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Taylor F, Page R, Wheeler J, Lorimer M, Corfield S, Peng Y, Burnton J. Distal humeral hemiarthroplasty compared to total elbow replacement for distal humeral fractures: a registry analysis of 906 procedures. J Shoulder Elbow Surg 2024; 33:356-365. [PMID: 37689104 DOI: 10.1016/j.jse.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Total elbow replacement (TER) is an accepted treatment for complex intra-articular distal humerus fractures in elderly patients. Distal humeral hemiarthroplasty (HA) is also a potential surgical option for unreconstructable fractures and avoids the concerns regarding mechanical wear and functional restrictions associated with TER. In the current literature, there are limited data available to compare the revision rates of HA and TER for the treatment of fracture. We used data from a large national arthroplasty registry to compare the outcome of HA and TER undertaken for fracture/dislocation and to assess the impact of demographics and implant choice on revision rates. METHODS Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from May 2, 2005, to December 31, 2021, included all procedures for primary elbow replacement with primary diagnosis of fracture or dislocation. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazards models. RESULTS There were 293 primary HA and 631 primary TER procedures included. The cumulative percentage revision (CPR) rate at 9 years was 9.7% for HA (95% confidence interval [CI] 6.0, 15.7), and 11.9% (95% CI 8.5, 16.6) for TER. When adjusted for age and gender, there was a significantly higher risk of revision after 3 months for TER compared to HA (HR 2.47, 95% CI 1.22, 5.03, P = .012). There was no difference in the rate of revision for patients aged <55 years or ≥75 years when HA and TER procedures were compared. In primary TER procedures, loosening was the most common cause of revision (3.6% of primary TER procedures), and the most common type of revision in primary TER involved revision of the humeral component only (2.6% of TER procedures). TER has a higher rate of first revision for loosening compared to HA (HR 4.21, 95% CI 1.29, 13.73; P = .017). In HA procedures, instability (1.7%) was the most common cause for revision. The addition of an ulna component was the most common type of revision (2.4% of all HA procedures). CONCLUSION For the treatment of distal humerus fractures, HA had a lower revision rate than TER after 3 months when adjusted for age and gender. Age <55 or ≥75 years was not a risk factor for revision when HA was compared to TER. Loosening leading to revision is more prevalent in TER and increases with time. In HA, the most common type of revision involved addition of an ulna component with preservation of the humeral component.
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Affiliation(s)
- Fraser Taylor
- Gold Coast University Hospital, Southport, QLD, Australia.
| | - Richard Page
- Barwon Centre of Orthopaedic Research and Education, Deakin University, Geelong, VIC, Australia; Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, SA, Australia
| | - James Wheeler
- Gold Coast University Hospital, Southport, QLD, Australia
| | - Michelle Lorimer
- Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, SA, Australia
| | - Sophie Corfield
- Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, SA, Australia
| | - Yi Peng
- Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, SA, Australia
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Loisel F, Amar Y, Rochet S, Obert L. Distal humerus fracture in older patients: ORIF vs. total elbow arthroplasty. Orthop Traumatol Surg Res 2024; 110:103759. [PMID: 37992865 DOI: 10.1016/j.otsr.2023.103759] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 06/16/2023] [Indexed: 11/24/2023]
Abstract
Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion.
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Affiliation(s)
- François Loisel
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Yassine Amar
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Severin Rochet
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France
| | - Laurent Obert
- Department of Orthopedic, Trauma, Plastic, Reconstructive and Hand Surgery, EA Laboratoire de Nano médecine Imagerie Thérapeutique (LNIT), CHRU of Besançon & CIC IT, 808, boulevard Fleming, 25033 Besançon, France.
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Kauta N, Bott A, Majirija ET, Du Plessis JP, Vrettos B, Maqungo S, Roche S. Surgical management of distal humerus gunshot fractures: descriptive case series. Eur J Orthop Surg Traumatol 2023; 33:3711-3716. [PMID: 37322263 PMCID: PMC10651556 DOI: 10.1007/s00590-023-03611-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa. METHODS A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification. RESULTS Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months. CONCLUSIONS These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | | | | | - Basil Vrettos
- Vincent Pallotti Private Hospital, Cape Town, South Africa
| | - Sithombo Maqungo
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Stephen Roche
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Oshika Y, Takegami Y, Tokutake K, Yokoyama H, Oguchi T, Imagama S. Ulnar Nerve Neuropathy After Surgery for Intraarticular Distal Humerus Fractures: An Analysis of 116 Patients. J Hand Surg Am 2023; 48:1171.e1-1171.e5. [PMID: 36932009 DOI: 10.1016/j.jhsa.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 01/13/2023] [Accepted: 02/01/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE To identify the incidence and the factors associated with a postoperative ulnar nerve neuropathy in patients who had undergone open reduction and internal fixation for intraarticular distal humerus fractures. METHODS We retrospectively reviewed 116 patients who had undergone surgery between January 2011 and December 2020. Age, sex, BMI, mechanism of injury, open or closed fracture, operation time, tourniquet time, and nerve injury at the final examination were collected from medical charts. We essentially used the paratricipital approach. In cases in which the reduction of intraarticular bone fragments was difficult, olecranon osteotomy was used. Ulnar nerve function was graded according to a modified system of McGowan. We conducted logistic regression analysis to investigate factors of neuropathy using items identified as statistically significant in univariate analysis as explanatory variables. RESULTS Thirty-four patients (29.3%) had persistent neuropathy at the final follow-up. In the modified McGowan classification, 28 patients had grade 1 and 6 patients had grade 2 neuropathy. Olecranon osteotomy emerged as a distinct explanatory variable for the prophylaxis of ulnar nerve neuropathy in the multivariate analysis (odds ratio, 0.30; 95% confidence interval, 0.12-0.73). Anterior transposition, however, was not a statistically significant factor (odds ratio, 1.91; 95% confidence interval, 0.81-4.56). CONCLUSIONS Olecranon osteotomy was the only independent factor associated with preventing the occurrence of ulnar nerve neuropathy. Ulnar nerve transposition might not be associated with prevention of ulnar nerve neuropathy. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Yasutaka Oshika
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Yokoyama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Oguchi
- Department of Orthopedic Surgery, Anjo Kosei Hospital, Konan, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Heifner JJ, Lacau GE, Davis TA, Mercer DM, Gray RRL, Hoekzema NA. Linking the distal humerus columns in articular fracture fixation. Injury 2023; 54:110931. [PMID: 37495450 DOI: 10.1016/j.injury.2023.110931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/07/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Concerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture. MATERIALS AND METHODS Ten matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths. RESULTS Mean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94). DISCUSSION Our results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments.
