Use of a hinged external fixator for elbow instability after severe distal humeral fracture

Arthrolysis and delayed internal fixation combined with hinged external fixation for elbow stiffness associated with malunion or nonunion of capitellum fracture

BACKGROUND

This study assessed outcomes after treatment of patients with capitellum fracture diagnosed >4 weeks after the trauma (delayed) who presented with stiff elbow.

METHODS

We reviewed 7 patients with stiff elbows after delayed diagnosis of capitellum fractures between February 2007 and February 2012. They were treated with arthrolysis by twin incisions, late open reduction and internal fixation, and a hinged external fixator. According to the Bryan-Morrey-McKee classification, 3 patients had type I capitellum fractures and 4 patients had type IV.

RESULTS

Mean follow-up was 28 months (range, 24-38 months). The mean delay from the initial trauma was 3.7 months. The flexion arc improved from a preoperative mean of 24° to a postoperative mean of 122°. The Mayo Elbow Performance Score increased from a mean of 56 points to 93 points. Anatomic fracture union occurred in all cases, and there was no secondary displacement.

CONCLUSIONS

Arthrolysis, late internal fixation, and use of a hinged external fixator can solve problems associated with stiff elbow after delayed diagnosis of capitellum fracture. Combined use of these techniques may be a safe and effective treatment option.

Ulnar collateral ligament reconstruction in posttraumatic elbow release

The purpose of this retrospective cohort comparison study was to determine the effect of ulnar collateral ligament reconstruction on postoperative range of motion (ROM) in patients undergoing posttraumatic elbow contracture release. Twenty-four consecutive patients underwent elbow arthrolysis. Six patients also underwent simultaneous collateral ligament excision and reconstruction, and 18 did not require ligament excision. All patients followed the same postoperative rehabilitation program. Minimum follow-up was 12 months. Final flexion/extension ROMs were similar in both groups. No subjective reports of postoperative elbow instability occurred in either group. Ligament reconstruction and early postoperative motion can be safely performed in the setting of posttraumatic elbow capsulectomy without sacrificing ROM gain or compromising stability provided by the ligament reconstruction.

Additional external hinged fixator after open repositioning and internal fixation of acute elbow instability in non-compliant patients

This is a retrospective analysis of the clinical and radiological outcome in 11 patients with complex acute posttraumatic elbow instability after dislocation. These patients had also been treated with a hinged external fixator after open reduction, capsular and ligamentous reconstruction and internal fixation, because of an expected diminished compliance, to avoid a secondary dislocation of the internal fixation. Concentric stability and a sufficient range of motion of the elbow joint were achieved in all cases. Non-compliant patients were classified by the surgeon as not compliant or not able or not willing to cooperate post-operatively for various reasons, such as alcoholism, drug abuse, mental disability, cerebral trauma or senile dementia. Non-compliant patients had undergone open reduction and internal fixation of an acute posttraumatic unstable elbow. The addition of a hinged external fixator allows early intensive mobilization, and can protect and improve the clinical outcome after these complex elbow injuries. This evaluation remains, of course, largely subjective and decision making is not easy because in most cases, the patient was not known before surgery. Thus, the only patient exclusion criteria in this study was surgeon classification as “compliant”.

The use of hinged external fixation to provide additional stabilization for fractures of the distal humerus

OBJECTIVE

To assess improvements in fixation stability when a hinged unilateral external fixator is used to supplement compromised internal fixation for distal humerus fractures.

METHODS

Removing a 1-cm section of the distal humerus in cadaveric whole-arm specimens created a comminuted distal humerus fracture model (AO type 13-A3). Fixation was then performed using different constructs representing optimal, compromised, or supplemented internal fixation. Internal fixation consisted of either 2 reconstruction plates with 1, 2, or 3 (optimal) distal attachment screws, or crossing medial and lateral cortical screws. A hinged external fixator was applied in combination with compromised internal fixation. The stability of the different constructs was then evaluated using 3-point bending stiffness and distal fragment displacement measurements during flexion and extension testing.

RESULTS

Addition of the external fixator increased the stiffness of all constructs. Stiffness of the compromised reconstruction plate constructs with supplemented fixation was similar to or significantly greater than that of optimal internal fixation. Addition of the fixator to the reconstruction plates with 1 screw or the crossing screws produced displacements of the distal fragment that were similar to those of the compromised constructs alone. However, medial/lateral and anterior/posterior displacements of the distal fragment during flexion and extension of the elbow for supplemented fixation were found to be greater than those for optimal internal fixation.

CONCLUSIONS

The use of a hinged external fixator for supplemental fixation of distal humerus fractures may be effective in cases where internal fixation is severely compromised, although displacements may increase above optimal fixation.

Der Bewegungsfixateur zur frühfunktionellen Behandlung komplexer osteoligamentärer Verletzungen des Ellenbogengelenks

BACKGROUND

The treatment of complex injuries of the elbow joint by a hinged fixator is a new concept of external transfixation with guided movement in a defined monocentric axis. Biomechanical investigations using cadaver specimens showed that the monocentric guidance ensures additional stability in these unstable osteoligamentous injuries, allows early functional treatment, and can be used in primary but also in revision surgery.

