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Brule N, Ozdag Y, Koshinski JL, Luciani AM, Grandizio LC. Ulnohumeral Cross-Pinning in the Management of Traumatic Elbow Instability. J Hand Surg Am 2024:S0363-5023(24)00262-4. [PMID: 39001767 DOI: 10.1016/j.jhsa.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE Traumatic elbow instability (subluxation and dislocation) represents a challenging clinical entity that can be complicated by persistent intraoperative instability after attempted stabilization or recurrent postoperative instability. Both static and dynamic supplemental stabilization procedures have been described for cases where fracture fixation and ligament repair fail to restore stability. There is a paucity of prior studies involving ulnohumeral cross-pinning (UCP), which is a type of static supplemental stabilization. Our purpose was to assess complications and outcomes after UCP. METHODS We reviewed all surgical cases involving primary and revision UCP for traumatic elbow instability at a single center from 2017-2023. Baseline demographics were recorded. Outcomes including radiographs, range of motion, patient-reported outcome measures, and surgical complications were analyzed. RESULTS Fourteen patients undergoing UCP were included with a mean follow-up of 27 months. Five cross-pinnings (36%) were performed during revision procedures. Mean visual analog scale (VAS) pain, Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and the Single Assessment Numeric Evaluation (SANE) scores were 2.4, 34, and 69, respectively. The mean flexion-extension and pronation-supination arcs were 114° and 140°, with 85% achieving at least a 100° arc for flexion and forearm rotation. Five patients (36%) had complications, all of which required reoperation. Two complications involved postoperative instability: one radial head subluxation and one radial head dislocation. Both occurred in revision UCP cases indicated for recurrent postoperative instability. CONCLUSIONS Ulnohumeral cross-pinning for persistent and recurrent elbow instability results in maintained ulnohumeral joint alignment, functional arcs of elbow range of motion, and acceptable patient-reported outcome measures, particularly in the setting of a primary procedure indicated for persistent intraoperative instability. Ulnohumeral cross-pinning is a reasonable supplemental stabilization procedure for complex elbow instability. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Nick Brule
- Division of Hand and Upper-Extremity Surgery, Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger MSKI, Scranton, PA
| | - Yagiz Ozdag
- Division of Hand and Upper-Extremity Surgery, Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger MSKI, Scranton, PA
| | - Jessica L Koshinski
- Division of Hand and Upper-Extremity Surgery, Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger MSKI, Scranton, PA
| | - A Michael Luciani
- Division of Hand and Upper-Extremity Surgery, Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger MSKI, Scranton, PA
| | - Louis C Grandizio
- Division of Hand and Upper-Extremity Surgery, Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger MSKI, Scranton, PA.
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Heifner JJ, Davis TA, Rowland RJ, Gomez O, Gray RR. Comparing internal and external stabilization for traumatic elbow instability: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:196-203. [PMID: 38706679 PMCID: PMC11065758 DOI: 10.1016/j.xrrt.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS. Methods A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment. Results The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals. Discussion The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.
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Affiliation(s)
| | - Ty A. Davis
- Larkin Hospital Department of Orthopaedics, Coral Gables, FL, USA
| | | | - Osmanny Gomez
- Larkin Hospital Department of Orthopaedics, Coral Gables, FL, USA
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Foster BK, Ayalon O, Hoyer R, Hoyen HA, Grandizio LC. Postoperative Elbow Instability: Options for Revision Stabilization. J Hand Surg Am 2024; 49:362-371. [PMID: 37999700 DOI: 10.1016/j.jhsa.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/25/2023] [Accepted: 10/01/2023] [Indexed: 11/25/2023]
Abstract
Persistent and recurrent postoperative elbow instability includes a spectrum of pathologies ranging from joint incongruity and subluxation to dislocation. Restoration of osseous anatomy, particularly the coronoid, is a priority in restoring elbow alignment and maintaining ulnohumeral joint stability. After managing bony deficiencies, soft-tissue and ligamentous structures are typically addressed. When required, both static and dynamic adjunctive stabilization procedures have been described, which aid in maintaining a concentric reduction. In these complex procedures, both complication avoidance and early recognition of postoperative complications assist in obtaining a good result. In this review, we discuss current treatment options for revision stabilization for patients with persistent and recurrent elbow subluxation or dislocation after primary stabilization.
