Posterior approach for surgical treatment of neglected elbow dislocation

Functional Outcomes of Neglected Elbow Dislocation Treated with Double Approach Surgery

Background

Neglected elbow dislocation is common in developing countries. The chronic nature of the disease results in a level of complexity that makes treatments and outcomes contradictory. Several treatment methods have been described for neglected elbow dislocations. The goal of this study was to evaluate the results of neglected elbow dislocations treated using the double approach of reduction and K-wire fixation.

Methods

This series included patients with neglected elbow dislocations who were treated with open reduction using double approaches (medial and lateral incisions) between November 2020 and March 2021. Patients were evaluated for a minimum of 6 months to ascertain functional recovery in accordance with the Mayo Elbow Performance Index (MEPI) and Disability of Arm, Shoulder, and Hand (DASH) score.

Results

Nine patients with neglected elbow dislocations were included in the study, with an average delay of 3.44 months. Four patients had an excellent MEPI and five had a good score at the final follow-up, with a mean MEPI score of 86.67. The average DASH score was 36 (31-59). Five patients (55.56%) experienced no pain, but four patients (44.44%) had mild pain, with a range of pain points of 30-45. The motion arc improvement was 60°-100°, with a mean of 74.44°. Almost all of the patients (eight patients, 88.89%) had elbow stability, but one patient had ulnar nerve paresthesia postoperatively. Heterotopic ossificans was associated in 1 patient, and triceps lengthening was needed in 1 patient; both came 5 months later.

Conclusion

Open reduction surgery with a double approach offers a good chance of a good result with few side effects and should be considered for all patients who have this condition.

Open reduction in treatment of neglected elbow dislocation in children

Elbow dislocation in children is uncommon condition in children, it's occurred in 3 to 6% of all elbow injuries. Only case reports and small series reported in the literature. The aim of our study is to evaluate the outcomes of open reduction of neglected elbow dislocation (NED) in children. A retrospective review of 26 neglected elbow dislocation was treated by open reduction at our institution between January 2010 and December 2018 was performed. Age, mechanism of injury, associated fracture, manipulation by bone- setters, infectious complications, were recorded. The SOFCOT criteria was used to assess the stiffness of the elbow in preoperative and in postoperative. Besides, in postoperative we used DI SCHINO Criteria to assess useful ROM and subjective criteria to evaluate pain and performance of daily activity. A total of 26 patients with a mean age of 10 years ranging from 5 to 14 years, were identified and followed for a median of 4 years postoperatively. The median duration before presentation was 5 months ranges from 22 days to 5 years. All patients except one were manipulated by bonesetters with massage and manipulation. The dislocation was postero-lateral in 15 cases (58%). 17 patients (65%) have associated fracture. 17 patients went for internal approach, 5 posterior approach, and 4 with combined internal and external approach. Reduction of the ulnar humeral joint was assisted with a lengthening of the triceps with a Speed V-Y muscle plasty in 13 patients. According to SOFCOT criteria at the last follow-up we obtained 15(58%) of minim and moderate elbow stiffness, and according to DI- SCHINO criteria at the last follow-up, 7(27 %) has a very good result, 7(27%) has a good result. The open reduction and the early rehabilitation remain the key stone of treatment of NED in children regardless the chronicity of the injury. Prevention remains the best way to improve the prognosis of neglected elbow dislocations.

Neglected posterior dislocation of elbow: A review

Untreated traumatic posterior dislocation of the elbow joint, 3 weeks or older, is defined as "neglected posterior dislocation of the elbow". Around 90% of these are of posterolateral type. These are much more common in the developing and underdeveloped countries. Patients presents with a deformed, stiff and painful elbow with difficulty to perform activities of daily living. The clinical picture looks quite similar to malunited supracondylar fracture of the elbow. Diagnosis is usually confirmed radiographically. CT and MRI scan give additional information and are recommended before embarking on surgery. Treatment is quite challenging due to the significant soft tissue contractures, ligamentous insufficiencies and fibrosis, with possible associated nerve injuries, myositis ossificans, non-compliant patients and the need for long-term postoperative physiotherapy. Goal of surgical treatment is to achieve a painless, stable and mobile elbow with a congruent joint space. We have reviewed the literature and present our view on the prognosis and recommended surgical technique to treat this condition.

