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Caredda M, Cianni L, De Fazio A, Ziranu A, Vitiello R, Maccauro G. Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series. J Orthop Surg Res 2024; 19:53. [PMID: 38212796 PMCID: PMC10782750 DOI: 10.1186/s13018-023-04465-2] [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: 10/14/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Managing distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock. METHODS A consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields. RESULTS Five patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures. CONCLUSIONS The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.
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Affiliation(s)
- Matteo Caredda
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Luigi Cianni
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy.
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy.
| | - Andrea De Fazio
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Antonio Ziranu
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Raffaele Vitiello
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Giulio Maccauro
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
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Barth KA, Schimizzi GV, Megerian MF, Lavalva S, Klinger CE, Dziadosz DR, Ricci WM, Campbell ST. Apex posterior angulation of the humerus: A characterization of normal sagittal plane anatomy with implications for surgical fixation. Injury 2023; 54:578-583. [PMID: 36503839 DOI: 10.1016/j.injury.2022.11.059] [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: 05/10/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION An understanding of the sagittal plane morphology of the humerus is relevant during surgical fixation of humeral fractures but is not well described in the literature. The purpose of this study was to better characterize the native sagittal plane morphology of the humerus. MATERIALS AND METHODS 170 patients with uninjured full length lateral humerus radiographs were retrospectively evaluated. The angle between the proximal humeral diaphyseal axis and the distal humeral diaphyseal axis was identified and measured. The proximal axis was defined by two points equidistant from the anterior and posterior cortex 10 mm and 100 mm distal to the metaphyseal flare, and the distal axis by two points at 10 mm and 50 mm proximal to the capitellum/trochlea. The relative location of the center of rotation of angulation (CORA) was calculated as a percentage of humeral length. RESULTS 114 radiographs were included in the analysis (66 right humeri, 48 left humeri). The average apex posterior angulation was 6.5 +/- 2.9°. The CORA occurred at an average of 80% (SD+/-13%) of the length of the humerus (proximal to distal). Total humeral length and absolute distance to CORA were greater in males compared to females (364 ± 50 mm versus 326 ± 30 mm; p<0.001; 290 ± 68 mm versus 260 ± 48 mm; p=0.003), but there were no significant sex differences with respect to magnitude of the apex posterior angulation (p=0.077) or location of CORA as a percentage of total humeral length (p=0.916). There were no statistically significant associations between age and total humeral length (p=0.056), distance to CORA (p=0.130), location of CORA as percentage of total humeral length (p=0.753), or magnitude of angulation (p=0.075). CONCLUSION An apex posterior bow consistently exists in the distal one-quarter of the humerus that is consistent across ages and between sexes. This normal anatomic bow is important to recognize to avoid an extension malreduction and has implications for implant fit and contouring.
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Affiliation(s)
- Kathryn A Barth
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States.
| | - Gregory V Schimizzi
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Mark F Megerian
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States; Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Scott Lavalva
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Craig E Klinger
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Daniel R Dziadosz
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - William M Ricci
- Orthopaedic Trauma Service, Hospital for Special Surgery, 535 E 70th St, New York, NY, United States
| | - Sean T Campbell
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, United States
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Tauber M. [Winter sports injuries to the elbow joint]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:903-909. [PMID: 36227359 DOI: 10.1007/s00132-022-04315-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Elbow injuries occur quite often when practicing winter sports. Due to the high sports dynamics and risk of fall the elbow joint is prone to injuries. Hereby, the most common injury is the dislocation of the elbow. TREATMENT Isolated ligamentous instabilities can usually be treated non-operatively when the joint is centered on post-reduction imaging. In the case of persistent symptomatic instability, secondary ligament reconstruction surgery is associated with reliable and good results. Most fractures of the elbow involve the radial head in terms of postero-lateral rotation instability, whereas distal humerus and olecranon fractures are more likely to occur in high-energy or direct trauma. Indication for surgical treatment is given according to common guidelines, including involvement of the joint line, fragment dislocation and instability with risk of secondary fracture dislocation. Minimally invasive techniques for the radial head as well as anatomic preformed locking plate systems seem to have reached a wide acceptance.
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Affiliation(s)
- Mark Tauber
- Deutsches Schulterzentrum in der ATOS Klinik München, Effnerstr. 38, 81925, München, Deutschland.
- Universitätsklinik für Orthopädie und Unfallchirurgie, Paracelsus Medizinische Universität Salzburg, Salzburg, Österreich.
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Toy Ş, Bakıcı RS, Şahin NE. Examination of the Correlation of Distal End Parameters of the Humerus with Other Parameters. MEANDROS MEDICAL AND DENTAL JOURNAL 2022. [DOI: 10.4274/meandros.galenos.2022.02439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Weber MB, Cho E, Evans PJ, Styron J, Bafus BT. Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study. J Shoulder Elbow Surg 2022; 31:1215-1223. [PMID: 35172209 DOI: 10.1016/j.jse.2022.01.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures. METHODS We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared. RESULTS A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7). CONCLUSIONS The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.
