L’ostéotomie de l’olécrâne dans le traitement des fractures de la palette humérale de l’adulte : évaluation anatomique et fonctionnelle du coude à propos de 14 cas

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.

Techniques and Fixation of Olecranon Osteotomy: A Systematic Review

Purpose

We aimed to characterize the incidence of complications regarding olecranon osteotomy, looking more specifically at the type of osteotomy and the fixation construct used to repair the osteotomy.

Methods

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search was performed. A study was included if it was an adult clinical study, a transverse or chevron olecranon osteotomy was performed, and the study explicitly states the fixation construct used to repair the osteotomy. A quality assessment was performed in each study prior to data extraction.

Results

We included 39 studies with a total of 1,445 patients. Most studies included patients who were being treated primarily for a distal humerus fracture. The overall incidence of delayed union was 27/643 (4.2%), with a higher rate in transverse osteotomy than in chevron osteotomy (5/49 (10.2%) vs 22/595 (3.7%)). Nonunion occurred in 43/811 (5.4%) of patients, with a higher rate in transverse osteotomy (6/73 (8.2%) vs. 37/712 (5.2%)). Implant failure or loss of reduction occurred in 44/746 (5.9%) of patients, with a higher rate in transverse osteotomy (11/49 (22.4%) vs 33/688 (4.8%)). The removal of implants occurred in 236/1078 (21.9%) of all patients, with the highest rate in those studies that used plate fixation 44/99 (44.4%).

Conclusions

Compared with chevron osteotomy, patients who underwent transverse osteotomy had a higher incidence of delayed union, nonunion, and implant failure or loss of reduction requiring revision surgery. The incidence of implant removal indicates that patients should be informed that nearly half of the osteotomy fixed with a plate was removed after implantation.

Type of study/level of evidence

Therapeutic III.

Comparison of double screw fixation versus tension-band fixation after olecranon osteotomy for complex distal humerus fractures

INTRODUCTION

Supra- and intercondylar elbow fractures are surgically challenging given the intra-articular comminution. Various surgical approaches have been described. Among these-olecranon osteotomy-provides optimal joint exposure but is associated with several complications. Tension band wiring (TBW) is the most commonly used fixation method. We hypothesized that double screw fixation would lead to fewer surgical revisions than TBW (all causes included) after olecranon osteotomy.

METHODS

We carried out a single-center retrospective study of 39 patients, treated between January 2007 and April 2016, for a supra- or intercondylar elbow fracture using the transolecranon exposure. There were 34 type C fractures (13 C1, 6 C2 and 15 C3), 3 type B fractures and 2 type A fractures, based on the AO classification. Fourteen patients received double screw fixation and 25 received TBW. The primary outcome measure was the number of surgical revisions, regardless of cause. Secondary outcome measures were the number of surgical revisions for olecranon nonunion, fixation failure or fixation device removal due to pain.

RESULTS

There were significantly more surgical revisions in the TBW group than in the double screw fixation group: 3 (21%) versus 14 (56%) (p=0.049, Fisher test). The three main reasons for revision in the TBW and double screw fixation groups were removal of the fixation device due to soft tissue impingement (11 [44%] versus 2 [14%]; p=0.08), failure of the olecranon fixation (6 [24%] versus 1 [7%] p=0.38), and olecranon nonunion (4 [16%] versus 0 [0%] p=0.27).

DISCUSSION

There are no published studies on the outcomes of this surgical technique. The posterior transolecranon approach provides the best exposure at the elbow joint. TBW fixation is associated with multiple complications. Double screw fixation for olecranon fractures yields good clinical and radiological outcomes.

CONCLUSION

Based on our findings, double screw fixation of the olecranon results in fewer surgical revisions (all causes combined) than TBW in supra- and intercondylar elbow fractures operated by a transolecranon approach.

LEVEL OF EVIDENCE

IV.