The burden of chronic elbow dislocations in Cambodia and early results of a cost-effective surgical approach

Chronic elbow dislocation presents a surgical challenge and there is difficulty in balancing stability with early mobilisation. We present a series of 103 patients treated with open reduction via a posterior approach and provide early results of an alternative combined medial and lateral approach (Soddo technique, Anderson et al.). Of the 103 patients, 81% initially consulted a traditional healer and the mean dislocation period was 11 weeks. There was significant loss to follow-up. Only 12 patients having undergone the posterior approach had complete datasets. The mean preoperative arc of movement was 10° and the postoperative arc was 65° at a mean follow-up of 16 weeks. Five patients treated with the Soddo technique had sufficient follow-up data. The mean preoperative arc was 20° and the mean postoperative arc was 95° (mean follow-up of 20 days). Those having undergone the Soddo technique achieved a 20° greater increase in range of movement and no re-dislocations.

The Patient-Specific Implant Created with 3D Printing Technology in Treatment of the Irreparable Radial Head in Chronic Persistent Elbow Instability

Successful treatment of the chronic persistent elbow instability is a challenge for orthopedic surgeons. In this form, it is important to recognize and restore the osseous stabilizer in order to obtain the concentric reduction. In the present report, we describe a case of such injury with irreparable radial head treated with patient-specific radial head prosthesis which was created with 3D printing technology. To our knowledge, this is the first report in clinical use of this kind of prosthesis for the radial head fracture. At a 24-month follow-up visit, the patient was satisfied with the functional outcomes. The Mayo Elbow Performance Index (MEPI) increased from 20 points at the preoperative day to 85 points, and the patient-based Disabilities of the Arm, Shoulder, and Hand (DASH) was reduced from 88.33 points to 28.33 points. Due to the favorable result, replacement of the radial head with the patient-specific implant could be a useful treatment for the irreparable radial head in chronic persistent elbow instability.

Surgical Treatment of Chronic Elbow Dislocation Allowing for Early Range of Motion: Operative Technique and Clinical Results

OBJECTIVES

To describe the surgical treatment and patient outcomes of chronic elbow dislocations.

DESIGN

Retrospective review.

SETTING

Two tertiary referral centers.

PATIENTS/PARTICIPANTS

All patients with surgically treated chronic elbow dislocation with no associated articular fracture from January 2009 to January 2015.

INTERVENTION

Review of patient demographics, injury chronicity, surgical technique, and patient outcomes.

MAIN OUTCOME MEASUREMENT

Clinical outcomes included elbow range of motion and complications. Radiographic outcomes included the presence of heterotopic ossification. Patient-reported outcomes included the Mayo Elbow Performance Index (MEPI) and the Summary Outcome Determination (SOD).

RESULTS

Thirty-two patients with mean follow-up of 22 months (range, 13-41 months) were included. The mean dislocation duration was 6 months (range, 1-34 months). The mean preoperative range of motion was 8 degrees (range, 0-30 degrees). There were no infections or recurrent dislocations. One patient developed transient ulnar nerve palsy postoperatively. There were no cases of new or progressive heterotopic ossification. The mean postoperative extension was 31 degrees (range, 0-75 degrees), and the mean postoperative flexion was 132 degrees (range, 95-150 degrees); the mean final arc of motion was 101 degrees (range, 50-140 degrees). The mean postoperative MEPI was 93 (range, 70-100), and the mean SOD score was 9 (range, 6-10). Using the MEPI, 97% (31/32 patients) had good or excellent outcome. There was no difference in flexion/extension arc or MEPI scores between groups of elbows older and younger than 17 years or dislocations less or more than 3 months.

