of distal humerus fractures (DHFs) in a consecutive series of elderly patients operatively treated by two surgeons, and second, to identify proper indications for two elderly age ranges and two fracture pattern groups.

MATERIALS AND METHODS

From January 2009 to June 2014, 51 patients (pts) underwent open reduction and internal fixation (ORIF) using the locking compression plate (LCP) distal humerus plate (DHP) system at our institution. Medical records and radiographs were retrospectively assessed. Patients were divided into 3 groups according to gender, age (pts <85 years, pts ≥85 years) and AO classification (13-B1-B2-C1-C2 or 13-C3). All subjects completed MEPS, Quick-DASH and SF-36 PCS/MCS scores at final follow-up, and statistical analysis was performed.

RESULTS

36 patients (20 women, 16 men), mean age 80.3 years, with AO type 13-B and 13-C DHFs were included with a mean follow-up of 56 months (range 24-92). The most common mechanism of trauma was a fall from ground level (55.6%). The mean MEPS was 78.9 points, Quick-DASH 28.4, SF-36 PCS 48.3 and MCS 48.9. There was statistically significant evidence that having a 13-C3 fracture leads to worse results in MEPS, Quick-DASH and SF-36. The female gender correlates with worse results in SF-36. The patients ≥85 years had a worse prognosis according to Quick-DASH and SF-36, while the AO 13-C3 pattern obtained the worst ROM outcomes versus AO 13 B1-B2-C1-C2 (normal ROM 0°-140°): mean ROM 24°-114° vs 10°-130°, mean flexion deficit 26° vs 10°, mean extension deficit 24° vs 10°, respectively). Complications were presents in 36.1% of patients, overall belonging to the AO type 13-C fracture pattern and to the group ≥85 years.

CONCLUSION

These study data seem to confirm our hypothesis that plate fixation for DHFs guarantees adequate fracture osteosynthesis and satisfactory functional outcomes at medium to long-term follow-up, not only in elderly patients, but also in octogenarian osteoporotic patients (≥85 years) with 13-C1 and 13-C2 fracture patterns, while an alternative solution should be considered for type C3 fractures, even in a primary trauma setting.

Plate Osteosynthesis of Proximal Ulna Fractures-A Biomechanical Micromotion Analysis

PURPOSE

Double plating has been promoted, in recent years, as an alternative treatment method for proximal ulna fractures. This study aimed to compare the biomechanical properties of double-plate osteosynthesis with posterior plate fixation using a novel investigational design utilizing a 3-dimensional camera system to analyze fracture micromotion.

METHODS

Fourteen fresh-frozen specimens were available for this study. Mayo type IIA fractures of the olecranon were created and internal fixation was performed with either an angular stable posterior plate or angular stable double plates. Fracture micromotion was evaluated by means of digital image correlation with a 3-dimensional camera system before and after dynamic cyclic loading from 15° to 90° of elbow flexion with a pulling force of 25 N to 80 N.

RESULTS

Micromotion of fragments was less pronounced in double-plate osteosynthesis when compared with single plates before and after cyclic loading. However, overall results were similar. Two of the single plates failed during cyclic loading but there were no failures in the double plates.

CONCLUSIONS

This biomechanical analysis shows that single and double plating results in comparable stability of fixation. Although the double-plating technique tends to provide more stable fixation, relevant differences were not observed.

CLINICAL RELEVANCE

Double plating potentially represents an efficient option for fixation of proximal ulna fractures. It could decrease the risk of soft tissue complications owing to their low profile and the superior soft tissue coverage.

Diagnostic strategies for posttraumatic osteomyelitis: a survey amongst Dutch medical specialists demonstrates the need for a consensus protocol

Introduction

Posttraumatic osteomyelitis (PTO) is a feared complication after surgical fracture care. Late diagnosis can result in interrupted and prolonged rehabilitation programmes, inability to work, medical dependency, unnecessary hospital admissions, and high medical and non-medical costs. Primary aim of this study was to assess preferred diagnostic imaging strategies for diagnosing PTO amongst orthopaedic and trauma surgeons, radiologists, and nuclear medicine physicians. Secondary aims were to determine the preferred serum inflammatory marker for diagnosing PTO and the existence of a local hospital protocol to diagnose and manage PTO.

Materials and methods

This study utilised an online survey based on four clinical scenarios, varying from early to late onset of PTO. It was designed to assess individual practitioners’ current preferred diagnostic strategy for diagnosing PTO. Eligible study participants were medical specialists and registrars in orthopaedic and trauma surgery, musculoskeletal (MSK) radiology, and nuclear medicine.

Results

There were 346 responders: 155 trauma surgeons, 102 orthopaedic surgeons, 57 nuclear medicine physicians, and 33 MSK radiologists. Trauma surgeons favour FDG-PET to image PTO, while orthopaedic surgeons prefer WBC scintigraphy. A similar difference was seen between radiologists and nuclear medicine physicians (MRI versus nuclear medicine imaging). CRP was regarded as the most useful serum inflammatory marker. Only one-third of all responders was aware of a local hospital protocol for the treatment of osteomyelitis.

Conclusions

The availability of and awareness towards local protocols to diagnose and treat PTO is poor. The results of this study support the need for future randomised controlled trials on optimal diagnostic strategies for PTO.