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Affiliation(s)
- John J Heifner
- Miami Orthopaedic Research Foundation, Miami, Florida, USA.
| | - Gustavo E Lacau
- Miami Hand and Upper Extremity Institute, Miami, Florida, USA
| | - Ty A Davis
- Larkin Hospital Department of Orthopaedic Surgery, Coral Gables, Florida, USA
| | - Deana M Mercer
- University of New Mexico, Department of Orthopedics and Rehabilitation, Albuquerque, Mexico, USA
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Kurashige T, Nakagawa T, Matsubara T, Kobayashi M. Modified paratricipital approach without mobilization of the ulnar nerve prevents postoperative ulnar neuropathy in distal humerus fractures. J Orthop Sci 2023; 28:1113-1117. [PMID: 35922365 DOI: 10.1016/j.jos.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/27/2022] [Accepted: 06/29/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND In distal humerus fracture surgery, postoperative ulnar neuropathy is a common complication. The present study assessed the utility of the modified paratricipital approach for preventing ulnar neuropathy. This approach preserved the continuity of the attachment of the triceps with the ulnar nerve and allowed anterior subluxation of the ulnar nerve onto the hardware to be avoided. METHODS From December 2018 to March 2020, 13 patients who underwent surgery for distal humerus fracture through the modified paratricipital approach at our hospital were prospectively enrolled in the study. Ulnar neuropathy, Mayo Elbow Performance Score (MEPS), and Range of motion (ROM) were evaluated. RESULTS No postoperative ulnar neuropathy was observed. At the final follow-up, the mean Mayo Elbow Performance score was 97.7 (range, 85-100). The mean arc motion was 132.7° (range, 115°-145°) with a mean flexion contracture of 4.2° (range, 0°-10°) and mean flexion of 136.2° (range, 120°-145°). Hardware breakage leading to a loss of reduction occurred in one case, but the other fractures united. CONCLUSIONS Our results demonstrated the effectiveness of the modified paratricipital approach for preventing postoperative ulnar neuropathy. The modified paratricipital approach is a safe and reliable method of performing distal humerus fracture surgery.
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Affiliation(s)
- Tomoaki Kurashige
- Orthopaedic Trauma Center, Yokohama Rosai Hospital. 3211 Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, Japan.
| | - Tomoo Nakagawa
- Orthopaedic Trauma Center, Yokohama Rosai Hospital. 3211 Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, Japan
| | - Takehiro Matsubara
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Makoto Kobayashi
- Orthopaedic Trauma Center, Yokohama Rosai Hospital. 3211 Kozukue-cho, Kohoku-ku, Yokohama, Kanagawa, Japan
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Liu C, Zhang D, Blazar P, Earp BE. Outcomes After Acute Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures. J Hand Surg Glob Online 2023; 5:612-619. [PMID: 37790826 PMCID: PMC10543816 DOI: 10.1016/j.jhsg.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/07/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose Compare outcomes of acute versus delayed total elbow arthroplasty (TEA) following distal humerus fractures (DHF). Methods This retrospective study included 39 patients who underwent primary TEA with semiconstrained implants for DHF, either within 4 weeks of their injury or after failing initial open reduction and internal fixation (ORIF) or nonsurgical management, between June 1, 2003 and February 1, 2018 with minimum 1-year follow-up. Our outcome measures included QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score, complications, reoperations, and range of motion (ROM). Demographics, clinical variables, and outcomes were compared using the Student's t-test, Mann-Whitney U test, and Fisher's exact test as appropriate. Kaplan-Meier curves for mortality, implant survivorship, and reoperation were created. Results Our patients were categorized into acute TEA (n = 22), ORIF to TEA (n = 10), and nonsurgical to TEA (n = 7) treatment groups. Additional analysis was performed comparing acute to delayed TEA, which combined data from failed ORIF and nonsurgical cohorts. The median follow-up, average age, and median Charlson comorbility index were similar between groups. The most common fracture pattern was AO13C. At median follow-up of 5.8 years, QuickDASH differed between cohorts: mean of 31 (SD 19) in acute TEA and 52 (SD 27) in delayed TEA, which further subdivided to 44.2 (SD 25) in failed ORIF and 76 (SD 23) in failed nonsurgical management. Poorer QuickDASH scores at final follow-up were associated with delayed TEA, initial nonsurgical management, and depression. Surgical complications were associated with delayed TEA. Higher Charlson comorbidity index was associated with death. No variables were associated significantly with ROM, revision, or reoperation. Conclusion Comminuted DHFs are difficult to treat in the elderly with high rates of complication and poor function after surgery. Our study suggests TEA performed acutely result in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management. Type of Study/Level of Evidence Therapeutic, III.