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Affiliation(s)
| | - Elizabeth Cho
- MetroHealth Medical Center, Cleveland, OH, USA; Cleveland Clinic Foundation, Cleveland, OH, USA
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Bilateral triceps tendon approach is flexible and efficient in the treatment of type C distal humerus fractures. Chin J Traumatol 2022; 25:145-150. [PMID: 34920951 PMCID: PMC9125722 DOI: 10.1016/j.cjtee.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/28/2021] [Accepted: 11/12/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The purpose of this study was to assess and compare elbow range of motion, triceps extension strength and functional results of type C (AO/OTA) distal humerus fractures treated with bilateral triceps tendon (BTT) approach and olecranon osteotomy (OO). At the same time, we are also trying to know whether BTT approach can provide sufficient vision for comminuted intra-articular fractures of the distal humerus, and whether it is convenient to convert to the treatment to total elbow arthroplasty (TEA) or OO. METHODS Patients treated with OO and BTT approaches for type C distal humerus fractures between July 2014 and December 2017 were retrospectively reviewed. Inclusion criteria include: (1) patients' age were more than 18 years old, (2) follow-up was no less than 6 months, and (3) patients were diagnosed with type C fractures (based on the AO/OTA classification). Exclusion criteria include: (1) open fractures (Gustillo type 2 or type 3), (2) treated by other approaches, and (3) presented with combined injuries of ipsilateral upper extremities, such as ulnar nerve. Elbow range of motion and triceps extension strength testing were completely valuated, when the fractures had healed. Assessment of functional results using the Mayo elbow performance score and complications were conducted in final follow-up. The data were compared using the two tailed Student's t-test. All data were presented as mean ± standard deviation. RESULTS Eighty-six patients of type C distal humerus fractures, treated by OO and BTT approach were retrospectively reviewed between July 2014 and December 2017. Fifty-five distal humerus fractures (23 males and 32 females, mean age 52.7 years) treated by BTT approach or OO were included in this study. There were 10 fractures of type C1, 16 type C2 and 29 type C3 according to the AO/OTA classification. Patients were divided into two surgical approach groups chosen by the operators: BTT group (28 patients) and OO group (27 patients). And the mean follow-up time of all patients was 15.6 months (range, 6-36 months). Three cases in BTT group were converted to TEA, and one converted to OO. Only one case in BTT group presented poor articular reduction with a step more than 2 mm. There were not significantly different in functional outcomes according to the Mayo elbow performance score, operation time and extension flexion motion are values between BTT group and OO group (p > 0.05). Complications and reoperation rate were also similar in the two groups. Triceps manual muscle testing were no significant difference in the two groups, even subdivided in elder patients (aged >60 years old). CONCLUSION BTT is a safe approach to achieve similar functional result comparing with OO. BTT were not suitable for every case with severe comminuted pattern, but it avoids the potential complications related to OO, and has no complications concerning with triceps tendon. It is convenient for open reduction internal fixation and flexible to be converted to OO, as well as available to be converted to TEA in elder patients.
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Efficacy of utilizing 3D printed models for preoperative surgical planning of open reduction, internal fixation of distal humerus fractures. ANNALS OF 3D PRINTED MEDICINE 2022. [DOI: 10.1016/j.stlm.2022.100047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Sudah SY, Puzzitiello RN, Nasra MH, Moverman MA, Pagani NR, Guss MS, Menendez ME. Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:96-102. [PMID: 37588281 PMCID: PMC10426674 DOI: 10.1016/j.xrrt.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Distal humerus fractures (DHFs) pose a treatment challenge in elderly patients. We sought to systematically review and report the clinical outcomes of the nonoperative approach (eg, "bag of bones") for the treatment of these injuries and the rate of conversion to delayed surgery. Methods A comprehensive review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Studies involving outcomes after nonoperative treatment of DHF in patients >65 years of age were included from 1985 to present. Data regarding patient age, DHF type, nonoperative treatment method, complications, conversion to delayed surgery, range of motion, union rate, and surgeon- and patient-reported outcome measures were extracted. Results A total of five studies met inclusion criteria (all level IV evidence), yielding a total of 143 patients (mean age: 73.5 years to 87.4 years) with 7.1 months to 55 months of follow-up. The mean Mayo Elbow Performance Index scores were good to excellent across several studies (range 83-93.1). Multiple studies reported good range of motion (mean arc of motion: 81 to 106 degrees) and low levels of upper extremity disability (mean Quick Disability of the Arm-Shoulder-Hand scores: 31.3 to 38.5) at the final follow-up. The rate of conversion to total elbow arthroplasty and operative fixation ranged from 0% to 7.5% and 0% to 5%, respectively. Conclusion Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. This information is important for patient counseling and treatment decision-making.
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Affiliation(s)
- Suleiman Y. Sudah
- Department of Orthopedic Surgery, Monmouth Medical Center, Long Branch, NJ, USA
| | - Richard N. Puzzitiello
- Department of Orthopedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | | | - Michael A. Moverman
- Department of Orthopedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Nicholas R. Pagani
- Department of Orthopedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Michael S. Guss
- Department of Orthopedic Surgery, Newton-Wellesley Hospital, Newton, MA, USA
| | - Mariano E. Menendez
- Department of Orthopedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
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Triceps Tenotomy as an Alternative Exposure for Fixation of OTA/AO 13-C Fractures: A Technical Trick. J Orthop Trauma 2021; 35:e511-e516. [PMID: 34369458 DOI: 10.1097/bot.0000000000002103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 02/02/2023]
Abstract
Intra-articular fractures of the distal humerus present challenges to treating physician and patient alike. The olecranon osteotomy is accepted as the standard exposure for intra-articular distal humerus fractures; nevertheless, complications such as nonunion and implant prominence are common. In this article, we describe the clinical outcomes and anatomic features of the triceps tenotomy as an alternative method of exposure for internal fixation of intra-articular distal humerus fractures. The olecranon osteotomy approach affords greater exposure of the distal humerus articular surface; however, there was no difference in quality of fracture reduction, progression to fracture union, posttraumatic arthrosis, or implant failure between approaches in our series. The osteotomy approach resulted in a greater need for reoperation (15% vs. 46%, respectively); largely as a result of olecranon implant-related complications. In summary, the triceps tenotomy offers an alternative exposure for intra-articular distal humerus fracture fixation with comparable clinical outcomes to the olecranon osteotomy technique.
