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Oh WT, Do WS, Oh JC, Koh IH, Kang HJ, Choi YR. Comparison of arthroscopy-assisted vs. open reduction and fixation of coronoid fractures of the ulna. J Shoulder Elbow Surg 2021; 30:469-478. [PMID: 32750532 DOI: 10.1016/j.jse.2020.06.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical and radiographic outcomes and complications for arthroscopy-assisted vs. open reduction and fixation of coronoid fractures in patients with complex elbow fracture-dislocations. METHODS This retrospective study analyzed patients with complex elbow fracture-dislocations who underwent surgical fixation for coronoid fractures of the ulna from March 2009 to January 2016. Subjects included those who received either arthroscopy-assisted (group A) or open surgery (group O) for coronoid fractures and concurrent reconstruction of the lateral column (radial head and/or lateral ulnar collateral ligament) with follow-up for at least 2 years. Clinical outcomes were assessed using the visual analog scale for pain, range of motion, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand score at 2 years after surgery. For radiographic assessment, union of the coronoid, development of heterotopic ossification, and arthritic changes were evaluated. We also reviewed surgery-related complications. RESULTS Twenty-five patients (mean age, 40.0 ± 12.4 years) were enrolled in this study (group A, 15 patients; group O, 10 patients), and there were no statistical differences in baseline data between the 2 groups. Clinical outcomes did not differ between the 2 groups. All fractures were united and that the prevalence of heterotopic ossification and arthritic changes were similar between the 2 groups. However, operation-related complications were more common in group O than in group A (group A, 13.3%; group O, 40.0%), including 1 patient who underwent ulnar nerve neurolysis and anterior transposition at 3 months after the initial operation. CONCLUSIONS Eliciting fewer complications, arthroscopy-assisted reduction and fixation of coronoid fractures shows union rates and clinical results comparable to open fixation in patients with complex elbow fracture-dislocation.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Woo-Sung Do
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Jin-Chul Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Il-Hyun Koh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Ho-Jung Kang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Yun-Rak Choi
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea.
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Jing L, Zhao H, Liu G. [Comparison of two techniques for lateral collateral ligament complex repair in treatment of terrible triad of elbow]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1550-1554. [PMID: 33319534 DOI: 10.7507/1002-1892.201908111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To compare the effectiveness of transosseous tunnel fixation and drilling fixation for repair of lateral collateral ligament complex (LCLC) in treatment of terrible triad of elbow (TTE). Methods A clinical data of 50 patients with TTE between June 2012 and January 2018 were retrospectively analyzed. The LCLC was repaired with transosseous tunnel fixation in 22 patients (transosseous tunnel fixation group) and with drilling fixation in 28 patients (drilling fixation group). There was no significant difference between the two groups ( P>0.05) in gender, age, fracture side, time from injury to admission, coronoid process fracture classification, radial head fracture classification, and TTE classification. The operation time, intraoperative blood loss, fracture healing time, and complications of the two groups were recorded. At last follow-up, the Mayo elbow performance system (MEPS) score, range of motion of elbow joint, and Broberg-Morrey classification were recorded. Results The operation of two groups were successfully completed. There was no significant difference in the operation time and intraoperative blood loss between the two group ( P>0.05). The follow-up time was (24.43±6.84) months in the transosseous tunnel fixation group and (21.55±6.16) months in the drilling fixation group, and the difference was not significant ( t=1.534, P=0.132). X-ray films showed that the coronoid process and radial head fractures in the two groups healed, and there was no significant difference in the healing time ( P>0.05). At last follow-up, there was no significant difference in the flexion-extension activity, rotation activity, MEPS score, and Broberg-Morrey grading ( P>0.05). During the follow-up, there was no re-dislocation or instability of the elbow joint. The incidence of complication was 28.57% (8/28) in the transosseous tunnel fixation group and 27.27% (6/22) in the drilling fixation group, showing no significant difference ( χ 2=2.403, P=0.121). Conclusion Both transosseous tunnel fixation and drilling fixation can achieve good results in repair of LCLC for TTE.
