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Heifner JJ, Lacau GE, Davis TA, Mercer DM, Gray RRL, Hoekzema NA. Linking the distal humerus columns in articular fracture fixation. Injury 2023; 54:110931. [PMID: 37495450 DOI: 10.1016/j.injury.2023.110931] [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: 06/14/2023] [Accepted: 07/07/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Concerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture. MATERIALS AND METHODS Ten matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths. RESULTS Mean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94). DISCUSSION Our results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments.
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Affiliation(s)
- John J Heifner
- Miami Orthopaedic Research Foundation, Miami, Florida, USA.
| | - Gustavo E Lacau
- Miami Hand and Upper Extremity Institute, Miami, Florida, USA
| | - Ty A Davis
- Larkin Hospital Department of Orthopaedic Surgery, Coral Gables, Florida, USA
| | - Deana M Mercer
- University of New Mexico, Department of Orthopedics and Rehabilitation, Albuquerque, Mexico, USA
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Warner C, Peach C, Davies R. Widening Access: Sterile Tourniquets for Surgery to the Distal Humerus. Cureus 2023; 15:e46148. [PMID: 37900452 PMCID: PMC10613037 DOI: 10.7759/cureus.46148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Purpose of the study The use of tourniquets during surgery of the distal humerus can improve visibility and reduce surgical time. However, the available operating field can be limited due to the size and placement of the tourniquet. This proof-of-concept study aimed to determine if sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus. Methods Volunteers (n = 5) were positioned to simulate access to the distal humerus. The distance from the posterior corner of the acromion to the tip of the olecranon was measured. Participants were draped according to the standard protocol for the use of a non-sterile or sterile tourniquet for distal humerus and humeral shaft fractures. Two non-sterile pneumatic tourniquets (standard and narrow) and two sterile tourniquets (pneumatic and elastic exsanguination) were tested. The surgical field was measured from the sterile drape or tourniquet proximally to the tip of the olecranon. A one-way repeated measures ANOVA was conducted to examine the effect of each tourniquet on the surgical field. Results The sterile elastic exsanguination tourniquet had the largest available field with a mean of 24.4 cm (71% of arm available for incision after application), followed by the sterile pneumatic tourniquet of 20.0 cm (58%), narrow non-sterile pneumatic of 19.2 cm (55%), and standard non-sterile pneumatic of 17.0 cm (49%). Repeated measures ANOVA determined that mean surgical field length is statistically significant between tourniquet devices (F (1.729, 6.914) = 21.783, p = .001). The surgical field length was statistically significantly increased from a non-sterile standard tourniquet to a sterile elastic tourniquet (7.4 (95% CI, 2.9-11.9) cm, p = .008) but not the other two tourniquet devices tested. Conclusion The use of certain types of sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus, specifically the sterile elastic exsanguination tourniquet providing a statistically significant mean gain of 7.4 cm from the non-sterile tourniquets. These findings suggest that the use of sterile tourniquets should be considered more frequently in surgery of the distal humerus, and a sterile exsanguinating tourniquet could be considered for midshaft humeral fractures, facilitating safer exposure of the radial nerve and reduced blood loss.
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Affiliation(s)
- Christian Warner
- Trauma and Orthopaedics, Manchester Shoulder and Elbow Unit, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, GBR
| | - Christopher Peach
- Trauma and Orthopaedics, Manchester Shoulder and Elbow Unit, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, GBR
| | - Ronnie Davies
- Trauma and Orthopaedics, Manchester Shoulder and Elbow Unit, Wythenshawe Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, GBR
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Yoshii Y, Iwabuchi S, Ikumi A, Kohyama S, Ogawa T, Ishii T. Correlations between 3D preoperative planning and postoperative reduction in the osteosynthesis of distal humeral fractures. J Orthop Surg Res 2023; 18:283. [PMID: 37031170 PMCID: PMC10082491 DOI: 10.1186/s13018-023-03772-y] [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: 02/01/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND Three-dimensional preoperative planning has been applied to the osteosynthesis of distal humerus fractures. The present study investigated the correlations between 3D preoperative planning and postoperative reduction for the osteosynthesis of distal humerus fractures using 3D parameters. METHODS Twenty-three elbows of 23 distal humerus fracture patients who underwent osteosynthesis with three-dimensional preoperative planning were evaluated. 3D images of the distal humerus were created after taking preoperative CT scans of the injured elbow. Fracture reduction, implant selection, and placement simulations were performed based on 3D images. Postoperative CT images were taken 1 month after surgery. Correlations were evaluated with preoperative plans and postoperative 3D images. The longitudinal axis and coordinates of the humerus were defined on the 3D images. The coronal angle (CA) was defined as the angle formed by the long axis and the line connecting the medial and lateral margins of the trochlea of the humerus on a coronal plane image. The sagittal angle (SA) was defined as the angle formed by the long axis and the line connecting the top of the lateral epicondyle and the center of the humeral capitellum on a sagittal plane image. The axial angle (AA) was defined as the angle between the sagittal plane and the line connecting the medial and lateral margins behind the trochlea of the humerus. The intraclass correlation coefficients (ICC) of each measurement value were assessed between preoperative planning and postoperative images. RESULTS Preoperative planning and postoperative measurement values were CA: 85.6 ± 5.9°/85.8 ± 5.9°, SA: 140.9 ± 8.5°/139.4 ± 7.9°, and AA: 84.0 ± 3.1°/82.6 ± 4.9°, respectively. ICCs were CA: 0.75 (P < 0.01), SA: 0.78 (P < 0.01), and AA: 0.34 (P < 0.05), respectively. CONCLUSIONS The 3D preoperative planning of distal humeral fractures achieved the good correlations of coronal and sagittal angles, but the relatively poor correlation of the axial angle. This may be attributed to an inability to assess the rotation angle during surgery. We propose the measurement indices shown in the present study as a three-dimensional evaluation index for distal humerus fractures. TRIAL REGISTRATION Registered as NCT04349319 at ClinicalTrials.gov.
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Affiliation(s)
- Yuichi Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan.
| | - Sho Iwabuchi
- Department of Orthopaedic Surgery, University of Tsukuba Hospital, Tsukuba, Ibaraki, 305-8576, Japan
| | - Akira Ikumi
- Department of Orthopaedic Surgery, University of Tsukuba Hospital, Tsukuba, Ibaraki, 305-8576, Japan
| | - Sho Kohyama
- Department of Orthopaedic Surgery, Kikkoman General Hospital, Noda, Chiba, 278-0005, Japan
| | - Takeshi Ogawa
- Department of Orthopaedic Surgery, Mito Medical Center Hospital, Ibaraki, Ibaraki, 311-3193, Japan
| | - Tomoo Ishii
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan
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Dirckx M, Tathgar A, Bellringer S, Phadnis J. Hemiarthroplasty versus open reduction internal fixation for intra-articular distal humerus fractures in older patients. Shoulder Elbow 2023; 15:83-92. [PMID: 36895603 PMCID: PMC9990103 DOI: 10.1177/17585732221093004] [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: 01/05/2022] [Accepted: 03/22/2022] [Indexed: 11/15/2022]
Abstract
Background Intra-articular distal humerus fractures in the older population remain a challenge to fix, due to the comminution of fragments and poor bone stock. Recently Elbow Hemiarthroplasty (EHA) has gained popularity to treat these fractures, however no studies exist comparing EHA to Open Reduction Internal Fixation (ORIF). Objectives To compare the clinical outcomes of patients over the age of 60 years treated with ORIF or EHA for multi-fragmentary distal humerus fractures. Methods Thirty-six patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of thirty-four months (12-73 months). Eighteen patients were treated with ORIF and eighteen with EHA. The groups were matched for fracture type, demographic characteristics and follow up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes. The quality of ORIF was judged against set radiographic criteria in order to understand the effect of sub-optimal ORIF technique. Results No significant clinical difference was found between EHA and ORIF in mean OES (42.5 vs 39.6, p = 0.28), mean VAS (0.5 vs 1.7, p = 0.08) or mean flexion-extension arc (123° vs 112°, p = 0.12). There were significantly more complications associated with ORIF compared to EHA (39% vs 6%, p = 0.04). ORIF executed with satisfactory fixation technique had a comparable complication rate compared to EHA (17% vs 6%, p = 0.6). Two ORIF patients required revision to Total Elbow Arthroplasty (TEA). None of the EHA patients required revision surgery. Conclusion This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age. Early complications and re-operations were higher in the ORIF group, although this could be related to improper ORIF technique and patient selection.
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Affiliation(s)
| | | | | | - Joideep Phadnis
- University Hospitals Sussex, Brighton, UK
- Brighton & Sussex Medical
School, UK
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Giordano V, Glória RC, Dos Santos TA, Koch HA, Giannoudis PV. Extra-articular Olecranon Osteotomy for Reconstruction of Distal Humerus Fractures: Technique and Clinical Results. Orthopedics 2022; 45:e220-e225. [PMID: 35245137 DOI: 10.3928/01477447-20220225-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Articular fractures of the distal humerus in adults are challenging fractures requiring adequate surgical exposure for optimum reconstruction. Most commonly, an articular osteotomy of the olecranon is performed, but complications have been reported related to both creating and repairing the articular osteotomy. We describe the use of an extra-articular olecranon osteotomy for approaching articular fractures of the distal humerus. We highlight the surgical steps required to obtain adequate exposure facilitating anatomical reduction, stable fixation, and early range of motion of the elbow joint. This technique can be added to the surgeon's armamentarium for the management of these complex injuries. [Orthopedics. 2022;45(4):e220-e225.].