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10
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Fram BR, Seigerman DA, Ilyas AM. Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes. Hand (N Y) 2021; 16:577-585. [PMID: 31625402 PMCID: PMC8461205 DOI: 10.1177/1558944719878817] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Fractures of the capitellum and trochlea are uncommon fractures of the elbow and can be challenging to treat due to their size, location, and articular nature. Because of their intra-articular nature and predilection toward displacement, these fractures are typically treated operatively. Furthermore, capitellum fractures have high rates of associated injuries, including radial head fractures or lateral collateral ligament injury in ~30% to 60% of patients. In addition to open reduction internal fixation, operative options include fragment excision, arthroscopic assisted reduction and fixation, and elbow arthroplasty. In this article, we undertake a comprehensive literature review of capitellum fractures of the distal humerus, in an attempt to summarize the existing body of evidence and propose areas of future study.
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Affiliation(s)
| | | | - Asif M. Ilyas
- Thomas Jefferson University Hospital, Philadelphia, PA, USA,Asif M. Ilyas, Rothman Institute of Orthopedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5 Floor, Philadelphia PA 19107, USA.
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Ricón-Recarey FJ, Lajara-Marco F, Fuentes-Díaz A, Correoso-Castellanos S. Results of the distal humeral hemiarthroplasty Latitude in distal humeral unreconstructable fractures treatment in patients older than 65 years old. ACTA ACUST UNITED AC 2021. [PMID: 34112447 DOI: 10.1016/j.recote.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM The aim of this study is evaluate clinical and radiographic outcomes of Latitude elbow hemiarthroplasty in the treatment of articular distal humerus multifragmentary fractures in patients older than 65 years. MATERIAL AND METHODS We included those patients older than 65 years who sustained an unreconstructable articular distal humeres fracture and it was replace with a Latitude hemiarthroplasty. We excluded those with a minimum follow up less than 2 years. The clinical outcomes were assessed with Mayo Elbow Performance Score (MEPS). Range of motion, pain, complications and elbow radiological assessments were recorded at the final follow up. RESULTS We have found that after a mean follow-up of 5 years, the five patients included in the study have mild pain in the elbow. They have recovered a median flexion arch of 100°, with a 10° extension lag. The MEPS was considered as good in all the cases. There were not any instability or prosthesis loosening, but two patients developed a moderate proximal cubitus wear. CONCLUSION Latitude elbow arthroplasty is an option in the distal articular humerus multifragmentary fractures treatment in osteoporotic and ageing patients with satisfactory results as long as the elbow ligamentous stability can be restored.
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Affiliation(s)
- F J Ricón-Recarey
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Vega Baja de Orihuela, Alicante, Spain.
| | - F Lajara-Marco
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Reina Sofía de Murcia, Murcia, Spain
| | - A Fuentes-Díaz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Morales Meseguer de Murcia, Murcia, Spain
| | - S Correoso-Castellanos
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Vega Baja de Orihuela, Alicante, Spain
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Cho E, Weber MB, Opel D, Lee A, Hoyen H, Bafus BT. Complications and functional outcomes after transolecranon distal humerus fracture. J Shoulder Elbow Surg 2021; 30:479-486. [PMID: 32712456 DOI: 10.1016/j.jse.2020.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Transolecranon distal humerus fractures are uncommon injuries. This is the first multipatient case series to describe outcomes and complications following transolecranon distal humerus fractures in the adult population. METHOD Design: retrospective; setting: single level 1 trauma center; patients/participants: 16 patients; intervention: surgical management of transolecranon distal humerus fracture; main outcome measurement: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after a minimum of 12 months. RESULTS A total of 16 patients with open (n = 12) or closed (n = 4) transolecranon distal humerus fractures were identified. Nine female and 7 male patients with a mean age of 47 years were included. Mechanisms of injury included motor vehicle collisions (n = 3), motorcycle crashes (n = 4), ground-level falls (n = 3), falls from height (n = 4), train collision (n = 1), and an industrial accident (n = 1). Seven patients (44%) presented with nerve injury. Patients underwent open reduction with internal fixation (n = 15), external fixation (n = 6), or both (n = 5). Additional surgeries were ultimately required in 11 patients (69%), with a mean of 3 surgeries to manage each patient's elbow injuries. All patients returned for at least 3 clinical follow-up visits; mean clinical follow-up was 15.8 months and mean radiographic follow-up was 12.3 months. Complications were observed in 15 patients (94%). Eleven patients (69%) had limited range of motion with a flexion arc of less than 100° at their last clinic visit. Seven patients (44%) developed deep wound infections requiring repeat débridement and intravenous antibiotics. Implant removal was performed in 10 patients (62.5%) because of infection (n = 5), symptomatic hardware (n = 4), or device failure (n = 1). Heterotopic ossification was seen in 8 patients (50%) and post-traumatic arthrosis in 4 (25%). Two patients (12.5%) required flap reconstruction for soft tissue defects. Nonunion occurred in 7 patients (44%). DASH scores were obtained for 10 patients (62.5%) at a mean of 3.8 years after injury. The mean DASH score was 40.2, ranging from 4.2 to 76.5. Among respondents, 7 (70%) were able to resume working, with an average DASH work module score of 25. CONCLUSION Management of transolecranon distal humerus fractures remain a challenge for orthopedic surgeons. Complication rates, including deep infection and nonunion, are high, with frequent long-term functional limitations posed to the patient, as evidenced by DASH scores.