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Affiliation(s)
- Lingyong Jing
- Medicine School of Ningbo University, Ningbo Zhejiang, 315211, P.R.China
| | - Huaguo Zhao
- Department of Orthopedics, Ningbo No.6 Hospital, Ningbo Zhejiang, 315040, P.R.China
| | - Guanyi Liu
- Department of Orthopedics, Ningbo No.6 Hospital, Ningbo Zhejiang, 315040, P.R.China
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Kholinne E, Lee HJ, Deslivia MF, Ga Yeong K, Lee SJ, Lim S, Jeon IH. Neuroanatomical distribution of sensory receptors in the human elbow joint capsule. Shoulder Elbow 2019; 11:300-304. [PMID: 31316591 PMCID: PMC6620800 DOI: 10.1177/1758573218760245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/06/2017] [Accepted: 01/19/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND The topographic arrangement of sensory receptors in the human elbow joint capsule is pertinent to their role in the transmission of neural signals. The signals from stimuli in the joint are concisely delivered via afferent pathways to allow recognition of pain and proprioception. Sensory receptors in the elbow joint include mechanoreceptors and free nerve endings acting as nociceptors, although the distribution of each of the structures has not been determined, despite their importance for the integrity of the joint. We therefore aimed to investigate the neuroanatomical distribution and densities of mechanoreceptors and free nerve endings in the capsule of the elbow, at the same time as considering surgical approaches that would result in the minimum insult to them. METHODS Four elbow joint capsules were harvested from fresh cadavers. The specimens were carefully separated from adjacent osteoligamentous attachments and the capsular complex was stained with a modified gold chloride method. Evaluations of free nerve endings, and Golgi, Ruffini and Pacinian corpuscles were performed under an inverted light microscope. The number and density of each structure were recorded. RESULTS Ruffini corpuscles observed to be the dominant mechanoreceptor type. No Golgi corpuscle was observed. Free nerve endings were found at the highest density at posterodistal sites, whereas mechanoreceptors were most frequent at bony attachment sites. CONCLUSIONS A consistent distribution pattern of articular sensory receptors was observed, which allows further understanding of elbow pathology. An awareness of the neuroanatomical distribution of sensory receptors in the elbow joint capsule may allow their preservation during surgical procedures for elbow joint pathology.
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Affiliation(s)
- Erica Kholinne
- Department of Orthopedic Surgery, St Carolus Hospital, Jakarta, Indonesia
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Hyun-Joo Lee
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Maria F Deslivia
- Department of Orthopedic Surgery, St Carolus Hospital, Jakarta, Indonesia
| | - Kim Ga Yeong
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Suk-Joong Lee
- Department of Orthopedic Surgery, Keimyung University, Dongsan Medical Center, Daegu, Korea
| | - Sungjoon Lim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
- In-Ho Jeon, Department of Orthopedic Surgery, University of Ulsan, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul, Korea.
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Guss MS, Hess LK, Baratz ME. The naked capitellum: a surgeon's guide to intraoperative identification of posterolateral rotatory instability. J Shoulder Elbow Surg 2019; 28:e150-e155. [PMID: 30713062 DOI: 10.1016/j.jse.2018.10.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/18/2018] [Accepted: 10/28/2018] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS This study's purpose was to provide a reproducible way for surgeons to intraoperatively assess the elbow's lateral ulnar collateral ligament origin and determine whether there is posterolateral rotatory instability (PLRI) despite an intact common extensor origin (CEO). We hypothesized that we could re-create clinically relevant disruption of lateral supporting structures despite an intact CEO and illustrate progressive elbow PLRI. METHODS The relationship of the lateral capsule to the capitellum articular surface was noted in 8 cadaveric upper extremities. The lateral capsule and extensor origin were sequentially sectioned at 4 stages: intact, release to the lateral epicondyle, release of the posterior capsular insertion, and release of the CEO. Posterior and lateral translation of the radial head (RH) relative to the capitellum was measured with the forearm in extension and supination. RESULTS The average specimen age was 78.9 years. The lateral capsule originated within 1 to 2 mm of the capitellum articular surface. Lateral capsular sectioning to the 6-o'clock position of the lateral epicondyle created an unstable elbow with posterior and lateral RH translation. Sequential sectioning of the posterior capsular insertion created significant additional RH translation posteriorly (P < .05). With release of the capsule and the extensor origin, the elbow was grossly unstable. CONCLUSIONS The elbow's lateral capsuloligamentous complex plays an important role in preventing PLRI. Larger degrees of elbow laxity are associated with further peel back of the capsuloligamentous complex despite an intact CEO. The surgeon must retract the extensor origin intraoperatively to assess for lateral ulnar collateral ligament and/or lateral capsule disruption to prevent a missed case of PLRI.