Comparison of olecranon fixation techniques following transolecranon approach in intra-articular fractures of distal humerus in adult patients

Background:

In this study, we assessed functional outcomes among olecranon fixation techniques used following transolecranon approach in patients with comminuted fracture of distal humerus.

Methods:

The study included 37 elbows that underwent olecranon osteotomy due to distal humerus fracture. Functional outcomes were assessed among patients who underwent fixation via tension band technique, plate, or screw fixation.

Results:

The implant irritation was seen in 18% of patients who underwent K-wire plus tension band fixation, in 75% of patients who underwent olecranon plate plus screw fixation, and in 18% of patients who underwent cancellous screw fixation. The rate for implant removal was 2.6 folds lower in K-wire plus tension band fixation when compared to olecranon plate plus screw fixation.

Conclusion:

We concluded that K-wire plus tension band technique and cancellous screw fixation performed in accordance with technical principles caused less skin problem when compared to other techniques. In olecranon fixation, both methods with enhanced stability by tension band can be preferred.

Triceps-sparing extra-articular step-cut olecranon osteotomy for distal humeral fractures: an anatomic study

BACKGROUND

This anatomic study investigated the distal humeral articular surface exposure achievable through a triceps-sparing oblique extra-articular osteotomy of the olecranon with a step-cut modification compared with the anconeus flap transolecranon apex distal chevron osteotomy. In addition, the bone contact surface areas of the osteotomized surfaces after transolecranon and extra-articular osteotomies were compared.

METHODS

Seven pairs of fresh adult cadaveric elbow joints were examined. Each of the right elbows underwent triceps-sparing extra-articular step-cut olecranon osteotomy (SCOOT) with an anconeus flap, and the left elbows underwent the anconeus flap transolecranon apex distal chevron osteotomies (CO). The articular surface exposed by each of the osteotomy techniques was then digitally analyzed using a 3-dimensional measurement system. The bone contact surface area of the osteotomized surfaces was also assessed.

RESULTS

The percentage of total joint exposed by the SCOOT group was less than the CO group (SCOOT: 64% ± 3% vs. CO: 73% ± 3%; P = .002). There was significantly greater bone contact surface area of the osteotomized surfaces in the SCOOT group compared with the CO group (SCOOT: 1172 ± 251 mm² vs. CO: 457 ± 133 mm²; P = .002).

CONCLUSION

The triceps SCOOT procedure with an anconeus flap provides excellent distal humeral articular surface exposure with the added benefit of a substantially increased (2.6-times) bone contact surface area of the osteotomized surfaces.

Functional outcome of intraarticular distal humerus fracture fixation using triceps-sparing paratricipital approach

BACKGROUND

Displaced intraarticular distal humerus fracture has been conventionally treated operatively with various triceps disrupting approaches. These approaches are associated with several complications, such as triceps weakness, nonunion or delayed union of osteotomy, implant prominence, and delayed mobilization of the elbow. We present the functional outcome of intraarticular distal humerus fracture fixation using a triceps-sparing paratricipital approach which allows early elbow mobilization and preserving triceps strength.

MATERIALS AND METHODS

Twenty five patients with intraarticular distal humerus fracture were operated using triceps-sparing paratricipital approach with orthogonal plate construct. There were 16 male and 9 female patients and average age was 42.16 years (range 23-65 years). The mechanism of injury was fall from height (n = 8), road traffic accident (n = 13) and ground level fall (n = 4). Clinical, radiological, and functional assessment with Mayo Elbow Performance Index (MEPI) were obtained at follow up period.

RESULTS

All fractures united primarily. At the mean follow up of 13.58 months (range 6-22 months), mean elbow flexion was 121.08° (range 94°-142°) and mean motion arc was 114.92°(range 65°-140°). The mean MEPI score was 94.40 points (range 70-100) with 17 excellent, five good, and three fair results. The mean flexion deformity or extension loss was 6.16° (range 5°-15°).