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Affiliation(s)
- Elizabeth Cho
- Case Western Reserve University School of Medicine, Health Education Campus, Cleveland, OH, USA
| | - Morgan B Weber
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Dayton Opel
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Adrienne Lee
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Harry Hoyen
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Blaine T Bafus
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA.
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Abstract
Background Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost. Methods We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC. Results Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor). Conclusion Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.
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14
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Resultados de la hemiartroplastía de húmero distal Latitude en el tratamiento de las fracturas articulares de húmero distal irreparables en mayores de 65 años. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recot.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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15
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Abstract
Distal humerus fractures in elderly patients are challenging due to poor bone quality and may threaten the independence of elderly patients due to loss of functional range of motion. Total elbow arthroplasty has gained popularity in the treatment of these injuries. This video demonstrates total elbow arthroplasty in an elderly patient with a comminuted distal humerus fracture.
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16
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Abstract
The elbow joint consists of the humeroulnar, humeroradial, and proximal radioulnar joints. Elbow stability is maintained by a combination of static and dynamic constraints. Elbow fractures are challenging to treat because the articular surfaces must be restored perfectly and associated soft tissue injuries must be recognized and appropriately managed. Most elbow fractures are best treated operatively with restoration of normal bony anatomy and rigid internal fixation and repair and/or reconstruction of the collateral ligaments. Advanced imaging, improved understanding of the complex anatomy of the elbow joint, and improved fixation techniques have contributed to improved elbow fracture outcomes.
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Affiliation(s)
- Kaare S Midtgaard
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA; Oslo University Hospital, Division of Orthopaedic Surgery, Kirkeveien 166, Oslo 0450, Norway; Norwegian Armed Forces Joint Medical Services, Forsvarsvegen 75, Sessvollmoen 2058, Norway
| | - Joseph J Ruzbarsky
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA
| | - Thomas R Hackett
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA
| | - Randall W Viola
- The Steadman Clinic, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA.
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17
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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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Patel SS, Mir HR, Horowitz E, Smith C, Ahmed AS, Downes K, Nydick JA. ORIF of Distal Humerus Fractures with Modern Pre-contoured Implants is Still Associated with a High Rate of Complications. Indian J Orthop 2020; 54:570-579. [PMID: 32850019 PMCID: PMC7429565 DOI: 10.1007/s43465-020-00124-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/15/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to identify complications after operative treatment of distal humerus fractures with anatomic, pre-contoured, locking distal humeral plates. We hypothesized that these fractures have high complication rates despite the use of these modern implants. MATERIALS AND METHODS Between 2010 and 2018, 43 adult patients with a distal humerus fracture underwent open reduction and internal fixation (ORIF) at a Level I trauma center. Pre-operative variables, including medical comorbidities, mechanism of injury, open or closed fracture, AO/OTA fracture classification (Type A, B, or C), and nerve palsy, were recorded. Intra-operative variables including surgical approach, ulnar nerve transposition, and plate configuration were recorded. Anatomic, pre-contoured, locking distal humeral plates were used in all patients. Various plating systems were used based on surgeon preference and fracture pattern. Post-operative complications including infection, nonunion, malunion, painful implants, nerve palsy, heterotopic ossification, stiffness, and post-traumatic arthritis were recorded. RESULTS Most fractures were Type C (53%). The posterior olecranon osteotomy approach (51%) and parallel plate configuration (42%) were used in most cases. At a mean follow-up of 15 months, the complication rate was 61% (26/43 patients). Among all patients, 49% (21/43 patients) required a reoperation. Elbow stiffness (19%) was the most common complication followed by nerve palsy (16%). There were four fracture nonunions (9%), deep infections (9%), painful implants (9%), post-traumatic arthritis (9%), and heterotopic ossification (9%). CONCLUSIONS Distal humerus fractures treated with ORIF utilizing anatomic, pre-contoured, locking distal humeral plates have a high complication rate, with many requiring reoperation. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Shaan S. Patel
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL 33606 USA
| | - Hassan R. Mir
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL 33606 USA
- Florida Orthopaedic Institute, 13020 N Telecom Parkway, Tampa, FL 33637 USA
| | - Evan Horowitz
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL 33606 USA
| | - Carson Smith
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL 33606 USA
| | - Adil S. Ahmed
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL 33606 USA
| | - Katheryne Downes
- Florida Orthopaedic Institute, 13020 N Telecom Parkway, Tampa, FL 33637 USA
- Foundation for Orthopaedic Research and Education, 5 Tampa General Circle, HMT 710, Tampa, FL 33606 USA
| | - Jason A. Nydick
- Department of Orthopaedic Surgery, University of South Florida, 5 Tampa General Circle, HMT 710, Tampa, FL 33606 USA
- Florida Orthopaedic Institute, 13020 N Telecom Parkway, Tampa, FL 33637 USA
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19