PATIENTS AND METHODS

Between 1997 and 2004, 23 patients with complex fractures of the elbow joint were treated with a hinged monocentric external fixator after open reduction and internal fixation. The early functional treatment started 6.4 days (mean) postoperatively; the average range of motion (ROM) was 58 degrees.

RESULTS

The early functional treatment using a hinged fixator resulted in a mean increase in the range of motion of up to 71 degrees within an average time course of 34.7 days. In 18 patients a significant increase in the ROM was seen; in 4 patients no improvement in the ROM could be achieved. Only one patient showed a decrease in ROM (5 degrees). Follow-up examinations after 10 months revealed a mean ROM of 88 degrees.

CONCLUSION

In agreement with the literature, our results provide evidence that the use of a hinged monocentric external fixator in combination with early functional therapy results in an increase in the ROM and represents a beneficial device and concept in the treatment of complex injuries of the elbow joint.

Hinged external fixation and closed reduction for distal humerus fracture

Elbow fractures are relatively rare in extremity injuries. Functional deficits often comprise the outcome. We report of a 77-year-old diabetic lady with a distal humerus fracture. She was treated with external fixation and closed reduction. Special emphasis was directed to early motion exercises. Follow-up after 1 year demonstrated a range of motion of 0-30-130 degrees for extension and flexion of the elbow joint. No neurovascular deficits were seen. The use of a hinged device was successful in re-establishing a good function. Although there are no earlier reports using this technique in acute treatment, we consider this strategy as an alternative option in carefully selected cases.

Tricortical bone graft for primary reconstruction of comminuted distal humerus fractures

A tricortical bone graft harvested from the ilium was used to reconstruct a severely comminuted open intra-articular distal humerus fracture in an adult patient. The patient demonstrated a satisfactory functional and radiologic outcome despite loss of the lateral trochlear lip. When the lateral portion of the fractured trochlea cannot be repaired, excision of the fragments and insertion of an autogenous corticocancellous bone graft from the iliac crest can restore satisfactory function, even in the setting of an open fracture provided there is limited contamination and tissue devitalization. Radiocapitellar contact may be essential to good elbow function in this situation, because the corticocancellous bone graft does not restore the important lateral lip of the trochlea.

An in vitro biomechanical study of a hinged external fixator applied to an unstable elbow

Details of the mechanical properties of hinged external fixators are essential to use the fixator properly in the clinical setting. A hinged external fixator (Dynamic Joint Distractor 2) was attached to the lateral side of 7 cadaveric elbows. Cantilever lateral bending tests were performed at 3 flexion angles in varus and valgus directions. Varied states of joint contact and axial loading were studied. Stiffness of the construct was calculated with uniaxial loading. Stiffness decreased with increased elbow flexion. Gap creation made the system less stiff. Axial loading made the system stiffer, especially in valgus testing. Stiffness in varus was approximately 4 times that in valgus. Lateral fixator application with half pins is most effective for protecting against varus-producing forces. When using the external fixator for unstable elbows, attention should be paid to the status of the articular surfaces and the integrity of the ligaments, and this should also be noted for elbow position during rehabilitation.

Hinged elbow fixation for recurrent instability following fracture dislocation

The purpose of this study was to evaluate the use of an articulated external fixator of the elbow in the management of instability after fracture dislocation. We retrospectively reviewed results of eight patients treated with an articulated external fixator between 1998 and 1999. Study inclusion criteria included recurrent/chronic dislocation following fracture dislocation. Patients were divided into two groups based on the onset of instability. Group I (n=3) included patients with acute instability. The indication for use of the articulated external fixator in this subset of patients was the inability to accomplish complete osseous and ligamentous repair secondary to high degrees of comminution and/or severe soft tissue defects. Group II (n=5) patients presented at least 6 weeks after the original injury; the indication for use of the external fixator was inability to maintain joint congruity following open reduction. Application of the fixator was performed as an alternative to reconstruction of both medial and lateral ligaments. Follow-up at 1.5 years consisted of radiographs, occupational therapy ROM and DASH outcome measurement. At follow-up, Group I patients maintained an average total arc of motion of 120 degree, average flexion contracture: 25 degree, average pronation: 90 degree, and average supination: 67 degree. Group II patients had an average total arc of motion of 84 degree, average flexion contracture: 33 degree, average pronation: 68 degree, and average supination: 43 degree. Radiographic appearance of patients in both groups revealed a congruent humero-ulnar joint. DASH forms indicated patients experienced mild difficulty with activities of daily living. In conclusion, global instability of the elbow after fracture dislocation remains a difficult problem. High-energy injuries may result in an inability to maintain a congruous humero-ulnar articulation despite osteosynthesis and direct repair of the medial collateral ligament (MCL) and LUCL. When repair of the coronoid process and MCL is not feasible secondary to excessive comminution or soft tissue defect, the use of an articulated external fixator permits concentric stability and reduction of the humero-ulnar articulation. In cases of chronic instability, application of an articulated external fixator provides an alternative to complete osseous and ligamentous reconstruction. In both acute and chronic situations, the use of the articulated elbow fixator results in most patients regaining very good functional use of the elbow.