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Affiliation(s)
- Christina Liu
- Division of Hand and Upper-Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Dafang Zhang
- Division of Hand and Upper-Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Philip Blazar
- Division of Hand and Upper-Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston
- Harvard Medical School, Boston, MA
| | - Brandon E. Earp
- Division of Hand and Upper-Extremity Surgery, Department of Orthopedics, Brigham and Women’s Hospital, Boston
- Harvard Medical School, Boston, MA
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McNeil DS, Barton KI, Faber KJ. A case report: instability after distal humerus hemiarthroplasty leading to revision with a total elbow arthroplasty. JSES Rev Rep Tech 2023; 3:431-435. [PMID: 37588511 PMCID: PMC10426479 DOI: 10.1016/j.xrrt.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
| | - Kristen I. Barton
- Roth|McFarlane Hand and Upper Limb Centre, London, ON, Canada
- Schulich School of Dentistry and Medicine, Western University, London, ON, Canada
- Faculty of Health Sciences, School of Physical Therapy, Western University, London, ON, Canada
| | - Kenneth J. Faber
- Roth|McFarlane Hand and Upper Limb Centre, London, ON, Canada
- Schulich School of Dentistry and Medicine, Western University, London, ON, Canada
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Zhang Q, Xiang M, Yang J, Dai F. Clinical and Radiographic Outcomes of Total Elbow Arthroplasty Using a Semi-constrained Prosthesis with a Triceps-preserving Approach over a Minimum Follow-up Period of 4 Years. Orthop Surg 2023; 15:2091-2101. [PMID: 37076437 PMCID: PMC10432419 DOI: 10.1111/os.13698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE Complications related to triceps after total elbow arthroplasty (TEA) have become a major surgical concern. The triceps-preserving approach has the advantage of not disturbing the insertion of triceps but is disadvantaged by the reduced exposure of the elbow joint. The aim of this study was to investigate the clinical and radiological outcomes of TEA with a triceps-preserving approach and to compare the outcomes of TEA to treat arthropathy with that of TEA to treat acute distal humerus fracture. METHODS From January 2010 to December 2018, 23 patients undergoing primary TEAs were retrospectively reviewed with a mean follow-up time of 92.6 months (range, 52-136 months). Each TEA was performed using the triceps-preserving approach with a semi-constrained Coonrad-Morrey prosthesis. Patient demographics, range of motion (ROM), pain visual analogue scale (VAS), and triceps strength (Medical Research Council [MRC] scale) were compared before and after surgery. The Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiographic outcome, and complications were evaluated at follow-up. RESULTS In total, seven males and 16 females were included in this study, with a mean age of 66.1 years (range:46-85 years). By the last follow-up, pain had been significantly relieved in all patients. The average MEPS in the arthropathy group and fracture group were 90.8 ± 10.3 points (range: 68-98 points) and 91.7 ± 0.4 (range: 76-100 points), respectively. The average DASH of the arthropathy group and fracture group was 37.3 ± 18.8 points (range: 18-52 points) and 38.4 ± 20.1 (range: 16-60 points). At the last follow-up after surgery, the mean flexion arcs in the arthropathy group and fracture group were 100.4° ± 24.1° and 97.8° ± 28.1°, respectively. The mean pro-supination arcs in the arthropathy group and fracture group were 142.4° ± 15.2° and 139.2° ± 17.5°, respectively. There were no significant differences in clinical outcomes between the two groups (P ≥ 0.05). Triceps strength was normal (MRC grade V) in 15 elbows and good in eight elbows. None of the cases experienced weakness of the triceps strength, infection, periprosthetic fractures, or prosthesis breakage. CONCLUSIONS The clinical and radiographical outcomes of TEA with the triceps-preserving approach were satisfactory in patients with distal humerus fracture, osteoarthritis and rheumatoid arthritis.
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Affiliation(s)
- Qing Zhang
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
| | - Ming Xiang
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
| | - Jin‐song Yang
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
| | - Fei Dai
- Department of Upper LimbSichuan Provincial Orthpaedics HospitalChengduChina
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Hakiminejad A, Nourani A, Ghias N, Mahmoudi A, Same K, Kamrani RS, Nabian MH. Biomechanical analysis of different osteosynthesis configurations in the pin and plate fixation method for distal humerus fractures. BMC Musculoskelet Disord 2023; 24:579. [PMID: 37460939 DOI: 10.1186/s12891-023-06709-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/08/2023] [Indexed: 07/20/2023] Open
Abstract
Distal humerus fractures commonly occur in adults with low bone mineral density causing major technical challenges for orthopedic surgeons. Persian fixation method was introduced as a novel technique to stabilize small fragments in comminuted distal humerus fractures using a set of K-wires and a reconstruction plate. The present study aims to measure this technique's stiffness and stability of this technique and analyze the effect of influential parameters with numerical simulation and biomechanical testing on a cadaveric specimen. Validation of the finite element (FE) model was conducted based on results of experiments. The results indicated that Delta configuration mainly led to a higher stiffness in the case of axial loading and anterior bending compared to L configuration. Analyzing the influential factors of this technique suggests that changes in diameter and number of K-wires have a similarly significant effect on the construct stiffness while the height of plate had a slight influence. Also, the diameter of wires was the most effective parameter for implant failure, particularly in the 3-pin construct, which caused a reduction in failure risk by about 60%. The results revealed that the Persian fixation method would achieve suitable stability compared to the dual-plating technique.