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Lauder A, Richard MJ. Management of distal humerus fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:745-762. [DOI: 10.1007/s00590-020-02626-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
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20
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Fei TT, Evans PJ, Bafus BT. Triceps fascial tongue exposure for intra-articular distal humerus fracture: revisiting the Van Gorder approach. JSES Int 2019; 4:39-43. [PMID: 32544931 PMCID: PMC7075759 DOI: 10.1016/j.jses.2019.10.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Timothy T Fei
- Department of Orthopedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Peter J Evans
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Blaine T Bafus
- Department of Orthopedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA
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21
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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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22
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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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23
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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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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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25
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Savvidou OD, Zampeli F, Koutsouradis P, Chloros GD, Kaspiris A, Sourmelis S, Papagelopoulos PJ. Complications of open reduction and internal fixation of distal humerus fractures. EFORT Open Rev 2018; 3:558-567. [PMID: 30662764 PMCID: PMC6335604 DOI: 10.1302/2058-5241.3.180009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Treatment of distal humerus fractures is demanding. Surgery is the optimal treatment and preoperative planning is based on fracture type and degree of comminution. Fixation with two precontoured anatomical locking plates at 90o:90o orthogonal or 180o parallel is the optimal treatment. The main goal of surgical treatment is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness. Despite evolution of plates and surgical techniques, complications such as mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, infection, and complications from olecranon osteotomy are quite common. Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.
Cite this article: EFORT Open Rev 2018;3:558-567. DOI: 10.1302/2058-5241.3.180009
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Affiliation(s)
- Olga D Savvidou
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Frantzeska Zampeli
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | | | - George D Chloros
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
| | - Aggelos Kaspiris
- Department of Trauma and Orthopaedics, Thriasio General Hospital-NHS, Athens, Greece
| | - Savas Sourmelis
- First Department of Orthopaedics, Hygeia Hospital, Athens, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece
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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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27
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Shearin JW, Chapman TR, Miller A, Ilyas AM. Ulnar Nerve Management with Distal Humerus Fracture Fixation: A Meta-Analysis. Hand Clin 2018; 34:97-103. [PMID: 29169602 DOI: 10.1016/j.hcl.2017.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ulnar nerve dysfunction following distal humerus fractures is a well-recognized phenomenon. There is no consensus regarding optimal handling of the ulnar nerve during surgical management of these fractures between in situ management and transposition. Using an electronic database to identify retrospective studies involving surgical fixation of distal humerus fractures yielded 46 studies, 5 trials meeting the authors' inclusion criteria, totaling 362 patients. An overall incidence of 19.3% for ulnar neuropathy was identified. Of those patients undergoing in situ release, the incidence was 15.3%. Of those who underwent transposition, there was a 23.5% incidence of ulnar neuropathy.
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Affiliation(s)
- Jonathan W Shearin
- Hand & Upper Extremity Surgery, Department of Orthopedic Surgery, Arnot Health, Elmira, NY, USA
| | - Talia R Chapman
- Department of Orthopedic Surgery, Thomas Jefferson University Hospital, 1025 Walnut Street, Suite 516, Philadelphia, PA 19107, USA.
| | - Andrew Miller
- Department of Orthopedic Surgery, Thomas Jefferson University Hospital, 1025 Walnut Street, Suite 516, Philadelphia, PA 19107, USA
| | - Asif M Ilyas
- Department of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, 925 Chestnut, Philadelphia, PA 19107, USA
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A biomechanical comparison of unilateral and bilateral String-of-Pearls™ locking plates in a canine distal humeral metaphyseal gap model. Vet Comp Orthop Traumatol 2017; 27:186-91. [DOI: 10.3415/vcot-13-10-0133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 03/11/2014] [Indexed: 11/17/2022]
Abstract
SummaryObjective: To compare the in vitro biomechanical performance of two String-of-Pearls (SOP) plate constructs in a canine distal humeral metaphyseal gap model.Methods: Seven pairs of canine cadaveric humeri, including the elbow joints, were prepared. One group consisted of a unilateral medially placed SOP plate with bicortical screws (UNI). The second group consisted of bilateral caudo-medial and caudo-lateral SOP plates applied with monocortical screws (BI). A 2 cm ostectomy was performed immediately proximal to the supratrochlear foramen. Constructs were tested in torsion and axial compression.Results: The UNI constructs had significantly lower stiffness in torsion and axial compression than the BI group. However, UNI constructs had a significantly higher ultimate strength than BI constructs. All UNI constructs failed by bending of the transcondylar screw and SOP plate. All BI constructs failed by axial pullout of the distal most screws.Clinical significance: In stabilizing canine supracondylar humeral fractures as modeled here, both the UNI model and the BI model demonstrated biomechanical advantages. The incorporation of a transcondylar screw through the medial plate appears to be beneficial to construct strength.
