The value of elbow arthroscopy in diagnosing and treatment of radial head fractures

Arthroscopic Percutaneous Fixation of Mason Type 2 Radial Head Fractures

Background

Management of radial head fractures around the elbow with open techniques can predispose to edema, postoperative pain, and adhesions. The resultant limitation in elbow range of motion negatively affects functional outcomes. Rehabilitation is then rendered a challenge in a joint with proneness to stiffness.

Hypothesis

Arthroscopic percutaneous fixation of Mason type 2 radial head fractures would provide satisfactory radiological and clinical outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 24 patients diagnosed with isolated Mason type 2 radial head fractures at a single institution between February 1, 2021, and December 31, 2021, received arthroscopic percutaneous fixation by headless screws. Functional evaluation included Mayo Elbow Performance Score and postoperative elbow range of motion measurements. Radiological evaluation was performed using elbow radiographs and computed tomography scans. Patients were evaluated for a minimum of 24 months.

Results

This study included 12 male and 12 female participants with a mean age of 37.29 ± 11.93 years. At the end of the follow-up period (mean, 27.75 months; range, 24-32 months), the mean elbow flexion was 140.17° ± 8.21° and the extension deficit was 4.17° ± 3.81°. The Mayo Elbow Performance Score revealed 21 patients with excellent results and 3 patients with good results. All patients returned to preinjury activities at a mean time of 3.1 months (range, 2-6 months) postoperatively. Union was reached in all patients at a mean time of 7.63 weeks (range, 6-10 weeks). No neurological complications or reoperations were reported at the end of the follow-up period.

Conclusion

Arthroscopic fixation was demonstrated to be a valid and valuable technique for managing isolated Mason type 2 radial head fractures. It allowed for accurate reduction without the need for soft tissue dissection, resulting in excellent clinical outcomes.

Emergency department utilization after elbow arthroscopy

Background

Elbow arthroscopy has defined indications for which technical pearls and outcomes have been described. However, other aspects of the postoperative course, such as postprocedural emergency department (ED) visits, have received less attention. The current study defined the incidence and factors associated with ED visits in the 90 days following elbow arthroscopy by leveraging a large, national, multiinsurance, administrative database.

Methods

Adult patients who underwent elective elbow arthroscopy were identified in the 2010 to Q1 2022 PearlDiver Mariner161 national administrative database. Those who visited the ED in the 90 days following surgery were identified and compared to those who did not based on age, sex, Elixhauser Comorbidity Index, geographic region of the United States, and insurance type by multivariate analyses. The timing (weeks following surgery), reasons for ED visit (elbow-related or not), and ED-to-hospital admission (presence or absence) were also assessed. Finally, the rate of those who were admitted during an ED visit was described.

Results

A total of 16,310 elbow arthroscopy patients were identified, of which ED visits in the 90 days following surgery were noted for 1086 (6.7%). ED visits were independently associated with younger age (odds ratio [OR, 95% confidence interval (CI)]: 1.23 [1.17, 1.29] per decade decrease), higher Elixhauser Comorbidity Index (OR [95% CI]: 1.21 [1.19, 1.23] per 1-point increase), different geographic region (OR [95% CI]: 1.42 [1.19, 1.71] for Midwest relative to West), and insurance (OR [95% CI]: 1.88 [1.48, 2.39] for Medicaid relative to Commercial) (P < .001 for each). The incidence of all-cause ED visits was highest during the first two postoperative weeks and gradually decreased over the following weeks. The reason for ED visits related to the elbow decreased from 65% in month one, to 37.7% in month two, to 26.6% in month three. Of those visiting the ED, 12.4% went on to be admitted (for any reason).

Conclusion

A significant proportion of patients from a large cohort of elbow arthroscopy patients visited the ED at least once in the 90 days following surgery. The defined associated factors and timing of these ED visits can help optimize postoperative care pathways.

FRACTURE-DISLOCATIONS OF THE ELBOW: CAN THEY INFLUENCE THE PATTERN FRACTURE OF RADIAL HEAD?

Introduction

Radial head fractures are consistently part of a terrible triad of the elbow and can occur in association with Monteggia fracture-dislocations, transolecranon fractures, and their variations. Understanding the degree of comminution of the radial head fracture and the location of fragments determines the course of action to be taken.

Objectives

To correlate fracture-dislocations with the pattern of radial head fracture (number of fragments) and involvement in the proximal radioulnar region.

Materials and Methods

A retrospective study (level II) of patients undergoing surgery for radial head fractures associated with fracture-dislocations. Patients had radiographs in anteroposterior and lateral views, as well as tomography. The number of radial head fracture fragments and the presence of fractures in the proximal radioulnar region were correlated with the type of fracture-dislocation and demographic variables.