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Affiliation(s)
- Michael S Guss
- Hand Surgery P.C., Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, MA, USA.
| | - Lindsay K Hess
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark E Baratz
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Tarassoli P, McCann P, Amirfeyz R. Complex instability of the elbow. Injury 2017; 48:568-577. [PMID: 24161720 DOI: 10.1016/j.injury.2013.09.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 09/02/2013] [Accepted: 09/19/2013] [Indexed: 02/02/2023]
Abstract
Injuries to the elbow are commonly encountered in orthopaedic practice. They range from low energy, simple isolated fractures, to high energy complex fracture dislocations with severe ligamentous disruption. Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness. This article discusses the important osseous and ligamentous stabilisers of the elbow joint and provides management protocols for the common patterns of complex injury encountered by the practising surgeon.
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Affiliation(s)
- Payam Tarassoli
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom.
| | - Philip McCann
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom
| | - Rouin Amirfeyz
- Department of Trauma and Orthopaedics, University Hospitals Bristol NHS Trust, Level 5, Queens Building, Upper Maudlin Street, Bristol BS2 8HW, United Kingdom
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Abstract
BACKGROUND Terrible triad injury (TTI), one of the main patterns of complex elbow instability, is difficult to treat and yields conflicting surgical results. We analyzed prospectively a series of patient affected by TTI and treated according to the current diagnostic and surgical protocols to investigate whether their application allow to obtain more predictable outcomes. MATERIAL AND METHODS We analyzed 26 patients with a mean age of 52 years. Preoperative X-rays and CT were performed; all patients were operated by the same elbow surgeon and underwent the same surgical and rehabilitation treatment. Final functional outcome was assessed by the Mayo Elbow Performance Score (MEPS), Quick-Disability of the Arm Shoulder and Hand-score (Q-DASH) and the modified-American Shoulder and Elbow Surgeons score (m-Ases). A radiographic evaluation was also performed. RESULTS Mean follow-up was 31 months. At final evaluation, mean flexion, extension, supination and pronation were 137°, 10°, 77° and 79°, respectively; mean MEPS, m-ASES and Q-DASH scores were respectively 96, 91 and 8 points. Complications observed after first surgery were: elbow stiffness in 5 cases, mild posterolateral instability in 3 cases, chronic subluxation in 1 case. Radiographic evaluation showed secondary arthritis in 9 cases, symptomatic HO in 3 cases and late hardware displacement in 2 cases. Six out of 26 patient underwent reoperation with final satisfactory results. CONCLUSION The current diagnostic and therapeutic protocols allow obtaining satisfactory clinical outcomes in majority of cases but a high number of major and minor unpredictable complications persist yet. In this series, low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery. On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon's inexperience. LEVEL OF EVIDENCE Level IV, Case series, Treatment study.