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Pantalone A, Vanni D, Guelfi M, Belluati A, Salini V. Double plating for bicolumnar distal humerus fractures in the elderly. Injury 2017; 48 Suppl 3:S20-S23. [PMID: 29025604 DOI: 10.1016/s0020-1383(17)30652-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Distal humerus fractures are uncommon injuries requiring specific clinical and radiographic analysis in order to plan the optimal therapeutic strategy. In particular, bicolumnar distal humerus fractures (Type A2, A3 and C) are complex fractures. In the last years, double plating fixation became the standard treatment: this procedure helped surgeons to obtain a stable and anatomical fixation and an early mobilization, which is the main outcome for obtaining valuable functional results. In this retrospective study, we evaluated the use of open bicolumnar 90-90 plating for fixation of acute fragility fractures of the distal humerus in elderly patients, using the olecranon osteotomy as surgical approach.
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Affiliation(s)
- Andrea Pantalone
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy
| | - Daniele Vanni
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy
| | - Matteo Guelfi
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy
| | | | - Vincenzo Salini
- Orthopaedic and Traumatology Division, Department of Medicine and Science of Aging, University of Study "G. d'Annunzio" Chieti-Pescara, Italy.
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Abstract
BACKGROUND To determine the radiographic and clinical outcomes of the surgical management of adolescent intra-articular distal humerus fractures. METHODS We performed a retrospective review of the clinical and radiographic outcomes of 31 consecutive adolescent patients surgically treated for acute distal humerus intra-articular fractures. Nine patients returned for objective measures of range of motion, strength testing, and completion of validated outcome scores including the Mayo Elbow Performance Score (MEPS); The Disabilities of the Arm, Shoulder, and Hand Score (DASH); and the SF-36. RESULTS The average age at the time of injury was 13.5 years (range, 12 to 16 y) with a mean follow-up of 1.22 years (range, 9 d to 5.5 y). Multiple surgical approaches were performed. Overall, the active range of motion for our patients was 10.7 to 133.9 degrees with a mean arc of 123.4 degrees. AO classification type C2 and C3 injuries lost significantly more motion than other fracture patterns. Twelve patients sustained perioperative nerve palsies that resolved by final follow-up; seven of these nerve injuries were iatrogenic and sustained during a Bryan-Morrey tricepital slide approach. Eight patients required implant removal; 7 of these patients had prominent olecranon screws after an olecranon osteotomy. Including postoperative neuropathies, there were 20 complications in 15 patients. Thirteen complications in 9 patients required a return to the operating room. Of the 9 patients who returned for objective testing, there was no statistically significant loss of range of motion or strength of the injured extremity when compared with the uninjured limb. The MEPS revealed 6 excellent, 1 good, and 2 fair results. The average DASH score was 5.1 (range, 0 to 19.1) and the physical (average 55.7; range, 47.4 to 59.0) and mental components (average 54.2; range, 29.8 to 63.4) of the SF-36 were comparable. CONCLUSIONS After surgical intervention for an adolescent intra-articular distal humerus fracture, one can expect no significant loss of motion or strength. The reported outcomes are not all excellent. The peri-operative complication rates are high and may be related to surgical approach and fracture pattern. LEVEL OF EVIDENCE Level IV.
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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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Chou YC, Hsu YH, Yu YH, Wu CC. Triceps-reflecting anconeus pedicle approach with double precontoured locking plate fixation is efficient in the treatment of orthopaedic trauma association type C distal humerus fracture. Injury 2016; 47:2240-2246. [PMID: 27424532 DOI: 10.1016/j.injury.2016.06.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 06/15/2016] [Accepted: 06/27/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to determine if the triceps-reflecting anconeus pedicle (TRAP) approach combined with the precontoured locking plate can provide acceptable clinical outcomes in the treatment of comminuted distal humerus fracture. METHODS Between August 2008 and June 2014, 48 patients with Orthopaedic Trauma Association type C (21 with C2, 27 with C3) distal humerus fractures underwent open reduction and internal fixation with orthogonal precontoured locking plate fixation using the TRAP approach. Occurrences of bony union, implant failure, posttraumatic arthrosis, and heterotopic ossification were detected with radiography. Clinical assessment included evaluation of range of motion and determination of the pain score, Mayo Elbow Performance Index (MEPI) score, and Disability of the Arm Shoulder and Hand (DASH) score. RESULTS The fractures healed within 3 months in 25 patients (53%) and within 6 months in 23 patients (47%). The 12-month assessment revealed improved elbow movement, with the mean arc of flexion-extension of 121° (range, 100°-140°), mean arc of supination-pronation of 163° (range, 150°-180°), and mean flexion contracture of 8° (range, 0°-30°). The mean MEPI score was 81 and the mean DASH score was 11.7. CONCLUSIONS By retaining the intact olecranon by the TRAP approach, orthopedic surgeon can get adequate surgical exposure for fracture fixation and can use olecranon as a three-dimensional template to restore the articular fragments. The promising results in this study obtain because that precise identification of the triceps muscle allowed the determination of a proper length-tension relationship for triceps reattachment. The combination of triceps tendon repair and anconeous muscle repair ensured the strength of the extensor mechanism. Therefore, the TRAP approach in combination with the usage of the precontoured locking plate can be recommended as the optimal surgical approach for the treatment of comminuted distal humerus fracture.