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Affiliation(s)
- Alireza Hakiminejad
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Amir Nourani
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran.
| | - Narges Ghias
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Alireza Mahmoudi
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Kaveh Same
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shahriar Kamrani
- Department of Orthopedic and Trauma Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Nabian
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran.
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Yoshii Y, Iwabuchi S, Ikumi A, Kohyama S, Ogawa T, Ishii T. Correlations between 3D preoperative planning and postoperative reduction in the osteosynthesis of distal humeral fractures. J Orthop Surg Res 2023; 18:283. [PMID: 37031170 PMCID: PMC10082491 DOI: 10.1186/s13018-023-03772-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND Three-dimensional preoperative planning has been applied to the osteosynthesis of distal humerus fractures. The present study investigated the correlations between 3D preoperative planning and postoperative reduction for the osteosynthesis of distal humerus fractures using 3D parameters. METHODS Twenty-three elbows of 23 distal humerus fracture patients who underwent osteosynthesis with three-dimensional preoperative planning were evaluated. 3D images of the distal humerus were created after taking preoperative CT scans of the injured elbow. Fracture reduction, implant selection, and placement simulations were performed based on 3D images. Postoperative CT images were taken 1 month after surgery. Correlations were evaluated with preoperative plans and postoperative 3D images. The longitudinal axis and coordinates of the humerus were defined on the 3D images. The coronal angle (CA) was defined as the angle formed by the long axis and the line connecting the medial and lateral margins of the trochlea of the humerus on a coronal plane image. The sagittal angle (SA) was defined as the angle formed by the long axis and the line connecting the top of the lateral epicondyle and the center of the humeral capitellum on a sagittal plane image. The axial angle (AA) was defined as the angle between the sagittal plane and the line connecting the medial and lateral margins behind the trochlea of the humerus. The intraclass correlation coefficients (ICC) of each measurement value were assessed between preoperative planning and postoperative images. RESULTS Preoperative planning and postoperative measurement values were CA: 85.6 ± 5.9°/85.8 ± 5.9°, SA: 140.9 ± 8.5°/139.4 ± 7.9°, and AA: 84.0 ± 3.1°/82.6 ± 4.9°, respectively. ICCs were CA: 0.75 (P < 0.01), SA: 0.78 (P < 0.01), and AA: 0.34 (P < 0.05), respectively. CONCLUSIONS The 3D preoperative planning of distal humeral fractures achieved the good correlations of coronal and sagittal angles, but the relatively poor correlation of the axial angle. This may be attributed to an inability to assess the rotation angle during surgery. We propose the measurement indices shown in the present study as a three-dimensional evaluation index for distal humerus fractures. TRIAL REGISTRATION Registered as NCT04349319 at ClinicalTrials.gov.
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Affiliation(s)
- Yuichi Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan.
| | - Sho Iwabuchi
- Department of Orthopaedic Surgery, University of Tsukuba Hospital, Tsukuba, Ibaraki, 305-8576, Japan
| | - Akira Ikumi
- Department of Orthopaedic Surgery, University of Tsukuba Hospital, Tsukuba, Ibaraki, 305-8576, Japan
| | - Sho Kohyama
- Department of Orthopaedic Surgery, Kikkoman General Hospital, Noda, Chiba, 278-0005, Japan
| | - Takeshi Ogawa
- Department of Orthopaedic Surgery, Mito Medical Center Hospital, Ibaraki, Ibaraki, 311-3193, Japan
| | - Tomoo Ishii
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan
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Luciani AM, Baylor J, Akoon A, Grandizio LC. Controversies in the Management of Bicolumnar Fractures of the Distal Humerus. J Hand Surg Am 2023; 48:177-186. [PMID: 36379867 DOI: 10.1016/j.jhsa.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/20/2022] [Accepted: 10/10/2022] [Indexed: 11/14/2022]
Abstract
Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.
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Affiliation(s)
- Alfred Michael Luciani
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jessica Baylor
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Anil Akoon
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
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Schmoelz W, Zierleyn JP, Hoermann R, Arora R. Standardized fracture creation in the distal humerus and the olecranon for surgical training and biomechanical testing. Arch Orthop Trauma Surg 2022; 142:3853-3861. [PMID: 34973090 PMCID: PMC9596540 DOI: 10.1007/s00402-021-04286-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/27/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Surgical training and biomechanical testing require models that realistically represent the in vivo injury condition. The aim of this work was to develop and test a method for the generation of distal humerus fractures and olecranon fractures in human specimens, while preserving the soft tissue envelope. METHODS Twenty-one cadaveric upper extremity specimens (7 female, 14 male) were used. Two different experimental setups were developed, one to generate distal humerus fractures and one to generate olecranon fractures. Specimens were placed in a material testing machine and fractured with a predefined displacement. The force required for fracturing and the corresponding displacement were recorded and the induced energy was derived of the force-displacement graphs. After fracturing, CT imaging was performed and fractures were classified according to the AO classification. RESULTS Eleven distal humerus fractures and 10 olecranon fractures with intact soft tissue envelope could be created. Distal humerus fractures were classified as AO type C (n = 9) and as type B (n = 2), all olecranon fractures were classified as AO type B (n = 10). Distal humerus fractures required significantly more load than olecranon fractures (6077 N ± 1583 vs 4136 N ± 2368, p = 0.038) and absorbed more energy until fracture than olecranon fractures (17.8 J ± 9.1 vs 11.7 J ± 7.6, p = 0.11), while the displacement at fracture was similar (5.8 mm ± 1.6 vs 5.9 mm ± 3.1, p = 0.89). CONCLUSION The experimental setups are suitable for generating olecranon fractures and distal humerus fractures with intact soft tissue mantle for surgical training and biomechanical testing.