CONCLUSION

Open reduction and internal fixation of intraarticular distal humerus fractures with triceps-sparing paratricipital approach provide adequate exposure with no adverse effect on triceps muscle strength and allows early initiation of elbow motion. We analyzed, age and injury to surgical interval with relation to functional range of elbow using Z-test which is insignificant.

Clinical results of the re-fixation of a Chevron olecranon osteotomy using an intramedullary cancellous screw and suture tension band

Exposure of the distal humerus in case of an articular fracture is often performed through a Chevron osteotomy of the olecranon. Several options have been described for re-fixation of the Chevron osteotomy. Pull-out of the hard-wear is often seen as complication. In this study, an evaluation of the re-fixation of the Chevron osteotomy through a cancellous screw and suture tension band was performed. The data of 19 patients in whom a Chevron osteotomy was re-fixated with a cancellous screw in combination with a suture tension band were used. Evaluation was performed by assessment of the post-operative X-rays and documentation of complications. In all 19 cases, evaluation of the post-operative X-rays showed complete consolidation without dislocation or other complications. Re-fixation of a Chevron osteotomy of the olecranon with a large cancellous screw with a suture tension band provides adequate stability to result in proper healing of the osteotomy in primary cases when early post-operative mobilisation is allowed. Complications as pull-out of the hard-wear were not reported.

Biomechanical testing of an innovative fixation procedure to stabilize olecranon osteotomy

For the treatment of distal humerus an approach involving olecranon osteotomy is frequently preferred as it offers a clearer view, especially in cases of complex intraarticular fractures. It is however associated with the high risk of osteotomy-related complications such as nonunion, delayed healing, implant failure and migration of wires. The aim of the present study was to evaluate the stability of different new procedures that stabilize olecranon osteotomy compared with conventional tension band wiring. We hypothesize that the new implants provide equivalent stability as the conventional tension band wiring. To test the hypothesis 27 biomechanically evaluated synthetic ulnae were osteotomized and stabilized with either the application of tension band wiring, the Olecranon Hook LCP (Synthes, Switzerland), or the Olecranon Osteotomy nail (Synthes, Switzerland). Loading was performed providing a tensile load to simulate the tensile force applied by the triceps muscle. Cyclic force-controlled loading was performed at 300 alternating forces between 10N and 500N at a speed of 200N/sec. An ultrasound-based system measured displacement to an accuracy of 0.1 mm. Statistical analysis showed significantly less displacement in the Olecranon Hook LCP and Olecranon Osteotomy nail groups compared with tension banding. Comparison of plate and nail yielded no differences in stability. Biomechanical testing did however show significantly higher stability for newer fixation methods for olecranon osteotomies compared with the frequently applied technique of tension band wiring. Whether the use of these implants will also lower complication rates remains to be evaluated in future clinical studies.

Level of evidence: Basic Science Study, Biomechanical Study.

[Intra-articular fractures of the distal humerus : aspects of fracture treatment in geriatric patients]

BACKGROUND

In the context of osteoporotic fractures, injuries to the distal humerus are quite uncommon, meaning that each surgeon will have only limited experience.

OBJECTIVE

This leads automatically to the question to what extent treatment recommendations can be transferred to the geriatric population.

METHODS

Looking at the evidence-based literature, recommendations could be limited to three prospective studies. However, this only means that the remaining literature sources do not provide sufficient statistical power to be able to draw conclusions.

RESULTS AND DISCUSSION

For the population of geriatric patients a thorough compilation of the contemporary literature is advisable. This review article on the currently available literature evaluates and individually discusses the relevant aspects of fracture treatment in order to develop recommendations for routine daily practice.

Open reduction and bi-columnar internal fixation of intra-articular distal humerus fractures through a combined medial and lateral approach

PURPOSE

The aim of this retrospective study was to investigate the suitability of bi-columnar internal fixation through a combined medial and lateral approach for the treatment of intra-articular distal humerus fractures.