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Jenkins CW, Edwards GAD, Chalk N, McCann PA, Amirfeyz R. Does preservation of columns affect the medium-term outcome in distal humerus hemiarthroplasty for acute unreconstructable fractures? Shoulder Elbow 2022; 14:85-94. [PMID: 35154409 PMCID: PMC8832714 DOI: 10.1177/1758573220977768] [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: 06/30/2020] [Accepted: 11/09/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND We assessed distal humeral column preservation effects on clinical, radiographic and patient reported outcomes following distal humerus hemiarthroplasty for acute unreconstructable fractures. METHODS Thirty-seven consecutive patients (mean age, 75; range, 29-93 years) with an average follow-up of 61 months (range, 24-105 months) after distal humerus hemiarthroplasty using a triceps preserving approach were studied. QuickDASH and Oxford Elbow Score assessed patient reported outcomes. Clinical and radiographic assessments comprised range of motion, grip strength, instability, implant loosening, chondral wear, heterotopic ossification and condylar union. RESULTS Average QuickDASH was 14.9 (range, 0-63) and Oxford Elbow Score 40.35 (range, 25-48). Mean flexion arc was 108°, extension deficit 17° and pronosupination arc 155°. Average operative sided grip strength was 31.05 kg versus 31.13 kg contralaterally. Column preservation had no statistically significant effect on QuickDASH (p = 0.75), Oxford Elbow Score (p = 0.78), flexion-extension (p = 0.87), pronosupination (p = 0.78) or grip strength (p = 0.87). No progressive radiographic loosening or symptomatic chondral wear occurred. All fixed columns united. Three cases of immediate post-operative laxity fully resolved on elbow mobilisation. Four post-operative complications required further surgery: one ulnar neuropathy, one heterotopic ossification, one wound breakdown and one traumatic dislocation. CONCLUSION Medium-term outcome of distal humerus hemiarthroplasty for acute unreconstructable distal humeral fractures is reliable irrespective of condylar preservation.
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Affiliation(s)
| | | | | | | | - Rouin Amirfeyz
- Rouin Amirfeyz, Department of Orthopaedic Surgery, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK.
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Nandi R, Ghosh S, Maiti A, Mandal A, Maiti G. Outcome of fixation of distal humerus fracture via paratricipital approach – A prospective study. JOURNAL OF ORTHOPAEDIC DISEASES AND TRAUMATOLOGY 2022. [DOI: 10.4103/jodp.jodp_10_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Taylor JR, Shea KE, Clark CF, Kelly JD, Schrumpf MA. Elbow hemiarthroplasty for intra-articular distal humerus fractures: results and technique. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:408-413. [PMID: 37588715 PMCID: PMC10426562 DOI: 10.1016/j.xrrt.2021.08.002] [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: 08/18/2023]
Abstract
Purpose The purpose of this study was to report results of elbow hemiarthroplasty for comminuted, intra-articular distal humerus fractures in low-demand elderly female patients. Methods This is a retrospective case series of eight patients who underwent elbow hemiarthroplasty for comminuted, intra-articular distal humerus fractures between 2015 and 2019. Patients were considered for the procedure if the humeral fractures were deemed nonreconstructable by open reduction internal fixation. Patients were excluded if the extensor mechanism was not intact, evidence of significant ulnohumeral osteoarthritis, or a fracture to the proximal radius or ulna. A "triceps-on" approach was used in all cases. Appropriate sizing of the spool and length of the implant were determined by intraoperative fluoroscopy. Both ulnar collateral ligament and the lateral ulnar collateral ligaments were repaired through the central spool after final placement of the implant. Postoperative radiographs, clinical data, and the Mayo Elbow Performance Score were used to assess elbow pain and function. Results Seven patients were included in final analysis. One patient was excluded from final analysis after sustaining a ground-level elbow dislocation at 13 weeks postoperatively, which subsequently revised to total elbow arthroplasty. The average age at the final follow-up was 72.1 years and duration of follow-up was 29.9 months (range 11.4-58.8 months). Average elbow range of motion was 21° ± 15° extension, 135° ± 9° flexion, 87° ± 5° pronation and 84° ± 8° supination. The average Mayo Elbow Performance Score was 88.3 (range 85-95; or "good" to "excellent") at the final follow-up. Postoperative ulnar neuropathy was reported by one patient at the first postoperative visit. This was followed up clinically and evaluation at 24 months revealed mild residual sensory deficits and adequate strength and motor function. Conclusion Elbow hemiarthroplasty using the humeral component of the total elbow arthroplasty is an option for treatment of isolated, comminuted distal humerus fractures in select patient populations. The ideal candidates are elderly, low-demand, and able to adhere to postoperative activity and weight-bearing restrictions. Overall patient satisfaction with off-label use of humeral component of commercially available total elbow implants in the United States is promising, yet development of a more anatomic spool is warranted to further optimize outcomes intraoperatively. Some advantages of elbow hemiarthroplasty are a less-demanding operation and avoids complications associated with linked design including polyethylene wear, periprosthetic fracture, or implant loosening. Limitations of this study include small sample size and retrospective nature of the study.
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Functional Outcome and Inflammatory Response of Patients with Extra-Articular Distal Humeral Fractures following Implantation of Anatomically Precontoured Locking Compression Plates through a Posterior Approach. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:2426298. [PMID: 34367298 PMCID: PMC8342152 DOI: 10.1155/2021/2426298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/23/2021] [Indexed: 11/17/2022]
Abstract
Distal humeral fractures are challenging injuries to surgically correct and account for up to 2% of all adult fractures. Surgical management of extra-articular distal humeral fractures is challenging considering surgical approach, implant selection, and position of the implant owing to the availability of different precontoured implants and plate configurations. Anatomically precontoured locking compression plates (APLCPs) allow the placement of angular stable screws right underneath the reduced joint surface fragments. To date, there is a lack of evidence supporting its superiority to conventional locking plate osteosynthesis (LPO) in treating extra-articular distal humeral fractures. The objective of the study is to evaluate the efficacy and safety of APLCPs in the treatment of extra-articular distal humeral fractures. A total of 100 patients diagnosed with humeral fractures and receiving treatments in our hospital between May 2018 and May 2020 fulfilled inclusion and exclusion criteria and were randomly assigned to LPO and APLCP groups according to the odd-even of the order of hospital admission, 50 cases per groups. Clinical endpoints were assessed including operation time; in-bed time; length of hospital stay; volume of intraoperative blood loss; VSA scores before and 24, 48, and 72 h after surgery; MEPS scores before and 3, 6, and 12 months after surgery; range of motion, flexion, and extension of the elbow; serum levels of CK, CRP, and IL-6; and incidence of complications after surgery. It was found that the APLCP group exhibited shortened operation time and in-bed time, decreased length of hospital stay, and reduced volume of intraoperative blood loss compared to the LPO group (all P < 0.001). The two groups had declined VSA scores concomitant with increased MEPS scores after surgery in a time-dependent manner (P < 0.001). Notably, the VSA scores in the APLCP group were all lower than those in the LPO group at indicated time points (24, 48, and 72 h) after surgery (P < 0.001). Besides, the MEPS scores in the APLCP group were all higher than those in the LPO group at indicated time points (3, 6, and 12 months) after surgery (P < 0.001). It was revealed that the patients receiving extra-articular distal humeral APLCP through posterior approaches exhibited greater ranges of motion, flexion, and extension of the elbow than those receiving LPO after surgery (P < 0.001). The patients receiving extra-articular distal humeral APLCP through posterior approaches exhibited lower serum levels of IL-6, CRP, and CK than those receiving LPO after surgery (IL-6: P=0.007, CRP: P=0.001, CK: P=0.001). The APLCP had a lower total incidence rate of complication than the LPO group (48.00% vs. 18.00%, P=0.003). In conclusion, these data support the notion that the implantation of anatomically precontoured APLCP through a posterior approach allows for improved functional outcomes and attenuated inflammatory response and prevents the incidence of postoperative complications compared to conventional LPO for internal fixation of extra-articular distal humeral fractures.
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Lim JR, Yoon TH, Lee HM, Chun YM. Anatomic fit of precontoured extra-articular distal humeral locking plates: a cadaveric study. Clin Shoulder Elb 2021; 24:66-71. [PMID: 34078013 PMCID: PMC8181839 DOI: 10.5397/cise.2021.00227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background Extra-articular distal humerus locking plates (EADHPs) are precontoured anatomical plates widely used to repair distal humeral extra-articular diaphyseal fractures. However, EADHPs frequently cause distal protrusion and resulting skin discomfort. The purpose of this study was to predict the occurrence of anatomic fit mismatch. We hypothesized that the smaller the humerus size, the greater the anatomic fit mismatch with EADHP. Methods Twenty humeri were analyzed in this study. Humeral length and distal humeral width were used as parameters of humeral size. Plate protrusion was measured between the EADHP distal tip and the distal humerus. We set the level of unacceptable EADHP anatomic fit mismatch as ≥10 mm plate protrusion. Results A significant negative linear correlation was also confirmed between humeral size and plate protrusion, with a coefficient of determination of 0.477 for humeral length and 0.814 for distal humeral width. The cutoff value of humeral length to avoid ≥10 mm plate protrusion was 293.6 mm (sensitivity, 88.9%; specificity, 81.8%) and for distal humeral width was 60.5 mm (sensitivity, 100%; specificity, 81.8%). Conclusions Anatomic fit mismatch in distal humeral fractures after EADHP fixation has a negative linear correlation with humeral length and distal humeral width. For patients with a distal humeral width <60.5 mm, ≥10 mm plate protrusion will occur when an EADHP is used, and an alternative implant or approach should be considered.