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Affiliation(s)
- Brian K Foster
- Department of Orthopaedic Surgery, Division of Hand and Upper-Extremity Surgery, Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Omri Ayalon
- Department of Orthopaedic Surgery, Division of Hand & Wrist Surgery, NYU Langone Health, New York City, NY, USA
| | - Reed Hoyer
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA
| | - Harry A Hoyen
- Department of Orthopaedic Surgery, Case Western University, Cleveland, OH, USA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Division of Hand and Upper-Extremity Surgery, Geisinger Commonwealth School of Medicine, Danville, PA, USA.
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Xu G, Chen W, Yang Z, Yang J, Liang Z, Li W. Finite Element Analysis of Elbow Joint Stability by Different Flexion Angles of the Annular Ligament. Orthop Surg 2022; 14:2837-2844. [PMID: 36106628 PMCID: PMC9627061 DOI: 10.1111/os.13452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/05/2022] [Accepted: 07/25/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The injury of the annular ligament can change the stress distribution and affect the stability of the elbow joint, but its biomechanical mechanism is unclear. The present study investigated the biomechanical effects of different flexion angles of the annular ligament on elbow joint stability. Methods A cartilage and ligament model was constructed using SolidWorks software according to the magnetic resonance imaging results to simulate the annular ligament during normal, loosened, and ruptured conditions at different buckling angles (0°, 30°, 60°, 90°, and 120°). The fixed muscle strengths were 40 N (F1), 20 N (F2), 20 N (F3), 20 N (F4), and 20 N (F5) for the triceps, biceps, and brachial tendons and the base of the medial collateral ligament and lateral collateral ligament. The different elbow three‐dimensional (3D) finite element models were imported into ABAQUS software to calculate and analyze the load, contact area, contact stress, and stress of the medial collateral ligament of the olecranon cartilage. Results The results showed that the stress value of olecranon cartilage increased under different conditions (normal, loosened, and ruptured annular ligament) with elbow extension, and the maximum stress value of olecranon cartilage was 2.91 ± 0.24 MPa when the annular ligament was ruptured. The maximum contact area of olecranon cartilage was 254 mm2 with normal annular ligament when the elbow joint was flexed to 30°, while the maximum contact area of loosened and ruptured annular ligament was 283 and 312 mm2 at 60° of elbow flexion, and then decreased gradually. The maximum stress of the medial collateral ligament was 6.52 ± 0.23, 11.51 ± 0.78, and 18.74 ± 0.94 MPa under the different conditions, respectively. Conclusion When the annular ligament ruptures, it should be reconstructed as much as possible to avoid the elevation of stress on the surface of the medial collateral ligament of the elbow and the annular cartilage, which may cause clinical symptoms.
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Affiliation(s)
- Guangming Xu
- Department of Orthopaedics Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, Guangzhou University of Chinese Medicine Shenzhen China
| | - Wenzhao Chen
- Department of Orthopaedics Foshan Jianxiang Orthopedic Hospital Foshan China
| | - Zhengzhong Yang
- Department of Orthopaedics Shenzhen Pingle Orthopedic Hospital & Shenzhen Pingshan Traditional Chinese Medicine Hospital Shenzhen China
| | - Jiyong Yang
- Department of Orthopaedics Shenzhen Pingle Orthopedic Hospital & Shenzhen Pingshan Traditional Chinese Medicine Hospital Shenzhen China
| | - Ziyang Liang
- Department of Orthopaedics The Second Xiangya Hospital of Central South University Changsha China
| | - Wei Li
- Department of Orthopaedics Shenzhen Pingle Orthopedic Hospital & Shenzhen Pingshan Traditional Chinese Medicine Hospital Shenzhen China
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Stenson JF, Lynch JC, Cheesman QT, DeBernardis D, Kachooei A, Austin LS, Rivlin M. Biomechanical comparison of elbow stability constructs. J Shoulder Elbow Surg 2022; 31:1938-1946. [PMID: 35247577 DOI: 10.1016/j.jse.2022.01.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/16/2022] [Accepted: 01/23/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined. METHODS Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct. RESULTS Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight. CONCLUSION The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.