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Affiliation(s)
- Werner Schmoelz
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Jan Philipp Zierleyn
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Romed Hoermann
- Division Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Rohit Arora
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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Gambhir N, Alben MG, Shankar D, Larose G, Kwon YW, Virk MS. Comparison of 90-day complication rates and readmissions of primary total elbow arthroplasty in elective and traumatic cases: a single center experience. Eur J Orthop Surg Traumatol 2022:10.1007/s00590-022-03425-6. [PMID: 36346474 DOI: 10.1007/s00590-022-03425-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The purpose of this study is to compare the 90 day complication rates of primary Total Elbow Arthroplasty (TEA) performed for arthritis (primary-OA; rheumatoid arthritis-RA) versus those performed for distal humerus fractures (DHF). METHODS Patients who underwent a TEA from 2015 to 2021 were identified from our institutional database and placed into cohorts based on surgical indications (TEA-OA, TEA-RA and TEA-DHF). Chart review was conducted to analyze the prevalence of complications, emergency department (ED) visits, readmissions, and secondary procedures in the first 90 day post-operative period. Complications included but were not limited to wound complications, hematoma, infection (superficial or deep), nerve palsy, periprosthetic fracture/failure and others. RESULTS 49 patients who underwent TEA were included in this study: (DHF = 19, OA = 14, RA = 16). Six complications occurred within the first 90 days of surgery. There were two periprosthetic joint infections (PJI) in the OA group, requiring irrigation and debridement (I & D) within the first 90 days of surgery. There were three post-operative ulnar nerve palsies and one PJI requiring I & D in the TEA-RA group. Compared to the TEA-DHF and TEA-OA groups, the RA group had higher rates of all-cause complications (p = 0.03) and nerve palsy (p = 0.03). There were no significant differences between groups in readmissions (p = 0.27) or secondary interventions (p = 0.27). CONCLUSION The 90-day complication/readmission rates of TEA preformed for DHFs is lower than those preformed for OA and RA. These differences could be related to the underlying chronic inflammatory etiology and side effect of treatments (intraarticular steroid injection, and biologics) received by patients with arthritis. LEVEL OF EVIDENCE Retrospective Cohort Study, level IV.
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Affiliation(s)
- Neil Gambhir
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Matthew G Alben
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Dhruv Shankar
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Gabriel Larose
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Young W Kwon
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Mandeep S Virk
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA.
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Chen J, Zhang W, Chen P. Three-dimensional printed bone cement prostheses can be used to treat bone defects in the distal humerus. JSES Rev Rep Tech 2022; 2:584-591. [PMID: 37588462 PMCID: PMC10426601 DOI: 10.1016/j.xrrt.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Jiaxin Chen
- Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, China
| | - Wendong Zhang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, China
| | - Pengtao Chen
- Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, China
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Han SH, Park JS, Baek JH, Kim S, Ku KH. Complications associated with open reduction and internal fixation for adult distal humerus fractures: a multicenter retrospective study. J Orthop Surg Res 2022; 17:399. [PMID: 36045372 PMCID: PMC9429783 DOI: 10.1186/s13018-022-03292-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Open reduction and plate fixation are the preferred treatment options for most distal humerus fractures in adults. However, it is often challenging for orthopedic surgeons because of the complex anatomy and the difficulty in achieving stable fixation. This multicenter study aimed to analyze the complication types and rates of patients with distal humerus fractures treated with open reduction and plate fixation, and compare the results with those found in the literature. In addition, we describe the clinical outcomes.
Methods This retrospective multicenter study was conducted between September 2001 and March 2021 and included data from four hospitals. In total, 349 elbows underwent surgical treatment at these hospitals during the study period. Patients > 17 years of age who were treated by plate fixation were included, and patients who were treated by other fixation methods were excluded. A total of 170 patients were included in the study. The following types of complications were investigated: (1) nerve related; (2) fixation and instrument related; (3) osteosynthesis related; (4) infection; and (5) others.
Results The following complications were found: (1) 26 (15.3%) cases of postoperative ulnar nerve symptoms; 4 (2.4%) of postoperative radial nerve symptoms; (2) one (0.6%) case of screw joint penetration and screw loosening; and eight (4.7%) cases of hardware removal due to instrument skin irritation; (3) seven (4.1%) cases of nonunion; (4) two (1.2%) and four (2.2%) cases of superficial and deep infection, respectively, and seven (3.9%) cases of wound complication; and (5) 37 (21.8%) cases of heterotrophic ossification, 79 (46.5%) cases of elbow stiffness (did not achieve functional range of motion [ROM]), and 41 (24.1%) cases of osteoarthritis over Broberg and Morrey Grade I. Paradoxically, the postoperative ulnar nerve symptoms were more frequent in the prophylactic ulnar nerve anterior transposition group. However, this difference was not statistically significant (p = 0.086). The mean ROM was 123.5° flexion to 9.5° extension. The average Disabilities of the Arm, Shoulder and Hand (DASH) score was 14.5 ± 15.6. Conclusions Open reduction and plate fixation for distal humeral fractures is a reasonable treatment option with acceptable complication rates and favorable clinical outcomes. Surgeons must be vigilant about ulnar nerve complications. Level of Evidence Therapeutic Level III. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03292-1.