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Affiliation(s)
- Joon-Ryul Lim
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hwan Yoon
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hwan-Mo Lee
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Karslioglu B. Transverse olecranon osteotomy with Gigli saw: A fast and reliable technique. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2021. [DOI: 10.25083/2559.5555/6.1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective. Distal humerus fractures constitute of approximately 2% of all fractures and 30% of elbow fractures. Olecranon osteotomy provides excellent exposure of distal humerus and articular surface. In this study, we aimed to compare transverse osteotomy with gigli saw and classical chevron osteotomy techniques in terms of osteotomy duration and clinical results. Materials and Methods. 40 elbows of 40 patients with Type B intraarticular distal humerus fractures according to AO classification were included in our study. Patients were divided into 2 groups as transverse or chevron osteotomy groups. Patients were evaluated in terms of intraoperative osteotomy time, postoperative time to union, range of motion in the elbow joint and Quick Dash scores at 6th, 12th and 24th months. Results. The mean age of the patients was 45.6 years (19-62). 40% of the patients (8 patients) in the Chevron group had more than 2 mm stepping at articular surface, while this rate was 10% (2 patients) in the gigli saw group. Union was obtained in all patients for both techniques. There was no significant difference between the mean QuickDASH scores and range of motion of the elbow joints except flexion in both groups. Range of motion of flexion was statistically better in the gigli saw group (p<0.05). Conclusions. Transverse osteotomy technique significantly reduces osteotomy and fixation time and will not cause problems in fracture union. It may be preferred because it is simpler and faster to apply than chevron osteotomy and because intra-articular stepping is less common.
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Celli A, Paroni C, Bonucci P, Celli L. Total elbow arthroplasty for acute distal humeral fractures with humeral condyle resection or retention: a long-term follow-up study. JSES Int 2021; 5:797-803. [PMID: 34223433 PMCID: PMC8245998 DOI: 10.1016/j.jseint.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Open reduction and internal fixation is the gold standard for the operative treatment of intra-articular distal humeral fractures. However, in elderly patients the approach involves a high rate of complications. We reviewed the long-term outcomes of 13 primary total elbow arthroplasties (TEAs) performed to treat acute fractures in non-rheumatoid patients who at the time of trauma were aged less than 70 years. The aim of the study was to establish whether condyle retention enhances hinge stability and influences outcomes in these patients, who are younger than those who typically undergo TEA. Methods In 13 consecutive patients with acute distal humeral fractures aged 61-67 years, a linked semi-constrained Coonrad-Morrey prosthesis was implanted. The medial and lateral condylar bone fragments were resected (7 patients) or stabilized to the diaphysis using k-wires or plates (6 patients). Results At a mean follow-up of 12 years, the mean Mayo Elbow Performance Score was 88 and patient satisfaction was 85%. Nine patients (70%) did not require surgical revision. All revisions involved the group managed by condyle resection. Discussion TEA can be considered in elderly subjects with acute distal humeral fracture. In our patients, resection of the medial and lateral condyle fragments did not influence outcomes, although clinical observation suggested that it involves greater mechanical stress on the hinge, heightening the long-term risk of bushing wear. Condyle fixation with plates or k-wires seems to afford longer implant survival and is recommended in younger patients with higher functional demands.
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Affiliation(s)
- Andrea Celli
- Department of Orthopaedic and Trauma Surgery, Shoulder and Elbow Unit, Hesperia Hospital, Modena, Italy
| | - Chiara Paroni
- Department of Orthopaedic and Trauma Surgery, Shoulder and Elbow Unit, Hesperia Hospital, Modena, Italy
| | - Pierluigi Bonucci
- Department of Orthopaedic and Trauma Surgery, Shoulder and Elbow Unit, Hesperia Hospital, Modena, Italy
| | - Luigi Celli
- Department of Orthopaedic and Trauma Surgery, Shoulder and Elbow Unit, Hesperia Hospital, Modena, Italy
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Olson JJ, Dyer GS. Skinny wire and locking plate fixation for comminuted intra-articular distal humerus fractures: a technical trick and case series. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:34-40. [PMID: 37588629 PMCID: PMC10426594 DOI: 10.1016/j.xrrt.2020.11.007] [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: 08/18/2023]
Abstract
Introduction Intra-articular distal humerus fractures present a challenge to orthopedic surgeons. Stable fixation is difficult to achieve in fractures with articular and metaphyseal comminution and osteoporotic bone. Hence, these fractures are more commonly being managed with total elbow arthroplasty. We describe a novel surgical technique that confers stable fixation, allowing for early range of motion resulting in a high rate of union, a functional range of motion, and excellent patient reported outcome scores without the activity restrictions of total elbow arthroplasty. Methods Retrospective case series of 30 patients with AO/OTA type B and C intra-articular distal humerus fractures who underwent ORIF from 2014-2019 utilizing a novel surgical technique that focuses on reconstructing a comminuted articular surface through meticulous, transverse fixation of the tiny articular fragments with long, thin Kirchner wires, which are then bent over and trapped under locking compression plates to create a fixed angle support to the metadiaphysis. Results Patient mean age of 59 (19-90) years and 61% were female. Median follow up was 1.2 years. Twenty-seven (87%) were type C fractures and 3 (13%) were type B. Five patients (16%) suffered a concurrent ipsilateral upper extremity injury and four (13%) had an open fracture. Two were polytrauma patients. All fractures healed with an average time to union of 11 weeks. Over 80% patients reported no or mild pain at final follow up. Mean arc of elbow motion was 102 degrees, mean QuickDASH score 25.2. Post-operative complications included ulnar nerve paresthesias (38%), wound infection (3.2%), heterotopic ossification (3.2%), and olecranon nonunion (3.2%). Eight patients underwent secondary procedures: 7 (23%) removal hardware, 3(9.6%) capsular release, 2 (6.4%) ulnar nerve transpositions, and 1 (3.2%) total elbow arthroplasty. Conclusion We describe a novel surgical technique that we believe results in strong, stable fixation of complex intra-articular distal humerus fractures irrespective of bone quality. In our series, all fractures healed and post-operatively patients reported low levels of pain, achieved excellent elbow range of motion, high patient reported outcome scores. Patients should be counseled about high rates of post-operative ulnar nerve paresthesias that can be expected to improve over time and high reoperation rates for symptomatic hardware.
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Affiliation(s)
- Jeffrey J. Olson
- Harvard Combined Orthopaedic Surgery Program, Boston, MA, USA
- Orthopaedic Trauma Initiative at Harvard Medical School, Boston, MA, USA
| | - George S.M. Dyer
- Harvard Combined Orthopaedic Surgery Program, Boston, MA, USA
- Orthopaedic Trauma Initiative at Harvard Medical School, Boston, MA, USA
- Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, MA, USA
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Cho JW, Kim BS, Yeo DH, Kang SH, Lim EJ, Sakong S, Cho WT, Oh JK. Clinical outcome of AO/OTA type C fracture of the distal humerus using the expanded paratricipital approach and cadaveric comparison of the exposure of the paratricipital and expanded paratricipital approaches to the distal humerus. J Shoulder Elbow Surg 2020; 29:1554-1563. [PMID: 32713465 DOI: 10.1016/j.jse.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/20/2020] [Accepted: 03/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach. METHODS Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows. RESULTS The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection. CONCLUSIONS The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.
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Affiliation(s)
- Jae-Woo Cho
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Do-Hyun Yeo
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Seong Hyun Kang
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Seungyeob Sakong
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea
| | - Won-Tae Cho
- Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Republic of Korea.
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University Medicine, Seoul, Republic of Korea.
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Saracco M, Smimmo A, De Marco D, Palmacci O, Malerba G, Vitiello R, Maccauro G, Minutillo F, Rovere G. Surgical approach for fracture of distal humerus: Posterior vs lateral. Orthop Rev (Pavia) 2020; 12:8664. [PMID: 32913599 PMCID: PMC7459372 DOI: 10.4081/or.2020.8664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022] Open
Abstract
Humeral fractures have an incidence of 3-5% and a bimodal age distribution. They may occur in young patients after highenergy traumas or in elderly osteoporotic patients after low-energy injuries. In nondisplaced fractures or in elderly patients, humeral fractures are treated by conservative methods. Open reduction and internal fixation (ORIF) should be the treatment of choice in case of multi-fragmentary fractures associated with radial nerve palsy or not. ORIF is usually regarded as the gold standard treatment, but, depending on the different types of fracture, the surgical approach can change. In this review, we compare results and complication rates between lateral and posterior surgical approaches in the management of extraarticular distal humeral shaft fractures. An internet-based literature research was performed on Pubmed, Google Scholars and Cochrane Library. 265 patients were enrolled: 148 were treated by lateral or antero-lateral approach, while 117 by posterior or postero-lateral approach. The literature shows that no differences between the posterior and lateral approach exist. Certainly, the posterior approach offers undoubted advantages in terms of exposure of the fracture and visualization of the radial nerve. In our opinion, the posterior approach may also allow better management of complex and multi-fragmentary fractures.
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Affiliation(s)
- Michela Saracco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Smimmo
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Davide De Marco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Osvaldo Palmacci
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Malerba
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaele Vitiello
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Felice Minutillo
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Rovere
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Università Cattolica del Sacro Cuore, Rome, Italy
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Association of Patient-reported Outcomes With Clinical Outcomes After Distal Humerus Fracture Treatment. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00122. [PMID: 32440623 PMCID: PMC7209807 DOI: 10.5435/jaaosglobal-d-19-00122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/15/2020] [Indexed: 01/09/2023]
Abstract
In this study, we assessed the patient-reported outcomes of distal humerus fracture treatment using Patient-Reported Outcomes Measurement Information System (PROMIS) or QuickDASH (Disabilities of the Arm, Shoulder, and Hand) scores and the association between patient-reported outcomes and clinical outcomes. Methods We performed a retrospective cohort study of 76 adult patients who sustained an acute distal humerus fracture between 2016 and 2018; 53 patients completed at least one patient-reported outcome measure used to assess physical function (PF) during their routine follow-up care (69.7% response rate). The average time to follow-up patient-reported outcome measure was 10.3 months. Patients completed the PROMIS PF 10a, PROMIS upper extremity (UE) 16a, and/or QuickDASH based on the treating institution/service. In addition, the PROMIS Global (Mental) subscale score was used as a measure of self-rated mental health. To assess clinical outcomes, we measured radiographic union, range of motion, and postoperative complications. Results Most fractures were intra-articular (67.9%), and 84.9% were treated surgically. After treatment, 98.1% of fractures united radiographically. By the final follow-up, the average arc of motion was 18° to 122°. Average (±SD) PROMIS PF and UE scores were 41.7 ± 11.1 and 40.8 ± 12.4, respectively. The average QuickDASH score was 39.4 ± 26.5. The arc of flexion-extension and PROMIS Global (Mental) score were independently associated with PROMIS PF and PROMIS UE scores. Conclusions We found that clinical factors (the arc of flexion-extension) and patient psychological factors (PROMIS Global [Mental] score) were independently associated with PROMIS measures of PF after distal humerus fracture treatment. These data can be used to contextualize patient outcomes and guide patient expectations.