METHODS

Nineteen cases of intra-articular distal humerus fractures were treated with open reduction and bi-columnar internal fixation through a combined medial and lateral approach. The reduction in the articular surface and functional recovery of the affected elbows was assessed at an average follow-up of 15.8 ± 7.9 (7-43) months.

RESULTS

The gap in the main articular fragments was less than 1 mm in 16 cases, while a gap of more than 1 mm and less than 2 mm was identified in 2 cases and of 3.7 mm in one case. All the fractures were united. At the latest follow-up, the mean flexion-extension of the elbows was 113.4° ± 20.7°, while the pronation-supination of the forearms was 158.3° ± 8.5°, and the mean Mayo Elbow Performance Index was 93.7 ± 9.1 points, leading to 13 excellent outcomes, and 6 with good results.

CONCLUSIONS

Intra-articular fractures of the distal humerus can be effectively treated by open reduction and internal fixation through a combined medial and lateral approach at the elbow.

Treatment of AO Type C Fractures of the Distal Part of the Humerus through the Bryan-Morrey Triceps-Sparing Approach

Several alternative approaches have been described to avoid the complications related to the olecranon osteotomy used to treat distal articular humerus fractures. The published experience with the triceps-sparing approach is scant. In this prospective study, a total of 12 patients with an articular humeral fracture were treated using this approach. At a mean followup of 1,7 years, the average range of motion was 112.8° (range from 85° to 135°); the elbow flexion averaged 125.5° (range from 112° to 135°) and the deficit of elbow extension 14.6° (range from 0° to 30°). All the elbows were stable. The Mayo Elbow Performance Score (MEPS) averaged 93.3 (range from 80 to 100). In the present series no failure of the triceps reattachment to the olecranon was found, and all the patients recalled returning to their previous daily life activities without impairment with a satisfactory MEPS. As a conclusion, the triceps-sparing approach can be considered for treating distal articular humerus fractures. We consider that three clinical settings can be more favorable to use this approach: those cases in which a total elbow prosthesis might be needed, cases of ipsilateral diaphyseal fracture, or presence of previous hardware in the olecranon.

Fixing simple olecranon fractures with the Olecranon Osteotomy Nail (OleON)

OBJECTIVE

Stable fixation of simple olecranon fractures or olecranon osteotomies in order to allow early functional treatment.

INDICATIONS

Simple (non-comminuted) olecranon fractures and (Chevron) osteotomies of the olecranon.

CONTRAINDICATIONS

Comminuted fractures and fractures more than 40 mm distal than the tip of the olecranon are contraindications.

SURGICAL TECHNIQUE

Using a slightly curved posterior approach, the fracture is anatomically reduced. The fracture is temporary stabilized using K-wires. A guiding K-wire is positioned centrally in the medullary canal in the lateral projection. The medullary canal is reamed over the K-wire. The distal part of the nail is inserted and locked. The proximal part is inserted and screwed onto the distal part to compress the fracture. For osteotomies, the distal part is inserted and locked (using the same technique as described before) prior to performing the osteotomy. At the end of the surgery, the osteotomy is reduced, the proximal part is inserted, and the osteotomy is compressed.

POSTOPERATIVE MANAGEMENT

As the stability of this compressive osteosynthesis is very high, early post-operative mobilization is allowed. No immobilization is used. Depending on the soft tissue situation, active range of motion and passive stretching is initiated immediately postoperatively.

RESULTS

Using this technique in 21 patients (mean age 42 years) with acute fractures or osteotomies, sound fracture healing was achieved in 19 of 21 patients. The active range of motion was 130.2° flexion, 10.6° extension deficit, and a normal pro-supination arch. In one patient, delayed union caused implant failure. In this patient, a surgical error jeopardized stability. In a second patient, a peri-implant fracture after adequate trauma made a change in therapy necessary.