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Affiliation(s)
- Soo-Hong Han
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, 59, Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Jin Sung Park
- Division of Hand & Wrist Surgery and Microsurgery, Department of Orthopedic Surgery, Yeson Hospital, 206, Bucheon-ro, Bucheon-si, Gyeonggi-do, 14555, Republic of Korea
| | - Jong Hun Baek
- Department of Orthopedic Surgery, Kyung Hee University Hospital, Kyung Hee University School of medicine, 23 Kyunghee-daero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Segi Kim
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, 59, Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, Republic of Korea
| | - Ki Hyeok Ku
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892, Dongnam-ro, Gangdong-gu, Seoul, 05278, Republic of Korea.
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Schultzel M, Rangarajan R, Blout C, Manuputy I, Lee BK, Itamura JM. Hemiarthroplasty for the treatment of distal humerus fractures: long-term clinical results. J Shoulder Elbow Surg 2022; 31:1510-1514. [PMID: 35063642 DOI: 10.1016/j.jse.2021.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty is a treatment for unreconstructable distal humerus fractures; implant longevity remains a concern, especially in younger patients. However, distal humeral hemiarthroplasty (DHH) offers an alternative with potential long-term advantages. METHODS This is a retrospective study of 10 patients who underwent DHH for distal humerus fractures over a 4-year period (2008-2012) by a single surgeon. Patients underwent testing of range of motion, Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test, Charlson Comorbidity Index (CCI), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores. Average patient age at surgery was 71.9 years (range 56-81 years); average follow-up was 115.2 months (range 96-144 months). RESULTS Patients maintained improvements in MEPS (mean 88, range 75-100) and DASH scores (mean 37.1, range 11.21-55.09), along with no statistically significant decrease in range of motion or scores in comparison to either short- or midterm results. Mean VAS score was 2.2 (range 0-7), SANE 69 (range 55-85), ASES 76.66 (range 51.67-100), and CCI 4.3 (range 1-7). Participants had an average flexion of 126° (range: 90°-140°), extension of 36° (range: 30°-45°), supination of 66° (range: 60°-70°), and pronation of 64° (range: 45°-80°). No elbow dislocations, subluxations, or heterotopic ossification were observed. Complications included 1 fracture and 1 complaint of prominent hardware. Four patients were deceased, and 1 patient was lost to follow-up. CONCLUSION This long-term review suggests that DHH may be an effective treatment for certain distal humerus fractures. The data suggest that elbow range of motion and functional use are maintained from comparison with short- and midterm studies, with no appreciable change in radiographic cartilage wear along the radius or ulna.
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Affiliation(s)
| | - Rajesh Rangarajan
- Marshfield Medical Center-Beaver Dam-Institute for Movement and Orthopedics, Beaver Dam, WI, USA
| | - Collin Blout
- Cedars-Sinai Kerlan-Jobe Institute at White Memorial Medical Center, Los Angeles, CA, USA
| | - Isaac Manuputy
- Cedars-Sinai Kerlan-Jobe Institute at White Memorial Medical Center, Los Angeles, CA, USA
| | - Brian K Lee
- Cedars-Sinai Kerlan-Jobe Institute at White Memorial Medical Center, Los Angeles, CA, USA
| | - John M Itamura
- Cedars-Sinai Kerlan-Jobe Institute at White Memorial Medical Center, Los Angeles, CA, USA
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Kervinen KV, Salmela MT, Lähdeoja TA. Outcomes of AO/OTA C-type fractures of the distal humerus after open reduction and internal fixation with locking plate constructs in patients at least 65 years old. BMC Musculoskelet Disord 2022; 23:523. [PMID: 35650611 PMCID: PMC9158207 DOI: 10.1186/s12891-022-05431-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background Modern treatment options of distal humerus fractures of active elderly patients are osteosynthesis and total elbow arthroplasty. The evidence of outcomes of ORIF after AO/OTA C-type fractures mostly predates the adoption of locking plates. We evaluated the results of open reduction and internal fixation of these fractures treated exclusively with anatomic locking plates. Methods A retrospective cohort of 39 patients aged 65 years or above with ORIF for AO/OTA C-type distal humerus fracture using locking plates was analysed. 23 provided follow-up data and 14 attended a follow-up visit. Primary outcome was the Oxford Elbow Score. Secondary outcomes were Mayo Elbow Performance Score, quickDASH, satisfaction, range of motion, complications and revision surgeries. Results Mean Oxford Elbow Score pain was 83 (SD 17), Oxford Elbow Score function 83 (17) and Oxford Elbow Score social-psychological 79 (20). Mean total Oxford Elbow Score was 81 (15). Among the 14 patients who attended a follow-up visit, Mayo Elbow Performance Score was 85 (17), qDASH 19 (16), active arc of motion 119 (19) degrees. Mayo Elbow Performance Score and arc of motion were worse than on the healthy side. One patient had a serious deep infection. Eleven patients had at least one revision surgery, of which 6 were implant removals and 2 subsequent total elbow arthroplasties. Conclusions Distal AO/OTA C-type distal humerus fractures in older adults can be treated reliably and with good outcomes with ORIF using modern locking plates. The mean qDASH scores are similar to population normal values, but when compared to the healthy arm, single-arm outcomes indicated somewhat impaired function. About 1 in 4 patients had at least one revision surgery.