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Atif M, Hasan O, Mohib Y, Rashid RH, Hashmi P. Does surgical approach affect outcome after fixation of intra-articular fractures of distal humerus? Retrospective cohort study from a level-1 trauma centre in a metropolitan city. Ann Med Surg (Lond) 2019; 43:48-51. [PMID: 31198551 PMCID: PMC6556481 DOI: 10.1016/j.amsu.2019.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction Fractures around the distal humerus fractures make up to 2% of all fractures. Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint. Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction. Conflict still persists regarding the choice of ideal approach. In this study we compare the effect of surgical approach triceps lifting vs olecranon osteotomy on the functional outcome after fixation of distal humerus fractures. Methods Non-funded, non-commercial, retrospective cohort study was conducted on patients with closed distal humerus intra-articular fractures between 2010 and 2015 at our tertiary care level-1 trauma and university hospital. Patients >18 years of age with closed complex intra-articular distal humerus fracture were operated using one of the two surgical approaches, either triceps lifting approach (Group1) or with olecranon osteotomy (Group 2). Functional evaluation using quick DASH scores at 1 year of follow-up. Study is registered with ID:NCT03833414 and work has been reported in line with the STROCSS criteria. Results Out of 43 patients 16 were treated with triceps lifting approach and 27 with olecranon osteotomy. The difference between the mean quick DASH score for both groups was not statistically significant (p = 0.52) although higher for group 1. Complications were comparable for both groups but 2 patients suffered delayed union of osteotomy site in group 2. Conclusion Triceps lifting approach can be used equally efficiently for exposure of these complex distal humerus injuries with no comprise in visibility of articular fragments. Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint. Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction. For long time, olecranon osteotomy approach was utilized to provide clear access to the joint. This is at the cost of creating osteotomy and the risk of its delayed/nonunion. Triceps lifting approach avoids this catastrophic complication.
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Affiliation(s)
| | - Obada Hasan
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
| | - Yasir Mohib
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
| | - Rizwan Haroon Rashid
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
| | - Pervaiz Hashmi
- Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
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18
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Lee HJ. Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures. Clin Shoulder Elb 2019; 22:113-117. [PMID: 33330205 PMCID: PMC7714297 DOI: 10.5397/cise.2019.22.2.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/01/2019] [Accepted: 04/07/2019] [Indexed: 12/02/2022] Open
Abstract
Treating distal humerus fractures, especially those involving intra-articular lesions, is complex and often technically demanding. Although there still exist many controversial issues, the goal of treatment is to establish anatomical stable fixation by restoring the two columns and the articular surface. Universally, a posterior midline incision is applied, and the approach varies according to the further management of the triceps or olecranon. Evidence supports dual plate fixation as the optimal fixation method, and debates regarding appropriate plating configuration are still ongoing. As multiple clinical studies comparing results of parallel and perpendicular plate fixation have shown no actual difference, it is important to place the plates according to the fracture configuration.
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Affiliation(s)
- Hyo-Jin Lee
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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19
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Jansen H, Eden L, Meffert RH, Heintel T, Frey SP. Posttraumatic elbow agility and reduction of muscle force after intra-articular distal fractures of the humerus in adults. Technol Health Care 2019; 27:431-439. [PMID: 31033473 DOI: 10.3233/thc-191659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Treatment of distal intra-articular humerus fractures is still a technical challenge. Until now, little is known about the regain of strength and elbow agility after surgical treatment of these fractures. Due to small collectives there is only limited data. OBJECTIVE Investigation of regained strength and elbow agility in patients with intra-articular distal humerus fractures. METHODS A total of 28 patients were treated with distal intra-articular humerus fractures followed up for an average period of 62.3 months. The following parameters were examined: Arthrosis, heterotopic ossification, functional outcome (MEPS, DASH score, LES) and isometric strength of the elbow in extension and flexion was tested in 30∘, 60∘ and 90∘ in a custom-made positioning device. RESULTS There was a high complication rate with 32%. At the 60th month post injury, range of motion (ROM) of the elbow was 114∘ with a reduction of 32∘ compared to the contralateral uninjured side (p< 0.001). The highest reduction was seen in extension with an average loss of 16∘ (p< 0.001). Loss of motion correlated with the fracture severity regarding the AO-classification (r= 0.54, p< 0.01). The average regained muscle force was 81.5% in flexion and 92% in extension in comparison to the contralateral healthy side. Patients over 60 years had less range of motion and inferior results in the DASH score compared to younger patients. CONCLUSIONS Functional impairment in terms of reduced ROM and muscle force is a common complication after distal intra-articular humerus fracture. Patients over 60 years have a higher deficit of motion in the injured elbow joint and an inferior clinical outcome. Superiority of modern angle-stable implants could yet not be shown.
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Affiliation(s)
- Hendrik Jansen
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University of Würzburg, Würzburg, Germany
| | - Lars Eden
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University of Würzburg, Würzburg, Germany
| | - Rainer H Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University of Würzburg, Würzburg, Germany
| | - Timo Heintel
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University of Würzburg, Würzburg, Germany
| | - Sönke P Frey
- Department of Orthopedics and Trauma Surgery, St. Josef-Hospital Bochum, Katholisches Klinikum Bochum, Ruhr University Bochum, Bochum, Germany
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20
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Federer AE, Mather RC, Ramsey ML, Garrigues GE. Cost-effectiveness analysis of total elbow arthroplasty versus open reduction-internal fixation for distal humeral fractures. J Shoulder Elbow Surg 2019; 28:102-111. [PMID: 30551781 DOI: 10.1016/j.jse.2018.08.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/21/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty (TEA) and open reduction-internal fixation (ORIF) are 2 viable surgical treatment options for acute, intra-articular distal humeral fractures in elderly patients. Whereas recent systematic reviews and randomized trials have suggested that TEA and ORIF result in similar functional outcome scores, no previous study has assessed the comparative cost-effectiveness between TEA and distal humeral ORIF in this specific demographic. METHODS A Markov model was created with the highest-level data available from the literature depicting transitioning health states based on treatment strategies. To populate the quality-of-life data points in the model lacking in the literature, a survey was conducted of patients at 2 referral institutions who underwent TEA or ORIF for acute, intra-articular distal humeral fractures via the European Quality of Life, 5 Domains (EQ-5D) questionnaire at least 2 years postoperatively. Cost data from 2016 for each strategy were used to calculate the comparative cost-effectiveness of TEA versus ORIF. RESULTS For patients aged 65 years, the total cost of TEA was $19,407 compared with $20,669 for ORIF. The effectiveness of TEA and ORIF was 8.17 and 7.72, respectively. Overall, the incremental cost-effectiveness ratio of TEA ($2375.76/quality-adjusted life-year) was favored more than ORIF ($2677.26/quality-adjusted life-year). CONCLUSION These findings suggest TEA is a slightly more cost-effective procedure than ORIF for most elderly patients who sustain acute, intra-articular distal humeral fractures. Still, the unique limitations, complications, and revision rates for each strategy must be carefully weighed for each patient when making a decision.
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Affiliation(s)
- Andrew E Federer
- Sports Division, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Richard C Mather
- Sports Division, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew L Ramsey
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
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21
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Wu ZZ, Wang JD, Ji XX, Ma ZJ, Wu JH, Wang QG. Surgical exposures of the distal humeral fractures: An anatomical study of the anterior, posterior, medial and lateral approaches. Chin J Traumatol 2018; 21:356-359. [PMID: 30598337 PMCID: PMC6354175 DOI: 10.1016/j.cjtee.2018.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/03/2018] [Accepted: 09/13/2018] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Exposure of the articular surface is the key to the successful treatment of intra-articular fractures of distal humerus. Anterior, posterior olecranon osteotomy as well as medial and lateral approaches are the four main approaches to the elbow. The aim of this study was to compare the exposure of distal articular surfaces of these surgical approaches. METHODS Twelve cadavers were used in this study. Each approach was performed on six elbows according to previously published procedures. After completion of each approach, the exposed articular surfaces were marked by inserting 0.5 mm K-wires along the margins. The elbow was then disarticulated and the exposed articular surfaces were painted. The distal humeral articular surfaces were then closely wrapped using a piece of fibre-glass screen net with meshes. The exposed articular surfaces and the total articular surfaces were calculated by counting the number of meshes, respectively. RESULTS The average percentages of the exposed articular surfaces for the anterior, posterior olecranon osteotomy, medial and lateral approaches were 45.7% ± 2.0%, 53.9% ± 7.1%, 20.6% ± 4.9% and 28.5% ± 6.3%, respectively. CONCLUSION The anterior and posterior approaches provide greater exposures of distal humeral articular surface than the medial and lateral ones in the treatment of distal humeral fractures.
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Affiliation(s)
- Zi-Zheng Wu
- Shanghai Trauma & Emergency Center, Shanghai General Hospital of Nanjing Medical University, Shanghai, China,Department of Orthopaedics, Baoshan Branch of Shanghai General Hospital of Shanghai Jiaotong University, Shanghai, China
| | - Jian-Dong Wang
- Shanghai Trauma & Emergency Center, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Xiao-Xi Ji
- Shanghai Trauma & Emergency Center, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Zhi-Jian Ma
- Shanghai Trauma & Emergency Center, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Jian-Hong Wu
- Shanghai Trauma & Emergency Center, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Qiu-Gen Wang
- Shanghai Trauma & Emergency Center, Shanghai General Hospital of Nanjing Medical University, Shanghai, China,Corresponding author.