[The bare area of the proximal ulna : An anatomical study on optimizing olecranon osteotomy]

BACKGROUND

Olecranon osteotomy is an established approach for the treatment of distal humerus fractures. It should be performed through the bare area of the proximal ulna to avoid iatrogenic cartilage lesions.

OBJECTIVES

The goal of this study was to analyze the anatomy of the proximal ulna with regard to the bare area and, thereby, to optimize the hitting area of the bare area when performing olecranon osteotomy.

MATERIALS AND METHODS

The bare areas of 30 embalmed forearm specimens were marked with a radiopaque wire and visualized three-dimensionally with a mobile C‑arm. By means of 3D reconstructions of the data sets, the following measurements were obtained: height of the bare area; span of the bare area-hitting area in transverse osteotomy; ideal angle for olecranon osteotomy to maximize the hitting area of the bare area; distance of the posterior olecranon tip to the entry point of the transverse osteotomy and the ideal osteotomy.

RESULTS

The height of the bare area was 4.92 ± 0.81 mm. The hitting area of the transverse osteotomy averaged 3.73 ± 0.89 mm. The "ideal" angle for olecranon osteotomy was 30.7° ± 4.19°. The distance of the posterior olecranon tip to the entry point was 14.08 ± 2.75 mm for the transverse osteotomy and 24.21 ± 3.15 mm for the ideal osteotomy. The hitting area of the bare area in the ideal osteotomy was enhanced significantly when compared to the transverse osteotomy (p < 0.0001).

CONCLUSIONS

This study provides guide values for correct osteotomy of the olecranon. Moreover, a 30° angulation of the osteotomy can significantly increase the hitting area of the bare area.

Treatment of Ipsilateral Distal Humerus and Diaphyseal Ulna Fractures by Using an Olecranon Osteotomy and Intramedullary Nail

OBJECTIVE

To evaluate the results of treatment of an osteotomy of the olecranon and an ulnar diaphyseal fracture with a single nail, in cases with an ipsilateral ulnar diaphyseal fracture and a comminuted fracture of the distal humerus.

DESIGN

Retrospective clinical study.

SETTING

University-affiliated teaching hospital.

PATIENTS

Eight patients with comminuted fractures of the distal humerus and ipsilateral ulnar diaphyseal fractures were included.

INTERVENTION

Using a transolecranon approach, internal fixation of the distal humeral fracture with medial and lateral plates was performed. The ulnar diaphyseal fracture and additional osteotomy were fixed using a locked intramedullary nail. Subjective pain assessment was performed by using a visual analog scale (VAS).

RESULTS

There were 6 (75%) male and 2 (25%) female patients, with a mean age of 40.9 (range, 32-56) years. The mean follow-up period was 24.6 (range, 12-36) months. All patients achieved union of the ulnar diaphyseal fracture and olecranon osteotomy. Union of the distal humeral fracture was observed in 7 (87.5%) patients. The mean time to union was 16.3 (range, 12-22) weeks, mean visual analog scale score was 1.8 (range, 0-3), median elbow performance score was 85 (range, 70-95), and median disabilities of the arm, shoulder, and hand score was 17.9 (range, 5-45.8).

CONCLUSIONS

Osteotomy of the olecranon and ulnar diaphyseal fracture using an intramedullary nail was a cosmetically advantageous and safe technique that enabled rehabilitation during the early postoperative period.

LEVEL OF EVIDENCE

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

What Factors are Associated With a Surgical Site Infection After Operative Treatment of an Elbow Fracture?

BACKGROUND

Surgical site infections are one of the more common major complications of elbow fracture surgery and can contribute to other adverse outcomes, prolonged hospital stays, and increased healthcare costs.

QUESTIONS/PURPOSES

We asked: (1) What are the factors associated with a surgical site infection after elbow fracture surgery? (2) When taking the subset of closed elbow fractures only, what are the factors associated with a surgical site infection? (3) What are the common organisms isolated from an elbow infection after open treatment?

METHODS

One thousand three hundred twenty adult patients underwent surgery for an elbow fracture between January 2002 and July 2014 and were included in our study. Forty-eight of 1320 patients (4%) had a surgical site infection develop. Thirty-four of 1113 patients with a closed fracture (3%) had a surgical site infection develop.

RESULTS

For all elbow fractures, use of plate and screw fixation (adjusted odds ratio [OR]= 2.2; 95% CI, 1.0-4.5; p = 0.041) and use of external fixation before surgery (adjusted OR = 4.7; 95% CI, 1.1-21; p = 0.035) were associated with higher infection rates. When subset analysis was performed for closed fractures, only smoking (adjusted OR = 2.2; 95% CI, 1.1-4.5; p = 0.023) was associated with higher infection rates. Staphylococcus aureus was the most common bacteria cultured (59%).

CONCLUSIONS

The only modifiable risk factor for a surgical site infection after open reduction and internal fixation was cigarette smoking. Plate fixation and temporary external fixation are likely surrogates for more complex injuries, therefore no recommendations should be inferred from this association. Surgeons should counsel patients who smoke.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Complications of Elbow Trauma

The elbow is a highly congruent trochoginglymoid joint allowing motion in both flexion-extension and pronosupination across 3 articulations. Therefore, treatment of fractures of the elbow can be technically challenging to manage, even after initial surgery. The posttraumatic elbow is prone to complications such as stiffness associated with heterotopic ossification, instability or subluxation (posterolateral rotatory instability and varus posteromedial instability patterns), and wound complications. This article discusses the pathoanatomy, prevention, and treatment of these complications.