CONCLUSION

This is the largest case series of surgically treated patients with chronic elbow dislocation. Using our surgical technique, 97% of patients had good or excellent outcome with a low complication rate. Open reduction of chronic elbow dislocation can be accomplished while permitting early motion with minimal recurrent dislocation risk.

LEVEL OF EVIDENCE

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

Management Of Recent Elbow Dislocations: Functional Treatment Versus Immobilization; A Prospective Study About 60 Cases

Objective:

To determine our therapeutic posture trough a comparison of functional treatment results versus immobilization in two different periods.

Introduction:

For years, the treatment of recent elbow dislocations consisted of reduction and immobilization during 21 days. Given the frequency of stiffness other methods have been tried out.

Method:

A prospective study was carried out from January 2010 to December 2014. Sixty patients averaging 28.3 years of age underwent elbow dislocation reduction. They were categorized into three separate groups. Patients in the first group had their elbow immobilized for 21 days whereas Group 2 patients were immobilized for 10 days. Group 3 patients were applied a functional treatment followed by a functional rehabilitation. Patients were evaluated according to the Mayo Clinic Elbow Performance Index and the results analyzed with statistical software (SPSS, version 18).

Results:

During the first month, the functional results of the patients were excellent and good in 19%, 94.7% and 90% respectively for Groups 1, 2 and 3. The pain was intense (10 on the visual analogue scale) in group 3 associated with swelling. At day 90, the results of the patients in Groups 2 and 3 were excellent in 100% of the cases versus 90% for Group 1. At 6 months, all the results were the same. We have not noted any instability, or recurrence or periarticular ossification in our patients.

Conclusion:

The treatment of stable elbow dislocations remains orthopedic. The risk of instability and pain motivates a short 10-day immobilization period followed by early mobilization.

Chronic Elbow Dislocation: Evaluation and Management

Chronic elbow dislocation is defined as a dislocation that has remained unreduced for >2 weeks. The soft-tissue and skeletal changes that develop during this time usually prevent successful closed reduction. These changes include the development of extensive intra-articular fibrotic tissue, as well as contracture of the triceps, collateral ligaments, and elbow capsule. Ulnar nerve involvement and associated fractures may also be present. Because treatment of chronic elbow dislocation is challenging, a stepwise approach is used in the evaluation and management of this condition. No large series of data are available to guide treatment. Most patients are treated on the basis of the surgeon's anecdotal experience. Treatment typically involves open reduction, often with the use of hinged external fixators. The role of triceps lengthening or primary collateral ligament reconstruction remains a topic of debate.

Open arthrolysis with pie-crusting release of the triceps tendon for treating post-traumatic contracture of the elbow

BACKGROUND

Extensive loss of elbow flexion compromises the performance of daily activities. We examined the clinical outcomes of patients with post-traumatic extension contracture of the elbow treated with open arthrolysis and pie-crusting release of the triceps tendon.

METHODS

We retrospectively reviewed the records of 7 patients (5 men and 2 women; mean age, 35 years) who underwent open arthrolysis via a combined lateral and medial approach with pie-crusting release of the triceps tendon for the treatment of post-traumatic elbow stiffness. All the patients had heterotopic ossification that restricted elbow motion and underwent removal of the ossified tissue and capsular release. The triceps tendon was gradually stretched by making multiple stab incisions on the tendon by using a No. 11 surgical blade. The range of motion of the elbow was recorded both preoperatively and at the final postoperative follow-up. Elbow function was assessed with the Mayo Elbow Performance Score.

RESULTS

The patients were followed up for a mean of 24 months. After treatment, significant improvement was noted in the total arc of motion (from 44° to 116°, P <.001), mean flexion (from 80° to 124°, P < .001), and mean extension (from 31° to 8°, P = .004). The mean Mayo Elbow Performance Score improved significantly from 59 points preoperatively to 92 points at the final evaluation. No major postoperative complications developed in any of the patients.

CONCLUSION

Our findings indicate that open arthrolysis with pie-crusting release of the triceps tendon is an effective and safe treatment approach for post-traumatic extension contracture of the elbow.