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Zarezadeh A, Mamelson K, Thomas WC, Schoch BS, Wright TW, King JJ. Outcomes of distal humerus fractures: What are we measuring? Orthop Traumatol Surg Res 2018; 104:1253-1258. [PMID: 30352777 DOI: 10.1016/j.otsr.2018.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 08/03/2018] [Accepted: 08/23/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We evaluate the most common outcome measures used in distal humerus fracture studies in order to suggest standardization for future research. MATERIALS AND METHODS A systematic review identified articles assessing the outcomes of acute distal humerus fractures from 2006 to 2016 from PubMed and Web of Science databases. The inclusion criterion was studies reporting on the outcomes of treatment of acute distal humerus fractures. Review articles, meta-analyses, studies with<5 patients, technique articles, biomechanical studies, and those focusing on one complication/outcome were excluded. Patient demographics and all outcome measures were reviewed. Journal and demographic factors were then compared. RESULTS One-hundred-nine of 2158 articles met inclusion criteria. The median number of fractures per study was 35. Mean patient age was 55.0 years. Average follow-up was 35 months. Range-of-motion and strength measurements were reported in 90% and 17% of studies, respectively. Twenty patient-reported outcome instruments were used. The most commonly reported measures were MEPS, DASH, VAS pain, and Quick DASH scores. An average of 1.9 outcome measures were reported per study. A journal impact factor of≥1.5 was associated with more reported outcome measures. Articles including elbow arthroplasty were associated with higher impact factor journals, more outcome measures, and longer follow-up. Level of evidence was not associated with the number of reported outcome measures. DISCUSSION The current distal humerus fracture literature inconsistently reports outcome measures. More outcome measures were reported in higher impact journals. Future distal humerus fracture studies should include MEPS, DASH or Quick DASH, and VAS Pain scores to allow for appropriate cross-study comparison. LEVEL OF EVIDENCE IV, Systematic review.
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Affiliation(s)
- Ali Zarezadeh
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Kelly Mamelson
- College of Medicine, Florida State University, Tallahassee, FL, USA
| | - W Christian Thomas
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA.
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Pediatric and Adolescent T-type Distal Humerus Fractures. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 1:e040. [PMID: 30211365 PMCID: PMC6132339 DOI: 10.5435/jaaosglobal-d-17-00040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although fractures of the elbow are extremely common in pediatric patients, the T-type distal humerus fracture is rare and offers unique challenges. The mechanism of injury may be similar to the adult counterpart and is usually caused by a fall onto a flexed elbow or from a direct blow. Diagnosing these injuries may be difficult. They often resemble extension-type supracondylar fractures, yet the treatment algorithm is quite different. In younger patients, percutaneous pinning remains a viable option, but for older adolescents, open reduction and internal fixation provides stable fixation at the elbow and the most reliable restoration of the articular surface. Appropriate imaging, careful radiographic diagnosis, and choice of surgical technique are of paramount importance when treating young patients with this injury. Most pediatric and adolescent patients with T-type distal humerus fractures have results better than those of adults but often worse than other elbow fractures in this age group.
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Sharma S, John R, Dhillon MS, Kishore K. Surgical approaches for open reduction and internal fixation of intra-articular distal humerus fractures in adults: A systematic review and meta-analysis. Injury 2018; 49:1381-1391. [PMID: 29934098 DOI: 10.1016/j.injury.2018.06.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/31/2018] [Accepted: 06/12/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND A number of surgical approaches have been described for open reduction and internal fixation (ORIF) of intra-articular distal humerus (IDH) fractures in adults. However, there is no consensus as to which approach is better in terms of functional outcomes and complications. The purpose of this study was to determine whether the functional outcomes and types and rates of complications are influenced by the choice of surgical approach for ORIF of IDH fractures (AO/OTA types 13 B & C). METHODS A systematic review of literature was performed using the PubMed, EMBASE and Cochrane Database of Systematic Reviews databases. Studies, both prospective and retrospective and comparative or non-comparative, dealing with surgical approaches for ORIF of IDH fractures in adult patients were included. Conference abstracts, studies looking primarily at the results of internal fixation rather than the surgical approach, those including extra-articular distal humeral fractures, pediatric distal humeral fractures (<18 years of age), delayed unions, non unions, malunions, cadaveric studies, pathological fractures and studies with <10 patients were excluded. Studies that looked at surgical modalities other than internal fixation (for e.g. total elbow arthroplasty) for intra-articular distal humerus fractures or those that did not report a validated functional outcome scoring system were also excluded. RESULTS 11 studies were included in the qualitative analysis, of which 5 were comparative studies and 6 were non-comparative. Quantitative analysis was performed on two sets of two studies, each set comparing the Bryan and Morrey or the triceps-split approach to the olecranon osteotomy approach, and revealed no significant differences in the Mayo Elbow Performance Score, range of motion and rates of complications. The overall methodological quality of the studies included in the review was low. CONCLUSIONS High-quality evidence on surgical approaches for ORIF of IDH fractures in adults is lacking. Evidence from low-quality studies indicates that there is no difference in the functional outcomes or complication rates when comparing the Bryan and Morrey or triceps-split to the olecranon osteotomy approach. Future research in the form of high-quality randomized controlled trials is needed to determine which approach is superior in terms of functional outcomes and complications.
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Affiliation(s)
- Siddhartha Sharma
- Department of Orthopedics, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
| | - Rakesh John
- Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India
| | - Mandeep S Dhillon
- Department of Orthopedics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Kamal Kishore
- Department of Biostatistics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Ogawa T, Shirasawa S. Conservative treatment in displaced fractures of the humeral capitellum: a reduction technique under local anaesthesia. BMJ Case Rep 2018; 2018:bcr-2017-223820. [PMID: 29666087 DOI: 10.1136/bcr-2017-223820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report the case of a 46-year-old woman who struck her right elbow on the ground after a fall on ice. Radiography showed a right humeral capitellar fracture, and CT further confirmed a Dubberley type 1A fracture. Closed reduction was performed under local anaesthesia, and an anatomical position was obtained. After the reduction, her right elbow was casted for 18 days. Three months after the injury, bone union was achieved without displacement, and the active range of motion of her right elbow recovered similar to the unaffected side. At 1 year postinjury, the Grantham score was excellent, and she obtained a two-point score on the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire. Although surgical treatment is recommended for a displaced humeral capitellar fracture, a Dubberley type 1A (no posterior column fracture of a distal humerus) can be effectively treated by early closed reduction.
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Affiliation(s)
- Takahisa Ogawa
- Department of Orthopaedics, Suwa Central Hospital, Chino-city, Nagano, Japan.,Department of Orthopaedics, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Shinichi Shirasawa
- Department of Orthopaedics, Suwa Central Hospital, Chino-city, Nagano, Japan
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Zheng W, Su J, Cai L, Lou Y, Wang J, Guo X, Tang J, Chen H. Application of 3D-printing technology in the treatment of humeral intercondylar fractures. Orthop Traumatol Surg Res 2018; 104:83-88. [PMID: 29248764 DOI: 10.1016/j.otsr.2017.11.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/29/2017] [Accepted: 11/08/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE OF THE STUDY This study was aimed to compare conventional surgery and surgery assisted by 3D-printing technology in the treatment of humeral intercondylar fractures. In addition, we also investigated the effect of 3D-printing technology on the communication between doctors and patients. MATERIAL AND METHODS A total of 91 patients with humeral intercondylar fracture were enrolled in the study from March 2013 to August 2015. They were divided into two groups: 43 cases of 3D-printing group, 48 cases of conventional group. The individual models were used to simulate the surgical procedures and carry out the surgery according to plan. Operation duration, blood loss volume, fluoroscopy times and time to fracture union were recorded. The final functional outcomes, including the motion of the elbow, MEPS and DASH were also evaluated. Besides, we made a simple questionnaire to verify the effectiveness of the 3D-printed model for both doctors and patients. RESULTS The operation duration, blood loss volume and fluoroscopy times for 3D-printing group was 76.6±7.9minutes, 231.1±18.1mL and 5.3±1.9 times, and for conventional group was 92.0±10.5minutes, 278.6±23.0mL and 8.7±2.7 times respectively. There was statistically significant difference between the conventional group and 3D-printing group (p<0.05). However, No significant difference was noted in the final functional outcomes between the two groups. Furthermore, the questionnaire showed that both doctors and patients exhibited high scores of overall satisfaction with the use of a 3D-printing model. DISCUSSIONS This study suggested the clinical feasibility of 3D-printing technology in treatment of humeral intercondylar fractures. LEVEL OF EVIDENCE Level II prospective randomized study.
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Affiliation(s)
- W Zheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109, Xueyuan Xi Road, Wenzhou 325000, China
| | - J Su
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - L Cai
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109, Xueyuan Xi Road, Wenzhou 325000, China
| | - Y Lou
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109, Xueyuan Xi Road, Wenzhou 325000, China
| | - J Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109, Xueyuan Xi Road, Wenzhou 325000, China
| | - X Guo
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109, Xueyuan Xi Road, Wenzhou 325000, China
| | - J Tang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109, Xueyuan Xi Road, Wenzhou 325000, China
| | - H Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109, Xueyuan Xi Road, Wenzhou 325000, China.