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Affiliation(s)
- Ying-Chao Chou
- Department of Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| | - Yung-Heng Hsu
- Department of Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| | - Yi-Hsun Yu
- Department of Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| | - Chi-Chuan Wu
- Department of Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
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Abstract
Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit.
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Affiliation(s)
- Ian McAlister
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Stephen Andrew Sems
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Clavert P, Javier RM, Charrissoux JL, Obert L, Pidhorz L, Sirveaux F, Mansat P, Fabre T. How to determine the bone mineral density of the distal humerus with radiographic tools? Surg Radiol Anat 2015; 38:389-93. [DOI: 10.1007/s00276-015-1569-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 10/07/2015] [Indexed: 01/12/2023]
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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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Usefulness and reliability of two- and three-dimensional computed tomography in patients older than 65 years with distal humerus fractures. Orthop Traumatol Surg Res 2014; 100:275-80. [PMID: 24709303 DOI: 10.1016/j.otsr.2014.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 11/12/2013] [Accepted: 01/21/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Distal humerus fractures are difficult to characterise and to classify according to the AO system. In this multicentre study, our objectives were to assess the usefulness of computed tomography (CT) and to measure intra-observer and inter-observer reliability according to observer experience. MATERIALS AND METHODS An online survey of professional practice was performed using a questionnaire based on a clinical case. Participants were asked to determine the AO classification using radiographs then to reappraise their answers after the addition of CT images. For the reliability study, 16 observers in five centres evaluated radiographs and CT scans of 26 distal humerus fractures. They used the radiographs to determine the AO classification and assess the main fracture characteristics then reappraised their findings after adding the CT images. The radiographs and 2D CT images were read twice at an interval of 2 weeks, and during the second reading, 3D CT images were available also. At least 1 month later, the same observers performed similar readings 2 weeks apart (radiographs and 2D CT images at the first reading and addition of 3D CT images at the second reading). RESULTS Correct fracture classification was achieved in 95% of cases with the CT images compared to only 73% with the radiographs. CT led to diagnostic and therapeutic changes in 90% and 25% of cases, respectively. Inter-observer reliability was poor for both AO classification and fracture characteristics, not only with the radiographs and 2D CT images, but also with the added 3D CT images. In contrast, intra-observer reliability improved after the addition of 3D CT images. Assessment accuracy was influenced by image quality and geographic origin of the observer but not by observer experience. CONCLUSION CT improves diagnostic accuracy and, in some cases, changes the surgical strategy. In our study of a large number of observers, CT did not improve inter-observer agreement about the study variables. Intra-observer agreement was improved by 3D CT but not by 2D CT. Accuracy was not influenced by years of observer experience but was dependent on image quality, proficiency with computer-based tools and, above all, image observation and interpretation. LEVEL OF EVIDENCE Level III.
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Beck NA, Ganley TJ, McKay S, Tomlinson L, Ahn J, Flynn JM, Baldwin K. T-condylar fractures of the distal humerus in children: does early motion affect final range of motion? J Child Orthop 2014; 8:161-5. [PMID: 24643671 PMCID: PMC3965770 DOI: 10.1007/s11832-014-0576-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 02/25/2014] [Indexed: 02/03/2023] Open
Abstract
PURPOSE T-condylar fractures of the distal humerus are infrequent injuries in children. There are little data regarding outcomes in this age group. The adult literature demonstrates a high rate of postinjury stiffness. We describe a large series of T-condylar fractures in children and set out to identify factors that influence the postoperative range of motion (ROM) in children. Our hypothesis was that starting motion early (<3 weeks) would favorably influence the postoperative ROM. METHODS Patients were identified based on the Current Procedural Terminology (CPT) code for ORIF of supracondylar distal humerus fractures with intracondylar extension (24546). Patient records and radiographs were reviewed to determine the demographics, fracture characteristics, surgical approach and fixation, and postoperative immobilization time. Our outcome measure was ROM in flexion/extension at 3 months, 6 months, 1 year, and final follow-up. Patients were analyzed by Morrey's criteria of -30° extension and 130° flexion to assess for postoperative elbow stiffness. RESULTS Thirty-eight potential patients from 1992 to 2010 were identified with specific T-condylar patterns. Twelve patients were excluded due to insufficient follow-up or lack of final ROM data. Our cohort included 26 patients (average age 13.4 years). The average postoperative immobilization time was 3.4 weeks (range 0.9-12 weeks). At the final follow-up, patients had -12° average extension and 130° average flexion. Nine patients (35 %) were stiff and 17 patients (65 %) had functional motion postoperatively. At 3 and 6 months, starting motion early yielded better flexion and extension ROM. Late-motion patients obtained similar results at the 1-year follow-up. Open fractures, gender, and age were all not significantly associated with elbow stiffness in our series, given the limited numbers. CONCLUSION Early ROM was associated with an earlier gain of functional motion without clear adverse consequences. Despite similar findings at the final follow-up, practitioners should consider instituting early ROM protocols to decrease the duration of stiffness and potential disability for the child and the family.