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Affiliation(s)
- Giuseppe Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - Piergiorgio Calella
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Andrea Piccioli
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Marco Scacchi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Stefano Gumina
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
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Giannicola G, Scacchi M, Sacchetti FM, Cinotti G. Clinical usefulness of proximal ulnar and radial fracture-dislocation comprehensive classification system (PURCCS): prospective study of 39 cases. J Shoulder Elbow Surg 2013; 22:1729-36. [PMID: 24129057 DOI: 10.1016/j.jse.2013.07.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 07/22/2013] [Accepted: 07/28/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Complex fracture-dislocations of the proximal ulna and radius represent a challenge even for expert orthopaedic surgeons. A new comprehensive classification, the proximal ulnar and radial fracture-dislocation comprehensive classification system (PURCCS), was recently proposed. The aim of this study was to analyze the clinical usefulness of this classification in a large series of patients. MATERIALS AND METHODS We studied 38 patients (39 elbows) with a mean age of 56 years. All patients were classified with the PURCCS by use of standard radiography, computed tomography, and intraoperative fluoroscopy. Surgical treatment was performed according to the PURCCS therapeutic algorithm. Patients were followed up for a mean of 23 months. The clinical evaluation was performed with the Mayo Elbow Performance Score and Index (MEPS and MEPI); the Disabilities of the Arm, Shoulder, and Hand (DASH) score; and the modified American Shoulder and Elbow Surgeons (m-ASES) score. RESULTS Each pattern of fracture-dislocation in our series finds its position within the PURCCS. At the last follow-up, the mean MEPS, DASH score, and m-ASES score were 91.2, 14.9, and 83.9, respectively. The mean extension, flexion, pronation, and supination were 19°, 136°, 81°, and 79°, respectively. According to the MEPI, 72%, 20%, and 8% of cases were rated excellent, good, and fair, respectively. Two patients with elbow stiffness underwent a reoperation, with final satisfactory results. CONCLUSION The PURCCS helps identify the main lesions of each injury pattern; the associated therapeutic algorithm helps select correct surgical strategies. This study showed that the clinical results were satisfactory in the majority of cases, with few major complications and reinterventions. The PURCCS is a comprehensive classification that may contribute to the surgical management of these difficult fracture-dislocations. LEVEL OF EVIDENCE Level IV, case series, treatment study.
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Giannicola G, Polimanti D, Sacchetti FM, Scacchi M, Bullitta G, Manauzzi E, Gumina S, Cinotti G. Soft tissue constraint injuries in complex elbow instability: surgical techniques and clinical outcomes. Orthopedics 2012; 35:e1746-53. [PMID: 23218631 DOI: 10.3928/01477447-20121120-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The surgical procedures for and outcomes of soft tissue constraint reconstruction in complex elbow instability have been rarely investigated. The purpose of this study was to analyze the clinical outcomes in a series of patients with complex elbow instability in whom the associated soft tissue constraint injures were identified and treated based on the pathoanatomic changes found intraoperatively. Forty-five patients (23 men and 22 women; mean age, 54 years) with complex elbow instability were followed prospectively. Surgical treatment included the anatomic reduction and internal fixation of any fracture and radial head replacement in Mason type III injuries. Soft tissue constraint lesions were then repaired based on the type of lesion (eg, proximal or distal ligament avulsion, middle-zone lesion, or presence of detached bony fragments). Posterolateral capsular lesions and common extensor and flexor origin injuries were also repaired. Patients were followed clinically and radiographically after a mean of 25 months. Functional range of motion was achieved in 39 (86%) patients. Average Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; and American Shoulder and Elbow Surgeons shoulder score were 94, 5.6, and 89, respectively. At last follow-up, 42 (93%) patients showed no evidence of elbow instability, 2 (4%) patients had mild varus instability, and 1 (2%) patient had moderate posterolateral instability. The accurate identification of pathoanatomic changes of elbow soft tissue constraint lesions associated with complex elbow instability is an essential prerequisite to planning proper surgical treatment. The results of this study show that, in patients with complex elbow instability, once the fracture has been treated and each type of soft tissue constraint lesion adequately repaired, a high percentage of satisfactory functional outcomes may be achieved.
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Affiliation(s)
- Giuseppe Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
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