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An In Vitro Study of the Role of Implant Positioning on Ulnohumeral Articular Contact in Distal Humeral Hemiarthroplasty. J Hand Surg Am 2017; 42:602-609. [PMID: 28450102 DOI: 10.1016/j.jhsa.2017.03.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 03/25/2017] [Accepted: 03/31/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the effect of implant positioning on ulnohumeral contact using patient-specific distal humeral (DH) implants. METHODS Seven reverse-engineered DH implants were manufactured based on computed tomography scans of their osseous geometry. Native ulnae were paired with corresponding native humeri and custom DH implants in a loading apparatus. The ulna was set at 90° of flexion and the humeral component (either native bone or reverse-engineered implant) was positioned from 5° varus to 5° valgus in 2.5° increments under a 100-N compressive load. Contact with the ulna was measured with both the native distal humerus and the reverse-engineered DH implant at all varus-valgus (VV) angles, using a joint casting method. Contact patches were digitized and analyzed in 4 ulnar quadrants. Output variables were contact area and contact pattern. RESULTS Mean contact area of the native articulation was significantly greater than with the distal humeral hemiarthroplasty (DHH) implants across all VV positions. Within the native condition, contact area did not significantly change owing to VV angulation. Within the DHH condition, contact area also did not significantly change owing to VV angulation. Conversely, in the DHH condition, contact pattern did significantly change. Medial ulnar contact pattern was significantly affected by VV angulation. Lateral ulnar contact was variably affected, but generally decreased as well. CONCLUSIONS Ulnar contact patterns were changed as a result of VV implant positioning using reverse-engineered DH implants, most notably on the medial aspect of the joint. Implant positioning plays a crucial role in producing contact patterns more like those observed in the native joint. CLINICAL RELEVANCE Recent clinical evidence reports nonsymmetrical ulnar wear after DHH. This work suggests that implant positioning is likely a contributing factor and that more exact implant positioning may lead to better clinical outcomes.
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Smith GCS, Bayne G, Page R, Hughes JS. The clinical outcome and activity levels of patients under 55 years treated with distal humeral hemiarthroplasty for distal humeral fractures: minimum 2-year follow-up. Shoulder Elbow 2016; 8:264-70. [PMID: 27660659 PMCID: PMC5023057 DOI: 10.1177/1758573216660958] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/31/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of the present study was to describe the clinical outcomes and activity levels of young patients after distal humeral hemiarthroplasty (DHH). METHODS Six patients under 55 years (mean 44 years; range 29 years to 52 years) treated with DHH at a mean postoperative time of 81 months (range 24 months to 133 months) were studied retrospectively. Two other patients had been revised for aseptic loosening and were excluded. RESULTS The mean Mayo Elbow Score (MEPS) (88), Subjective Elbow Value (SEV) (89), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) (12) and American Shoulder and Elbow Surgeons (ASES) elbow pain (6), function (23) and satisfaction scores (9) were satisfactory. The mean University of California, Los Angeles (UCLA) activity score was 7.2. CONCLUSIONS Although only rarely indicated, DHH has satisfactory clinical outcomes in young patients and allows a higher level of function than is generally advised after total elbow arthroplasty.
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Affiliation(s)
- Geoffrey C. S. Smith
- St George Hospital, Gray Street, Kogarah, NSW, Australia,Geoffrey C. S. Smith, St George Hospital, Gray Street, Kogarah, NSW 2217, Australia.
| | - Grant Bayne
- Barwon Orthopaedic Research Unit, The Geelong Hospital, Barwon Health, Geelong, VIC, Australia
| | - Richard Page
- Barwon Orthopaedic Research Unit, The Geelong Hospital, Barwon Health, Geelong, VIC, Australia
| | - Jeff S. Hughes
- Orthopaedic and Arthritis Specialist Centre, The Gallery, Chatswood, NSW, Australia
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Abstract
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.
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Affiliation(s)
- Steinitz Amir
- Department of Traumatology and Orthopedic Surgery, University Hospital Basel, Spitalstr. 21, 4031 Basel, Switzerland
| | - Sailer Jannis
- Department of Traumatology and Orthopedic Surgery, University Hospital Basel, Spitalstr. 21, 4031 Basel, Switzerland
| | - Rikli Daniel
- Department of Traumatology and Orthopedic Surgery, University Hospital Basel, Spitalstr. 21, 4031 Basel, Switzerland
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Willing R, King GJ, Johnson JA. Contact mechanics of reverse engineered distal humeral hemiarthroplasty implants. J Biomech 2015; 48:4037-4042. [DOI: 10.1016/j.jbiomech.2015.09.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 08/27/2015] [Accepted: 09/27/2015] [Indexed: 11/29/2022]
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Phadnis J, Banerjee S, Watts AC, Little N, Hearnden A, Patel VR. Elbow hemiarthroplasty using a "triceps-on" approach for the management of acute distal humeral fractures. J Shoulder Elbow Surg 2015; 24:1178-86. [PMID: 26117619 DOI: 10.1016/j.jse.2015.04.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/08/2015] [Accepted: 04/11/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty is an established option for the primary treatment of acute distal humeral fractures, but there are sparse data regarding elbow hemiarthroplasty (EHA) as an alternative. We present the outcome of EHA performed with a modular anatomic prosthesis and a "triceps-on" surgical technique. METHODS Eighteen consecutive patients underwent EHA for an acute fracture. Two patients died, leaving a study group of 16 patients with minimum 2-year follow-up. Clinical evaluation included range of motion; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder, and Hand score; and Oxford Elbow Score. Radiographic assessment looked at alignment, evidence of loosening, ulnar and radial head wear, heterotopic ossification, and whether healing of the condyles had occurred. RESULTS Mean follow-up was 35 months (24-79 months). The mean scores were as follows: Mayo Elbow Performance Score, 89.6; shortened Disabilities of the Arm, Shoulder, and Hand score, 11.2; and Oxford Elbow Score, 43.7. The mean flexion and pronation-supination arcs were 116° and 172° respectively. Radial head wear was absent in 13 patients and mild in 3. Ulnar wear was absent in 6 patients, mild in 8, and moderate in 2. Wear was not associated with greater pain or inferior functional scores. There was no sign of aseptic loosening, and complete condylar bone union occurred in 15 elbows. There was 1 complication, a transient ulnar nerve neurapraxia that resolved without intervention. CONCLUSION EHA with a modular anatomic implant using a triceps-on approach is a reliable technique for the management of acute unreconstructible distal humeral fractures in older patients.
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Affiliation(s)
| | | | | | - Nicholas Little
- Department of Orthopaedic, Epsom and St Helier University Hospitals NHS Trust, Epsom, Surrey, UK
| | | | - Vipul R Patel
- Department of Orthopaedic, Epsom and St Helier University Hospitals NHS Trust, Epsom, Surrey, UK
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Illical EM, Farrell DJ, Siska PA, Evans AR, Gruen GS, Tarkin IS. Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures. Injury 2014; 45:1545-8. [PMID: 24813383 DOI: 10.1016/j.injury.2014.04.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/27/2014] [Accepted: 04/07/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. DESIGN Retrospective review. SETTING Two level one trauma centres. PATIENTS Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. INTERVENTION Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). MAIN OUTCOME MEASUREMENTS Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333). CONCLUSIONS A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Emmanuel M Illical
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Dana J Farrell
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter A Siska
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew R Evans
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gary S Gruen
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ivan S Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Habib M, Tanwar YS, Jaiswal A, Singh SP, Sinha S, Lal H. Anconeus pedicle olecranon flip osteotomy: an approach for the fixation of complex intra-articular distal humeral fractures. Bone Joint J 2014; 96-B:1252-7. [PMID: 25183599 DOI: 10.1302/0301-620x.96b9.33343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.
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Affiliation(s)
- M Habib
- RML Hospital and PGIMER, Department of Orthopedic Surgery, New Delhi, 110001, India
| | - Y S Tanwar
- RML Hospital and PGIMER, Department of Orthopedic Surgery, New Delhi, 110001, India
| | - A Jaiswal
- Bokaro General Hospital, Bokaro, Jharkhand, India
| | - S P Singh
- RML Hospital and PGIMER, Department of Orthopedic Surgery, New Delhi, 110001, India
| | - S Sinha
- RML Hospital and PGIMER, Department of Orthopedic Surgery, New Delhi, 110001, India
| | - H Lal
- RML Hospital and PGIMER, Department of Orthopedic Surgery, New Delhi, 110001, India
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Smith GCS, Hughes JS. Unreconstructable acute distal humeral fractures and their sequelae treated with distal humeral hemiarthroplasty: a two-year to eleven-year follow-up. J Shoulder Elbow Surg 2013; 22:1710-23. [PMID: 24054974 DOI: 10.1016/j.jse.2013.06.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/01/2013] [Accepted: 06/09/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to describe for the first time the medium to long-term outcome after distal humeral hemiarthroplasty (DHH). METHODS Twenty-six patients (mean age, 62; range, 29-92 years) treated with DHH for intra-articular distal humeral fractures and its sequelae were studied retrospectively. RESULTS Four patients had died and 4 had been revised to total elbow arthroplasty: 2 for periprosthetic fractures and 2 for primary component loosening (all in prostheses without an anterior flange). Six other complications had occurred: ulnar neuritis, 4; stiffness, 1; and wound necrosis, 1. Seventeen patients underwent assessment at a mean of 80 months after surgery. The mean values of the American Shoulder and Elbow Surgeons (ASES) elbow score (pain, 9.93; function, 25; satisfaction, 9.06); Mayo Elbow Performance Score (90); Quick Disabilities of Arm, Shoulder and Hand (19), and EuroQol EQ5D (Index, 0.84; Visual Analog Scale, 80) outcome measures demonstrated good function and satisfaction with little pain. The mean flexion extension arc was 116°. There was no evidence of instability. Radiologic evidence of ulnar wear was seen in 13 patients and may be related to prosthetic design to some extent. Worse wear was associated with a higher ASES pain score, lower satisfaction score, and lower EuroQoL Visual Analog Scale of quality of life. Degree of wear correlates with time after surgery but not with age at the time of surgery. CONCLUSION DHH offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome. LEVEL OF EVIDENCE Level IV, case series, treatment study.