Conclusion

Elbow fracture-dislocation types could not predict the number of fragments and the location of radial head fractures. However, most injuries presented three or more fragments in the radial head, and many had involvement of the proximal radioulnar region, suggesting high-energy trauma. Level of Evidence II; Retrospective Study.

The role of arthroscopy in the management of adult elbow trauma

Fractures around the elbow are often challenging to treat and in most cases require an extensive approach. Since the development of elbow arthroscopy, most authors have pointed out the potential advantages of a less invasive technique that can be useful for visualization and reduction of the articular fragments with an eventual percutaneous fixation. Arthroscopic techniques provide a limited exposure that may lead to a faster wound healing, lower rate of complications and thus, better recovery of range of motion. However, elbow arthroscopy is also a demanding technique, especially in a swollen and fractured joint, and it is not exempt of risks. The overall rate of complications has been rated from 1.5% to 11% and nerve injury rates from 1.26-7.5%.The objective of this review is to present the arthroscopic setup and general surgical technique for the management of elbow trauma and to define some clear indications. Patient positioning and operating room display is key in order to obtain success. In addition to the arthroscopic equipment, fluoroscopy is almost always necessary for percutaneous fixation and precise preparation is mandatory. In the last decade, literature regarding new portals or surgical tips for arthroscopic treatment of elbow fractures have been published.The main indications for fracture arthroscopic-assisted fixation are those articular fractures involving the coronoid, distal humerus shear fractures in the coronal plane (trochlear and capitellum fractures) and, more controversially, those affecting the radial head. The treatment of these type of fractures all arthroscopically is exponentially demanding as it might also require ligament repair. For coronoid fractures, it can be useful in Morrey type II and III, and O´Driscoll anteromedial facet fractures associated to a posteromedial instability pattern that also require a repair of the LCL. Although excellent results have been published, comparative series are scarce. Radial head fractures can also be approached arthroscopically in simple non-comminute fractures that can be fixed percutaneously.In conclusion, arthroscopy of the elbow is an excellent tool to better understand and visualize articular fractures of the elbow. However, despite the advances in surgical technique, whether it improves clinical and radiological results is still to be proven.

Screw placement in arthroscopically assisted osteosynthesis of radial head fractures using a reference k-wire in the radiocapitellar joint: a cadaveric study

PURPOSE

The optimal screw placement in arthroscopically assisted fixation of radial head fractures is still an issue and no guiding methods have been evaluated in the recent literature. The study hypothesis was that using a "reference k-wire" percutaneously inserted in and parallel to the radiocapitellar joint would enable to achieve a trajectory more parallel to the radial head articular surface as compared to a free-hand k-wire placement.

METHODS

Arthroscopically assisted placement of a k-wire in the radial head was performed in seven fresh-frozen human cadaver specimens by three surgeons. Three different techniques were evaluated: freehand drilling (technique A), placement using a "reference" k-wire in the radiocapitellar joint as a reference without (technique B), and with the AO parallel k-wire guide (technique C). Radiographs from all procedures were obtained and the inclination angle "α" between the k-wire and the articular surface of the radial head was measured and compared among the techniques.

RESULTS

Angles of 84 radiographs were obtained and showed a mean α angle of 30.1° ± 13° for technique A, 5.7° ± 4.5° for technique B, and 5.4° ± 3.7° for technique C. The angle α was significantly higher with technique A as compared to B (p < 0.0001) and C (p < 0.0001). There was no difference between methods B and C (n.s.). No difference was observed among the surgeons for all three methods (p = 0.66).

CONCLUSION

With the use of an additional "reference" k-wire placed in the radiocapitellar joint, the guiding k-wire for screw drilling can be placed almost parallel to the radial head joint line with limited variability and a good reproducibility during arthroscopically assisted radial head fracture fixation.

CLINICAL RELEVANCE

The here-presented method of an additional, percutaneous introduced "reference" k-wire is easily applicable and helpful to achieve parallel screw placement during arthroscopically assisted radial head fracture fixation.

LEVEL OF EVIDENCE

IV, biomechanical cadaver study.

Elbow Arthroscopy for the Treatment of Radial Head Fractures: Surgical Technique and 10 Years of Follow Up Results Compared to Open Surgery

BACKGROUND

This study aimed to describe the ARIF (Arthroscopic Reduction Internal Fixation) technique for radial head fractures and to compare the results with ORIF (Open Reduction Internal Fixation) at mean 10 years.

METHODS

A total of 32 patients affected by Mason II or III fractures of the radial head who underwent ARIF or ORIF by screws fixation were retrospectively selected and evaluated. A total of 13 patients were treated (40.6%) by ARIF and 19 patients (59.4%) by ORIF. Mean follow-up was 10 years (7-15 years). All patients underwent MEPI and BMRS scores at follow-up, and statistical analysis was performed.