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Affiliation(s)
- Nicholas A. Beck
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN 55454 USA
| | - Theodore J. Ganley
- Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Scott McKay
- Division of Orthopaedic Surgery, Texas Children’s Hospital, Houston, TX, USA ,Department of Orthopaedic Surgery, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin St. CCC650.01, Houston TX, 77030 USA
| | - Lauren Tomlinson
- Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104 USA
| | - John M. Flynn
- Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Keith Baldwin
- Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104 USA
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Ditsios K, Boutsiadis A, Agathangelidis F, Tyllianakis M, Christodoulou A. Elbow Hemiarthroplasty for Late Reconstruction of a Traumatic Elbow Bone Defect in a Young Patient: A Case Report. JBJS Case Connect 2013; 3:e129. [PMID: 29252285 DOI: 10.2106/jbjs.cc.m.00137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Konstantinos Ditsios
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
| | - Achilleas Boutsiadis
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
| | - Filon Agathangelidis
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
| | - Minos Tyllianakis
- Department of Orthopaedic Surgery, Medical School, University of Patras, Rion 26504, Greece.
| | - Anastasios Christodoulou
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
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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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Koh KH, Lim TK, Lee HI, Park MJ. Surgical release of elbow stiffness after internal fixation of intercondylar fracture of the distal humerus. J Shoulder Elbow Surg 2013; 22:268-74. [PMID: 23352470 DOI: 10.1016/j.jse.2012.10.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/26/2012] [Accepted: 10/03/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Loss of motion is common after intercondylar fracture of the distal humerus despite proper management. The purpose of the current study was to report the results of contracture release for stiffness that developed after open reduction and internal fixation (ORIF) of distal humeral intercondylar fractures. METHODS Twenty-four consecutive patients with a stiff elbow after ORIF of intercondylar fractures (20 AO type C2 and 4 type C3 fractures) were managed with contracture release at a median of 13 months. The surgical indication was total arc of motion of less than 100° despite physical therapy for more than 6 months. Plates and screws for ORIF were removed concomitantly in 16 patients. Each patient was evaluated by final arc of motion and Mayo Elbow Performance Score (MEPS). RESULTS The main lesions causing stiffness were heterotopic ossification or excessive callus in 13 patients and capsular fibrosis in 11. The mean total range of motion (ROM) was improved from 60.2° preoperatively to 104.8° postoperatively. At the final follow-up, 17 of the 24 elbows (71.8%) obtained a total ROM of more than 100°. The mean MEPS improved from 69 points preoperatively to 87 points at the final follow-up (P < .05). Refracture occurred during ROM exercise in 4 patients who had undergone concomitant implant removal during the contracture release. CONCLUSION Surgical release of a stiff elbow that develops after ORIF of intercondylar fractures can result in satisfactory restoration of ROM in most patients. However, potential risk of refracture after release should be considered when implants are concomitantly removed.
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Affiliation(s)
- Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
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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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Are conventional reconstruction plates equivalent to precontoured locking plates for distal humerus fracture fixation? A biomechanics cadaver study. Clin Biomech (Bristol, Avon) 2012; 27:697-701. [PMID: 22538250 DOI: 10.1016/j.clinbiomech.2012.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 03/26/2012] [Accepted: 03/27/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal plate type and configuration for distal humerus fracture fixation has yet to be defined. Available biomechanical studies show conflicting results. No existing studies compare conventional reconstruction plates to newer precontoured distal humerus locking plates in both parallel and perpendicular configurations. METHODS Three groups of humerus specimens were compared via biomechanical testing in a cadaver model simulating metaphyseal comminution. Group 1 consisted of conventional reconstruction plates in a perpendicular configuration. Group 2 used precontoured locking plates in a perpendicular configuration. Group 3 used precontoured locking plates in a parallel configuration. Each group was tested for stiffness in anterior bending, posterior bending, axial compression, and torsion. The specimens then underwent cyclic loading followed by single load to failure in posterior bending. FINDINGS There was no significant difference between the three groups for anterior bending, posterior bending, axial compression, or torsional stiffness. There was no significant difference in load to failure for any of the three groups. Screw loosening was significantly higher in Group 1 when compared to Groups 2 and 3 after cyclic loading. INTERPRETATION In the early postoperative period, less expensive perpendicular conventional reconstruction plate constructs provide similar stiffness and load to failure properties to newer precontoured locking plate systems regardless of plate configuration.
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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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48
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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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Corradi A, Talamonti T, Cabitza P, Bottiglieri G, Secondi F. Innovative techniques for the osteosynthesis of distal humeral fractures. Injury 2010; 41:1117-9. [PMID: 20934694 DOI: 10.1016/j.injury.2010.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Adequate restoration of the mechanical alignment, anatomic reduction of the articular surface, and stable fixation allowing early motion of the elbow joint are the primary goals in the treatment of distal humeral fractures. The purpose of our study is the comparison of the effectiveness between distal humeral locking compression plates (LCP) and conventional reconstruction and one third tubular plates. Between January 2008 and January 2009, 11 consecutive patients (4 men and 7 women) with distal humeral fractures were treated with plates in our hospital; eight patients were treated with LCP distal humeral plates and three cases were fixed with a combination of 1/3 tubular plates and reconstruction plates. They were all followed up for 12 months using the functional score of Cassebaum and radiologically with standard X-rays. Good to excellent results were obtained in 6/11 patients with a mean range of motion of 115°. At this small cohort of patients no significant differences between the two fixation methods was identified regarding clinical outcome, complications and function of the affected limb.
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Affiliation(s)
- A Corradi
- Academic Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Milan, Italy, I.R.C.C.S. Policlinico San Donato, Piazza E. Malan, 20097, San Donato M.se, MI, Italy
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