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Affiliation(s)
- Geoffrey C S Smith
- Sydney Orthopaedic Arthritis and Sports Medicine, Sydney, NSW, Australia.
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Does timing of surgery affect the outcome of open articular distal humerus fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:777-82. [DOI: 10.1007/s00590-013-1358-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
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Meloy GM, Mormino MA, Siska PA, Tarkin IS. A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: single-column plating. Injury 2013; 44:1620-4. [PMID: 23932222 DOI: 10.1016/j.injury.2013.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/27/2013] [Accepted: 07/05/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The study aimed (1) to examine if there are equivalent results in terms of union, alignment and elbow functionally comparing single- to dual-column plating of AO/OTA 13A2 and A3 distal humeral fractures and (2) if there are more implant-related complications in patients managed with bicolumnar plating compared to single-column plate fixation. DESIGN This was a multi-centred retrospective comparative study. SETTING The study was conducted at two academic level 1 trauma centres. PATIENTS/PARTICIPANTS A total of 105 patients were identified to have surgical management of extra-articular distal humeral fractures Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 13A2 and AO/OTA 13A3). INTERVENTION Patients were treated with traditional dual-column plating or a single-column posterolateral small-fragment pre-contoured locking plate used as a neutralisation device with at least five screws in the short distal segment. MAIN OUTCOME MEASUREMENTS The patients' elbow functionality was assessed in terms of range of motion, union and alignment. In addition, the rate of complications between the groups including radial nerve palsy, implant-related complications (painful prominence and/or ulnar nerve neuritis) and elbow stiffness were compared. RESULTS Patients treated with single-column plating had similar union rates and alignment. However, single-column plating resulted in a significantly better range of motion with less complications. CONCLUSIONS The current study suggests that exposure/instrumentation of only the lateral column is a reliable and preferred technique. This technique allows for comparable union rates and alignment with increased elbow functionality and decreased number of complications.
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Affiliation(s)
- Gregory M Meloy
- University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Pittsburgh, PA, USA
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Abstract
BACKGROUND Distal humeral fractures in adults are relatively uncommon injuries that require surgical intervention in most cases. There is a lack of consensus regarding the best management of distal humeral fractures in adults, including the role of conservative treatment, appropriate surgical approach, fixation strategies, the role of total elbow arthroplasty and handling of nerves such as the ulnar nerve. OBJECTIVES To assess the effects (benefits and harms) of surgical interventions for distal humeral fractures in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 4), MEDLINE (1946 to April Week 4 2012), EMBASE (1980 to 2012 Week 17), Current Controlled Trials (1st May 2012), the WHO International Clinical Trials Registry Platform (1st May 2012) and the bibliographies of trial reports and relevant articles. SELECTION CRITERIA All randomised and quasi-randomised controlled trials pertinent to the management of distal humeral fractures in adults were included. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, assessed of risk of bias and extracted data. Pooling of data was impossible due to study heterogeneity. MAIN RESULTS Three small randomised controlled trials, with a total of 109 participants with Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen (OTA/AO) type C distal humeral fractures, were included. Overall, the quality of the available evidence is limited. As well as the small sample sizes and detection bias from the lack of blinding of subjective outcomes, the methods and results of all three trials were incompletely reported.One trial, involving 42 participants, compared open reduction-internal fixation (ORIF) with total elbow arthroplasty (TEA) in patients aged over 65 years. Of the 40 participants followed up for two years, five allocated ORIF underwent intraoperative conversion to TEA. These participants were crossed-over to the TEA group in the analyses. The reported Mayo Elbow Performance Score (MEPS) results were consistently better in the TEA group at follow-up after 6, 12, and 24 months, whereas the Disability of the Arm, Shoulder, Hand (DASH) scores showed short term (after 6 months), but not longer term (after 12 and 24 months), superiority in the TEA group. The reoperation rate, complication rate and elbow range of motion results showed no statistically significant differences between the two groups. While an intention-to-treat analysis of treatment failure, where the five cross-over participants are placed in their original allocated group, is in favour of TEA, the result did not reach statistical significance (9/21 versus 3/21; RR 3.00, 95% CI 0.94 to 9.55).The second trial, involving 38 patients but reporting results for 35, compared perpendicular versus parallel double plate fixation strategies. There was a consistent finding of a lack of significant differences between the two treatment groups in terms of MEPS, re-operation for complications (3/17 versus 3/18; RR 1.06, 95% CI 0.25 to 4.54), complications and elbow joint range of motion.The third trial, which included 29 patients with preoperative ulnar nerve compression symptoms, compared anterior subfascial transposition with in situ decompression of the ulnar nerve. Although results for complete recovery of ulnar nerve function (12/15 versus 8/14; RR 1.4, 95% CI 0.83 to 2.35) and grades based on the Bishop rating system tended to favour the transposition group, none of the differences were statistically significant. AUTHORS' CONCLUSIONS Overall, this review found there is either no or insufficient evidence from randomised or quasi-randomised controlled trials to determine whether surgery is, and which surgical interventions are, the most appropriate for the management of different types of distal humerus fractures. Well designed and reported large and multi-centre randomised controlled trials testing current interventions, such as pre-contoured and locking plating systems, are needed.
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Affiliation(s)
- Yan Wang
- Department of Orthopaedic Surgery, Chinese PLA General Hospital, Beijing, China
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Abstract
Distal humeral fractures are relatively rare and complex injuries. With appropriate preoperative planning and execution of surgical technique, good outcomes may be obtained in most patients. Patients should be counseled regarding loss of motion in these injuries, and elderly, osteoporotic patients with extensive comminution should be considered for total elbow arthroplasty as an alternative to open reduction and internal fixation.
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Affiliation(s)
- Anna N Miller
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1070, USA
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Got C, Shuck J, Biercevicz A, Paller D, Mulcahey M, Zimmermann M, Blaine T, Green A. Biomechanical comparison of parallel versus 90-90 plating of bicolumn distal humerus fractures with intra-articular comminution. J Hand Surg Am 2012; 37:2512-8. [PMID: 23174063 DOI: 10.1016/j.jhsa.2012.08.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 08/28/2012] [Accepted: 08/30/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical properties of 90-90 versus mediolateral parallel plating of C-3 bicolumn distal humerus fractures. METHODS We created intra-articular AO/Orthopaedic Trauma Association C-3 bicolumn fractures in 10 fresh-frozen matched pairs of cadaveric elbows. We determined bone mineral density of the metaphyseal region with dual-energy x-ray absorptiometry. The matched pairs of elbows were randomly assigned to either 90-90 or parallel plate fixation. We tested anteroposterior displacement at a rate of 0.5 mm/s to a maximum load of ± 100 N for both the articular and entire distal humerus segments. We tested torsional stability at a displacement rate of 0.1 Hz to a maximum torque of ± 2.5 Nm. After cyclical testing, we loaded the specimens in torsion to failure. RESULTS There was no significant difference in the bone density of the paired specimens. Compared with parallel fixation, 90-90 plate fixation had significantly greater torque to failure load. Both plating constructs were equally sensitive to bone density. Both techniques had the same mode of failure in torsion, a spiral fracture extending from the medial plate at the metaphyseal-diaphyseal junction. There was no significant difference in the stiffness of fixation of the articular fragment or the entire distal segment in anteroposterior loading. CONCLUSIONS This study demonstrated that 90-90 and parallel plating had comparable biomechanical properties for fixation of comminuted intra-articular distal humerus fractures, and that 90-90 plating had greater resistance to torsional loading.
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Affiliation(s)
- Christopher Got
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI 02903, USA.
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Trinh TQ, Harris JD, Kolovich GP, Griesser MJ, Schickendantz MS, Jones GL. Operative management of capitellar fractures: a systematic review. J Shoulder Elbow Surg 2012; 21:1613-22. [PMID: 22694882 DOI: 10.1016/j.jse.2012.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 03/01/2012] [Accepted: 03/05/2012] [Indexed: 02/01/2023]
Abstract
PURPOSE This study was conducted to evaluate reports of clinical outcomes of isolated capitellar fractures. MATERIALS AND METHODS We conducted a systematic review of medical databases reporting clinical outcomes of patients undergoing nonoperative and operative management of isolated capitellar fractures. RESULTS We identified 28 studies for inclusion comprising 174 patients. All included studies were level IV evidence. Capitellar fractures were more common among women than men and were more likely to involve the nondominant arm. Type I fractures (84%) were more common than type II (14%) and III fractures (2%). Operative and nonoperative management both led to satisfactory clinical outcomes. No significant difference in outcomes was observed in those undergoing operative management compared with those undergoing closed reduction and immobilization. CONCLUSIONS Nonoperative and operative management of isolated capitellar fractures leads to satisfactory clinical outcomes as determined by postoperative range of motion, improvement in pain, and a return to previous levels of function. No statistical difference in outcomes was observed between those undergoing operative management compared with those treated with closed reduction and immobilization.