RESULTS

No statistical significance was reported in Surgical Time (p = 0.805) or BMRS (p = 0.181) values. Significative improvement was recorded in MEPI score (p = 0.036), and between ARIF (98.07, SD ± 4.34) and ORIF (91.57, SD ± 11.67). The ARIF group showed lower incidence of postoperative complications, especially regarding stiffness (15.4% with ORIF at 21.1%).

CONCLUSIONS

The radial head ARIF surgical technique represents a reproducible and safe procedure. A long learning curve is required, but with proper experience, it represents a tool that might be beneficial for patients, as it allows a radial head fracture to be treated with minimal tissue damage, evaluation and treatment of the concomitant lesions, and with no limitation of the positioning of screws.

Application of ultrasound in avoiding radial nerve injury during elbow arthroscopy: a retrospective follow-up study

BACKGROUND

A safe and effective technique for anterolateral portal placement in elbow arthroscopy is significant. We compared the outcomes of patients who underwent elbow arthroscopy using different ultrasound-assisted techniques.

METHODS

From May 2016 to June 2021 a retrospective analysis on all patients who underwent elbow arthroscopy in our department was performed. Patients were separated into three groups: non-ultrasound; preoperative ultrasound; and intraoperative ultrasound. The minimum follow-up period was 1 year. Nerve injuries, visual analog scale (VAS), Mayo elbow-performance score (MEPS), Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), and range of motion (ROM) of the elbow were evaluated for comparison among the three groups pre- and post-operatively.

RESULTS

All 55 patients completed a 1-year follow-up: non-ultrasound (n = 20); preoperative ultrasound (n = 17); and intraoperative ultrasound (n = 18). There were 3 cases (15.0%) of transient radial nerve palsy in the non-ultrasound group. No nerve complications occurred in preoperative ultrasound and intraoperative ultrasound groups. The probability of postoperative radial nerve injury in the three groups was statistically different (P < 0.05). There was no significant difference in the VAS score, MEPS, DASH score, and ROM among the three groups at the follow-up evaluation (P > 0.05).

CONCLUSION

Performing anterolateral portal placement during elbow arthroscopy with ultrasound-assisted techniques successfully avoided radial nerve injury.

Arthroscopic-assisted reduction plus internal fixation and traditional open reduction plus internal fixation for talus fractures: a comparative study

OBJECTIVE

To explore the efficacy of arthroscopic-assisted reduction and internal fixation (ARIF) and traditional open reduction and internal fixation in the treatment of talus fractures.

METHODS

This study retrospectively analyzed the clinical data of 92 patients with talus fractures admitted to our hospital. The patients were divided into a control group (treated with traditional open reduction and internal fixation) and a research group (with ARIF) with 46 cases in each. The operation indices, the score of the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scoring System (AOFAS-AH), callus growth score, pain score, treatment effect, complications and quality of life score were compared between the two groups.

RESULTS

The research group showed shorter time of fracture healing, hospitalization and less intraoperative blood loss than the control group (all P<0.001). The ankle-hindfoot score in the research group was higher than those in the control group 3 and 6 months after surgery (both P<0.001). The excellent and good rate of treatment in the research group (93.48%) was higher than that in the control group (78.26%; P<0.05). Compared with the control group, the VAS score was lower and the callus growth score was higher in the research group at 1^st, 3^rd and 6^th month after surgery (all P<0.01). The incidence of complications in the research group (2.17%) was lower than that in the control group (13.04%; P<0.05). Six months after surgery, the SF-36 score increased compared with that before surgery, with higher parameters in the research group than in the control group (P<0.001).

CONCLUSION

ARIF is more effective than traditional open reduction and internal fixation in treating talus fractures, with less complications and higher safety.

Radial head fractures

Radial head fractures are the commonest fractures in the elbow. They are often associated with other injuries: ligamentous, cartilaginous or other fractures. Associated injuries are important determinant of the management of the radial head fracture. These should be carefully looked for, diagnosed and treated. The original Mason classification for this fracture has been modified to include the associated injuries and their treatment. CT scan is a helpful diagnostic tool and should be used if available. Radial head fractures can be treated either conservatively or operatively (by excision, open reduction and internal fixation or prosthetic replacement). Undisplaced or minimally displaced fractures should be treated non-operatively. Internal fixation by headless cannulated screws is the preferred treatment for displaced fractures. It provides satisfactory biomechanical stability, can be done through a smaller incision, has less complications and lesser requirement of later removal of screws. Small number of fractures with comminution of neck would require plate fixation. Unfixable fractures in elderly can be treated by excision while such fractures in younger population or associated with significant soft tissue or bony injuries would require prosthetic replacement.