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Affiliation(s)
- James F Stenson
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Jeffrey C Lynch
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | | | | | - Amir Kachooei
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Luke S Austin
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Moharram AN, Mahmoud M, Lymona A, Afifi A, Ezzat M, Abdel-Wahed M. Temporary spanning plate across the elbow for complex fractures of the distal humerus. BMC Musculoskelet Disord 2021; 22:875. [PMID: 34645437 PMCID: PMC8515665 DOI: 10.1186/s12891-021-04764-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Open reduction internal fixation (ORIF) is the gold standard management of fractures of the distal humerus. Stable fixation to allow early mobilization is not always possible in cases with comminuted fracture patterns and bone loss, with a high failure rate. We propose augmentation of internal fixation in these unstable situations with a spanning plate across the elbow to protect the fixation construct temporarily until bone union. METHODS Eighteen patients with complex distal humeral fractures were managed with standard ORIF technique augmented with a temporary plate spanning across the elbow as an internal fixator. Cases included were either very distal, comminuted (6 cases) or insufficiency fractures (4 cases) or revision fixation cases (8 cases). The temporary spanning plate was removed as soon as signs of early radiographic union were detected. RESULTS Seventeen patients were available for final follow up at a mean 28.3 months. The spanning plate was removed after 3.4 months on average. At the final follow-up, the mean elbow total arc of motion was 86.3°. The mean Mayo Elbow Performance Score (MEPS) was 80, and the mean Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score was 27. CONCLUSION Spanning the elbow temporarily with a plate in adjunct to standard ORIF technique is both simple and effective in achieving fracture stability and union and minimizes failure rates after fixation of comminuted, very distal fractures, osteoporotic cases, or revision fixation cases with bone loss. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Affiliation(s)
| | - Mostafa Mahmoud
- Kasr El-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Lymona
- Kasr El-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Afifi
- Kasr El-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mostafa Ezzat
- Kasr El-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Qian Y, Yu S, Shi Y, Huang H, Fan C. Risk Factors for the Occurrence and Progression of Posttraumatic Elbow Stiffness: A Case-Control Study of 688 Cases. Front Med (Lausanne) 2020; 7:604056. [PMID: 33392226 PMCID: PMC7772462 DOI: 10.3389/fmed.2020.604056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Elbow stiffness is a severe complication after trauma. Surgical or conservative treatments may be ineffective for restoring functional elbow motion. We aim to evaluate intrinsic and extrinsic factors for the occurrence and severity of elbow stiffness. Methods: This retrospective case–control study included mild/moderate stiffness, severe stiffness, and non-stiffness groups between January 2011 and December 2017 at a single orthopedic center. Multivariable logistic regression analysis and subgroup analysis were used to evaluate age, gender, body mass index, muscle strength, fracture type and site, injury mechanism, immobilization time, elbow dysfunction time, multiple surgeries, nerve symptoms, physical therapy, smoking and alcohol abuse, and dominant hand of stiff elbow as potential risk factors for the occurrence and severity of elbow stiffness. Results: There were 461 patients in the stiffness group and 227 patients in the non-stiffness group. The odds ratios (ORs) of the age, muscle strength, and injury mechanism were 0.960, 0.333, and 0.216 for the occurrence of elbow stiffness. In subgroup evaluation, increased cast immobilization time might be a risk factor for patients receiving conservative therapies (OR = 2.02; p = 0.014). In the evaluation on factors for progression of elbow stiffness, “multiple surgeries” might be a risk factor in surgical treatment by subgroup analysis (OR = 1.943; p = 0.026). Nevertheless, alcohol abuse might increase severity of elbow stiffness in conservatively treated patients (OR = 3.082; p = 0.025). Conclusion: Increased cast immobilization time in the conservative therapy might be a risk factor for stiffness occurrence. Multiple surgeries might be risk factors for stiffness progression. Alcohol abuse potentially increased stiffness severity after conservative treatment.
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Affiliation(s)
- Yun Qian
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Youth Science and Technology Innovation Studio, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shiyang Yu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Youth Science and Technology Innovation Studio, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Shi
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hengye Huang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,Youth Science and Technology Innovation Studio, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China
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Rellán I, Nicholson LT, Ruch DS. Ulnohumeral Bridge Plating for Massive Distal Humerus Bone Loss: A Case Report. JBJS Case Connect 2020; 10:e0273. [PMID: 32224682 DOI: 10.2106/jbjs.cc.19.00273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Massive bone loss around the elbow is a challenging clinical condition. Short periarticular osseous segments present few reconstructive options in the setting of distal humerus bone loss. We report the case of a 20-year-old man who sustained an open, intra-articular distal humerus fracture with a massive metaphyseal defect of 15 cm after a motorcycle accident. The defect was reconstructed using an induced membrane technique with temporary ulnohumeral bridge plate stabilization. CONCLUSION Temporary ulnohumeral spanning plate fixation is a reliable method for periarticular reconstruction in the setting of massive distal humerus bone loss.
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Affiliation(s)
- Ignacio Rellán
- Department of Orthopaedics, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Luke Thomas Nicholson
- Clinical Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - David S Ruch
- Department of Orthopaedic Surgery, Division of Hand, Upper Extremity, and Microvascular Surgery, Duke University Medical Center, Durham, North Carolina
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