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Affiliation(s)
| | - Mikko T Salmela
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, 00029, Helsinki, HUS, Finland
| | - Tuomas A Lähdeoja
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, 00029, Helsinki, HUS, Finland.
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Patrick CM, Tadlock JC, Nesti LJ, Dunn JC, Parnes N. Treatment trends in distal humerus fractures between ABOS part II candidates. Injury 2022; 53:1044-1048. [PMID: 34654550 DOI: 10.1016/j.injury.2021.09.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF). METHODS The American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications. RESULTS There were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%). CONCLUSION Our data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cole M Patrick
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, Texas, USA; Texas Tech University Health Science Center, Department of Orthopaedic Surgery, El Paso, Texas, USA.
| | - Joshua C Tadlock
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, Texas, USA; Texas Tech University Health Science Center, Department of Orthopaedic Surgery, El Paso, Texas, USA
| | - Leon J Nesti
- Uniformed Services University, Clinical and Experimental Orthopedics, Bethesda, Maryland, USA
| | - John C Dunn
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, Texas, USA; Texas Tech University Health Science Center, Department of Orthopaedic Surgery, El Paso, Texas, USA; Uniformed Services University, Clinical and Experimental Orthopedics, Bethesda, Maryland, USA
| | - Nata Parnes
- Carthage Area Hospital, Department of Orthopaedic Surgery, Carthage, NY, USA
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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 Rev Rep Tech 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Moursy M, Wegmann K, Wichlas F, Tauber M. Distal humerus fracture in patients over 70 years of age: results of open reduction and internal fixation. Arch Orthop Trauma Surg 2022; 142:157-164. [PMID: 33151362 PMCID: PMC8732916 DOI: 10.1007/s00402-020-03664-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 10/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Due to the complexity of distal humerusfractures and often poor bone quality in elderly patients, these entities remain a challenge. However, because of a high rate of complications related to total elbow prostheses, reconstruction of distal humerus fractures should still be considered a therapeutic option, also in the elderly patient. The purpose of the present study was to investigate the clinical outcomes after open reduction and internal fixation and to evaluate whether the results justify reconstruction even in elderly patients. We hypothesized that despite advanced age, reasonable clinical results can be achieved, using a standardized surgical technique and aftertreatment protocol for the treatment of distal humerus fractures in elderly patients. METHODS Between 2004 and 2012, 30 patients with a mean age of 78 years at the time of injury with a recent distal humerus fracture were evaluated. All patients underwent the identical aftertreatment protocol with no weight bearing for 6 weeks and weekly increasing range of motion. Follow-up rate was 90%. 22 patients were treated with double plate, 4 with single plate, and 1 with screw fixation only. Patients were evaluated based on clinical criteria. Primary outcome measures were Mayo Elbow Performance Score, VAS and joint range of motion, secondary was radiological evaluation. RESULTS After a mean follow-up period of 3.8 years (min. 1 year, max. 9 years, SD ± 2), the average range of motion was flexion of 127° (min. 100°; max. 150°; SD ± 16.5) and average loss of extension of 20.9° (min. 5°; max. 40°; SD ± 11). Average pronation and supination was 68.3° (min. 0°; max. 90°; SD ± 25.3) and 75.3° (min. 0°; max. 90°; SD ± 19.7), respectively. Average Mayo Elbow Performance (MEPS) score was 88.7 (min. 60; max. 100; SD ± 12.1). 6 patients developed heterotopic ossification without significant effect on the clinical outcome. 7 patients had radiological evidence of at least partial non-union with one requiring revision, 2 discrete hardware dislocations were treated conservatively. There were no infections in the presented cohort. Our results regarding the surgical approach showed significantly higher patient satisfaction scores in the osteotomy group, compared to the group with Triceps-On Approach (PTOA). CONCLUSION The present data support indication for open reduction internal fixation (ORIF) even in the elderly patient. Advanced age should not be seen as a contraindication for ORIF of fractures of the distal humerus. Although the rate of complications is higher than in younger patients, complications such as non-union are often asymptomatic, patient satisfaction scores are high, and the possible devastating complications of failed elbow replacement can be evaded. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Mohamed Moursy
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Kilian Wegmann
- University of Cologne, Faculty of Medicine, Cologne, Germany
- University Hospital Cologne, Center of Orthopedic and Trauma Surgery, Cologne, Germany
| | - Florian Wichlas
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Mark Tauber
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
- Shoulder and Elbow Surgery, ATOS Clinic, Munich, Germany
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Abstract
Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.
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Affiliation(s)
- Naoko Onizuka
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Julie Switzer
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Chad Myeroff
- TRIA Orthopedic Center, 155 Radio Drive, Woodbury, MN 55125, USA.
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Abstract
Background Distal humerus fractures (DHFs) constitute one-third of elbow fractures approximately. In this study, we aim to define and analyze the fracture lines and morphological features of DHFs using mapping technique. Methods One hundred and two DHFs were retrospectively reviewed. All the computed tomography (CT) data were used to manually reconstruct and virtually reduce the DHF fragments to fit a standard 3D model. Smooth curves were depicted accurately onto the surface of the template to represent the fracture lines. All the curves were overlapped onto the model to create the 3D fracture map and heat map. Results Our analysis was based on 102 CT images of DHFs, contributed by 59 male and 43 female patients (mean age, 46 years; range, 18-93 years), and included 15 type A, 25 type B, and 62 type C fractures. On mapping, the hot zones were located in the radial fossa, coronoid fossa, olecranon fossa, and the external part of the trochlear. Conversely, the cold zones were noted in medial condyle, the medial side of the trochlear, and the anterolateral area on the supracondylar ridge. Conclusions Our study firstly shows the fracture lines and morphological features of distal humeral fractures by three-dimensional mapping technology. Distal humerus fracture lines are characteristic and highly related to the micro-architecture difference of distal humerus, which may provide some guidance for the treatment plan selection and surgical fixation design.
