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

Triceps Split and Snip Approach for Distal Humerus Fractures

Background: The senior author adopted a Triceps Split and Snip approach in 2011. This paper details the results of patients for whom this approach was utilised for open reduction and internal fixation of complex AO type C distal humerus fractures. Methods: A retrospective analysis of a single surgeon's cases was conducted. Range of movement, as well as Mayo Elbow Performance Score (MEPS), and QuickDASH scores were evaluated. Two independent consultants with upper extremity practises evaluated pre- and post-operative radiographs. Results: Seven patients were available for clinical review. The mean age at the time of surgery was 47.7 years (range, 20.3-83.2) and the mean follow-up time was 3.6 years (range, 0.58-8). The average QuickDASH score was 15.85 (range, 0-52.3), average MEPS was 86.88 (range, 60-100) and average total arc of movement (TAM) was 103° (range, 70°-145°). All patients demonstrated 5/5 MRC triceps strength compared to the contralateral side. Conclusions: The Triceps Split and Snip approach for complex distal humerus fractures provided comparable mid-term clinical outcomes when compared to other published data regarding distal humerus fractures. It is versatile and does not compromise the intra-operative option of conversion to a total elbow arthroplasty. Level of Evidence: Level IV (Therapeutic).

Como escolher entre as abordagens transolecraniana e por reflexão do tríceps para tratar fraturas distais do úmero em adultos: Um estudo prospectivo

Objective  To choose an appropriate posterior approach for distal humerus fractures in adults.

Methods  Fifty patients with distal humerus fractures were analyzed prospectively. The fractures were classified using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO, Working Group for Bone Fusion Issues, in German/OTA) classification. The patients were divided into group A and group B. Olecranon osteotomy (the transolecranon approach) was performed in 30 patients, and the triceps-reflecting approach was used in 20 patients. The functional results were evaluated using the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Results  The average operative time was of 92.62 ± 8.73 minutes for group A, and of 78.63 ± 7.02 minutes for group B, ( p  < 0.01), and the average blood loss was of 222.78 ± 34.93 mL for group A, and of 121.61 ± 19.85 mL for group B, ( p  < 0.01), which were statistically significant. The mean scores on the MEPS and DASH of both groups were found to be insignificant. Complications like infection, neurapraxia and soft tissue irritation where observed more in group A.

Conclusion  The triceps-reflecting approach results in a shorter operative time, a lower levels of blood loss, and a low rate of complications, and olecranon osteotomy provides better accuracy in terms of articular reduction. But there were no significant differences between the two groups regarding the functional outcome. Therefore, we have proposed a new classification that is a modification of the AO/OTA classification: type 1 includes AO grades 13A to C2 (B3 excluded); and type 2, AO 13C3. For type-1 fractures, the triceps-reflecting approach may be considered, and, for type-2 fractures, olecranon osteotomy.

Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis

BACKGROUND

Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years.

METHODS

We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating.

RESULTS

Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01).

CONCLUSIONS

This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.

Management of type 13C2 distal humerus fractures by olecranon osteotomy approach versus triceps sparing approach-our experience with sixty cases

BACKGROUND

Intercondylar humerus fractures (AO type 13C), though less common (less than 1%), are increasing over the last few years. Open reduction and internal fixation (ORIF) of these fractures are now well recognised and preferred management. These fractures are principally approached from posterior side and various posterior approaches have been mentioned. Triceps sparing is a relatively newer approach for fixation of these fractures. Here, we are ascertaining the outcomes of triceps sparing approach and olecranon osteotomy approach and also investigating the preferred approach in various age groups.

MATERIALS AND METHODS

A level III non-randomized retrospective comparative study was conducted with a total of 60 patients belonging to AO type 13C2 in the age group of 16-70 years, operated upon during the period of September 2013 to March 2019. They were analysed for various outcome measures and complications. MEPS and DASH were used to determine outcome.

RESULTS

Out of a total of 60 patients (mean age 37.52 years), 28 were in olecranon osteotomy (OO) group and 32 were in the triceps sparing (TS) group. The mean operative time for group OO was 93.11 ± 8.78 minutes compared with group TS where it was 77 ± 4.64 minutes and the difference was statistically significant. Similarly, blood loss was 224 ± 46 ml in group OO compared with 197 ± 39 ml in group TS and it was also statistically significant. The average MEPS score was slightly better in the group TS (86.56 ± 10.66) compared with group OO (83.57 ± 10.96), though not statistically significant. Similarly, DASH score was 35.72 ± 8.35 in group TS and 35.32 ± 8.89 in group OO. The MEPS score was excellent (≥ 90) in 12 patients of group OO and 16 patients of group TS, good (75-89) in 11 patients of each group and fair (60-74) in 5 patients of each group. The patients in the age group of ≥ 60 years tend to have inferior functional outcomes, though not statistically significant, when treated with triceps sparing approach compared with olecranon osteotomy approach.

CONCLUSION

In conclusion, we found that, compared with the olecranon osteotomy technique, better results though not statistically significant, can be expected with triceps sparing approach while treating type C2 distal humerus fractures in younger patients without significantly compromising the articular reduction or impairing stability of fracture fixation.

Distal humerus fractures: a review of current therapy concepts

Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment.

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.