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Affiliation(s)
- Thai Q Trinh
- Department of Orthopaedics, Division of Sports Medicine, The Ohio State University Sports Medicine Center, Columbus, OH 43221, USA
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Erpelding JM, Mormino MA, Fehringer EV. Distal Humeral Fracture Fixation with an Extensor Mechanism-on Approach. JBJS Essent Surg Tech 2012; 2:e9. [PMID: 31321132 DOI: 10.2106/jbjs.st.k.00047] [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] Open
Abstract
Introduction Open treatment of extra-articular and intra-articular distal humeral fractures can be effectively accomplished through an extensor mechanism-on approach. Step 1 Preoperative Planning Assess all images for multiplane fracture lines involving the capitellum or trochlea. Step 2 Operative Setup Verify with fluoroscopy that the patient and arm positions allow for adequate imaging of the distal part of the humerus. Step 3 Surgical Approach Perform medial and lateral arthrotomies posterior to the collateral ligament complexes and excise the intra-articular fat pad and posterior aspect of the capsule. Step 4 Fracture Reduction and Provisional Fixation Reduce the distal humeral fragments anatomically under direct visualization posteriorly and indirectly with fluoroscopy using the intact sigmoid notch as a template for reduction. Step 5 Definitive Fixation Place multiple screws distally through the plates medially and laterally; each screw should be of maximal length and engage the opposite column. Step 6 Wound Closure and Postoperative Management Remove the dressing on postoperative day two and begin full active-assisted elbow range of motion and grip-strengthening therapy program. Results In our series of thirty-seven patients12, all fractures healed primarily with a median motion arc of 126° (range, 60° to 141°). The median triceps strength loss was 10% (range, 0% to 49%). What to Watch For IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Jason M Erpelding
- Medical College of Wisconsin, 8700 Watertown Plank Road, Milwaukee, WI 53226. E-mail address:
| | - Matthew A Mormino
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 981080 Nebraska Medical Center, Omaha, NE 68198
| | - Edward V Fehringer
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 981080 Nebraska Medical Center, Omaha, NE 68198
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Erpelding JM, Mailander A, High R, Mormino MA, Fehringer EV. Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach. J Bone Joint Surg Am 2012; 94:548-53. [PMID: 22438004 DOI: 10.2106/jbjs.j.01785] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Distal humeral fractures have traditionally been managed with surgical approaches that disrupt the extensor mechanism. We hypothesized that an extensor mechanism-on approach for operative fixation of distal humeral fractures with parallel or orthogonal plate constructs would allow excellent healing, a motion arc of the elbow exceeding 100°, and maintenance of extensor mechanism strength. METHODS Distal humeral open reduction and internal fixation (ORIF) was performed with either orthogonal or parallel plate constructs in seventy-nine elbows. Thirty-seven elbows were fixed via an extensor mechanism-on surgical approach, and twenty-four of them were available for additional evaluation. Radiographs as well as MEPI (Mayo Elbow Performance Index), DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores were obtained. RESULTS All thirty-seven fractures healed primarily. Three elbows underwent later release because of stiffness. The median arc of elbow motion was 126° (range, 60° to 141°). The mean MEPI was 91.5 points and the mean DASH score was 15.9 points, indicating excellent scores with mild impairment. The median percent loss of triceps strength was 10% (range, 0% to 49%) compared with the contralateral, normal elbow. CONCLUSIONS Open treatment of distal humeral fractures with an extensor mechanism-on approach results in excellent healing, a mean elbow flexion-extension arc exceeding 100°, and maintenance of 90% of elbow extension strength compared with that of the contralateral, normal elbow.
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Affiliation(s)
- Jason M Erpelding
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 981080 Nebraska Medical Center, Omaha, NE 68198, USA.
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Comparative functional outcome of AO/OTA type C distal humerus fractures. J Trauma Acute Care Surg 2012; 72:E27-32. [DOI: 10.1097/ta.0b013e31821915ae] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ljungquist KL, Beran MC, Awan H. Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review. J Shoulder Elbow Surg 2012; 21:126-35. [PMID: 22014615 DOI: 10.1016/j.jse.2011.06.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/27/2011] [Accepted: 06/29/2011] [Indexed: 02/01/2023]
Affiliation(s)
- Karin L Ljungquist
- Department of Orthopaedics, The Ohio State University, Columbus, OH, USA
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Mehlhoff TL, Bennett JB. Distal humeral fractures: fixation versus arthroplasty. J Shoulder Elbow Surg 2011; 20:S97-106. [PMID: 21281926 DOI: 10.1016/j.jse.2010.11.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 11/12/2010] [Accepted: 11/12/2010] [Indexed: 02/01/2023]
Affiliation(s)
- Thomas L Mehlhoff
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX 77030-4509, USA.
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Abstract
BACKGROUND The surgical approach, type of olecranon osteotomy, method of stabilization of osteotomy, type of fracture stabilization, orthogonal vs parallel plate fixation, need for transposition of ulnar nerve, place for primary total elbow replacement, and type of rehabilitation schedule after surgical fracture treatment are the controversial issues in the treatment of complex intra-articular distal humerus fractures (C2 and C3) in adults. Severe comminution, bone loss, and osteoporosis at the site of distal articular fractures of humerus often lead to unsatisfactory results due to inadequate fixation. We hereby report the outcome of a series of intracondylar fractures of the humerus treated by open reduction and internal fixation and discuss the controversies in light of published literature. MATERIALS AND METHODS One hundred and eighty-four patients of intra-articular fractures of distal humerus (C2 and C3) were operated by posterior transolecranon approach between January 1980 and December 2008. Initially, in the first part Chevron intra-articular osteotomy (n=108) was performed out of which 94 have been published in another publication. In later second part (1993 onward), extra-articular olecranon osteotomy (n=76) was routinely performed. Both columns were stably fixed by orthogonal methods; (n=174) however, during the last 2 years, in 10 patients with severe comminution with bone loss, stabilization was achieved by parallel plating. The osteotomy was routinely stabilized by tension band wiring with two parallel K-wires introduced up to the anterior ulnar cortex. The results were evaluated by the staging system of Caja et al. at a minimum follow-up of 2 years. RESULTS In the first part of the study (n=94), there was delayed union in 4% (n=4), with the fracture taking more than 20 weeks for union. There was delayed union of ulnar osteotomy (n=3) and failure of one tension band wiring, requiring revision. Some loss of motion was seen in 20% of cases and these patients did not achieve full flexion and extension. However, all these patients had useful range of function, with 20°-110° of flexion and full pronation-supination. As per the staging system of Caja et al., the results were in the range of excellent to good in 72% cases (n=67), fair in 19% (n=18), and poor in 9% patients (n=9). In the second part of study (n=90) dual plate fixation of both columns by orthogonal methods (n=80) and parallel plate fixation in 10 patients was performed. The results were excellent to good in 78 patients (86%). CONCLUSIONS The high rate of union can be achieved in complex intra-articular fractures of distal humerus if the proper principles of stable fracture fixation are followed, i.e., a posterior transolecranon approach and dual fixation of both columns and restoration of the continuity of articular surface. The stability achieved by this technique permits institution of early intensive physiotherapy to restore elbow function.
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Affiliation(s)
- Sudhir Babhulkar
- Department of Orthopedics, Indira Gandhi Medical College, Nagpur, India,Address for correspondence: Dr. Sudhir Babhulkar, Sushrut Hospital, Research Center and Postgraduate Institute of Orthopaedics, Ramdaspeth, Nagpur - 440 010, India. E-mail:
| | - Sushrut Babhulkar
- Sushrut Hospital, Reseach Center and Postgraduate Institute of Orthopedics, Nagpur, India
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Treatment of distal humeral fractures using conventional implants. Biomechanical evaluation of a new implant configuration. BMC Musculoskelet Disord 2010; 11:172. [PMID: 20684752 PMCID: PMC2921352 DOI: 10.1186/1471-2474-11-172] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 08/04/2010] [Indexed: 11/26/2022] Open
Abstract
Background In the face of costly fixation hardware with varying performance for treatment of distal humeral fractures, a novel technique (U-Frame) is proposed using conventional implants in a 180° plate arrangement. In this in-vitro study the biomechanical stability of this method was compared with the established technique which utilizes angular stable locking compression plates (LCP) in a 90° configuration. Methods An unstable distal 3-part fracture (AO 13-C2.3) was created in eight pairs of human cadaveric humeri. All bone pairs were operated with either the "Frame" technique, where two parallel plates are distally interconnected, or with the LCP technique. The specimens were cyclically loaded in simulated flexion and extension of the arm until failure of the construct occurred. Motion of all fragments was tracked by means of optical motion capturing. Construct stiffness and cycles to failure were identified for all specimens. Results Compared to the LCP constructs, the "Frame" technique revealed significant higher construct stiffness in extension of the arm (P = 0.01). The stiffness in flexion was not significantly different (P = 0.16). Number of cycles to failure was found significantly larger for the "Frame" technique (P = 0.01). Conclusions In an in-vitro context the proposed method offers enhanced biomechanical stability and at the same time significantly reduces implant costs.
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The role of locking technology in the upper extremity. J Hand Microsurg 2010; 1:82-91. [PMID: 23129939 DOI: 10.1007/s12593-009-0021-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Accepted: 07/06/2009] [Indexed: 01/27/2023] Open
Abstract
The technique of locked plating has been a major advance in Orthopaedic fracture surgery and has had an equal impact on the management of upper extremity fractures. The recognition of the role of vascularity and soft tissues in fracture healing was central to the research and development of newer plate designs that left minimal footprints on the surface of the bone. Subsequently, innovative locking technology has improved our ability to manage cases with extensive communition, inadequate bone stock, and peri-articular fractures. This paper will review the role of locking technology in the management of fractures of the upper extremity.
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Abstract
A distal humerus fracture can be a debilitating and difficult injury to treat. The anatomy of the distal humerus is highly complex, as it articulates with both the radius and ulna and allows for motion in multiple planes. Furthermore, comminution and osteopenia may render the metaphyseal-diaphyseal junction weak, making adequate stabilization difficult. Various methods of surgical fixation have been described, with bicolumnar plating being the most popular. Controversy over fixation techniques and the introduction of recently developed implants, including precontoured plates and locking plates, have led to renewed focus on biomechanical testing of various fixation constructs. Failure of adequate reconstruction or fixation can be addressed with adjunctive measures such as incorporation of structural bone grafts, external fixation, or, in certain instances, salvage with total elbow arthroplasty. The articular surface can also be injured from a shear force, resulting in fractures of the capitellum and trochlea in the coronal plane. This article presents a review of current literature concerning the diagnosis, classification, treatment, and outcome of distal humerus fractures.
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Affiliation(s)
- Andrew S Wong
- Allegheny General Hospital, Pittsburgh, PA 15212, USA
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