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Affiliation(s)
- Chao Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Yong Zhu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Haitao Long
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Zhangyuan Lin
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Ruibo Zhao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Buhua Sun
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Shushan Zhao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Liang Cheng
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
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Yetter TR, Weatherby PJ, Somerson JS. Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis. J Shoulder Elbow Surg 2021; 30:1957-67. [PMID: 33711499 DOI: 10.1016/j.jse.2021.02.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years. METHODS We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating. RESULTS Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01). CONCLUSIONS This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.
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Li J, Martin VT, Su ZW, Li DT, Zhai QY, Yu B. Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature. World J Clin Cases 2021; 9:4318-4326. [PMID: 34141796 PMCID: PMC8173410 DOI: 10.12998/wjcc.v9.i17.4318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/24/2021] [Accepted: 04/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage. Open reduction and internal fixation (ORIF) has become the preferred treatment because it provides anatomical reduction, stable internal fixation, and early motion, but the optimal surgical approach remains controversial.
CASE SUMMARY We report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach, in which lateral epicondyle osteotomy was performed based on the extended lateral approach. We named the novel surgical approach the lateral epicondyle osteotomy approach. All patients underwent surgical treatment and were discharged successfully. All patients had excellent functional results according to the Mayo elbow performance score. The average range of motion was 118° in flexion/extension and 172° in pronation/ supination. Only case 2 had a complication, which was implant prolapse.
CONCLUSION We demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.
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Affiliation(s)
- Jie Li
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Vidmi Taolam Martin
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Zhi-Wen Su
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Dong-Tai Li
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Qi-Yi Zhai
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Bo Yu
- Department of Orthopedics, Zhujiang Hospital of Southern Medical University, Guangzhou 510282, Guangdong Province, China
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Thomrungpiyathan T, Luenam S, Lohwongwatana B, Sirichativapee W, Nabudda K, Puncreobutr C. A custom-made distal humerus plate fabricated by selective laser melting. Comput Methods Biomech Biomed Engin 2021; 24:585-596. [PMID: 33797978 DOI: 10.1080/10255842.2020.1840560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This study aims to evaluate the mechanical performance of custom 3D-printed titanium plates in the treatment of distal humerus fractures. Rigidity of four plating configurations were investigated by finite element analysis. The results reveal that implementation of custom designs with minimal screw holes, lateral-medial linking screw and lateral brim could significantly improve stiffness and consequently leads to better biomechanical stability as compared to standard osteosynthesis design. Biomechanical testing was also performed to validate practical usability. The results confirm that newly designed custom plates fabricated by selective laser melting is a possible alternative for the treatment of distal humerus fracture.
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Affiliation(s)
- Thansita Thomrungpiyathan
- Advanced Materials Analysis Research Unit, Department of Metallurgical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Suriya Luenam
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Boonrat Lohwongwatana
- Advanced Materials Analysis Research Unit, Department of Metallurgical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand.,Biomedical Engineering Research Center, Chulalongkorn University, Bangkok, Thailand
| | - Winai Sirichativapee
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kriengkrai Nabudda
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chedtha Puncreobutr
- Advanced Materials Analysis Research Unit, Department of Metallurgical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand.,Biomedical Engineering Research Center, Chulalongkorn University, Bangkok, Thailand
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Grogan BF, Danford NC, Lopez CD, Maier SP, Kongmalai P, Kovacevic D, Levine WN, Jobin CM. Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate. SICOT J 2021; 7:25. [PMID: 33812466 PMCID: PMC8019548 DOI: 10.1051/sicotj/2021006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 01/31/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. Methods: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. Results: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). Conclusion: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.
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Affiliation(s)
- Brian F Grogan
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA - Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, UW Health at The American Center, 4602 Eastpark Boulevard, Madison, 53718 WI, USA
| | - Nicholas C Danford
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Cesar D Lopez
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Stephen P Maier
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Pinkawas Kongmalai
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - David Kovacevic
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, 10032 NY, USA
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Tarallo L, Novi M, Porcellini G, Giorgini A, Micheloni G, Catani F. Surgical tips and tricks for coronal shear fractures of the elbow. Arch Orthop Trauma Surg 2021; 141:261-270. [PMID: 32495117 DOI: 10.1007/s00402-020-03500-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/31/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Coronal shear fractures of the distal humerus represent an uncommon lesion and could be burdened by high complications. This complex lesion requires an accurate reduction and surgical fixation for a better outcome. Different techniques have been described, however no standard protocol have been proposed. Purpose of this retrospective study, is to evaluate the clinical and radiological outcome with posterior cannulated self-tapping headless screws followed by an early-active-motion protocol and to outline the surgical tips and tricks for different fracture patterns. MATERIALS AND METHODS From 2013 to 2019, a consecutive series of 24 patients with coronal shear fracture undergoing ORIF were included in the study. Fractures were classified according to Dubberley's classification. Cannulated self-tapping headless screws were used to fix the fragments. When necessary, additional cannulated half-threaded screws on the lateral edge of the humerus were used, as well as bone chips and fibrin sealant on severe comminution. All patients underwent an assisted early-active-motion rehabilitation protocol. Mean follow-up was 30 months; patients underwent standard X-rays and clinical outcome assessment with range of motion, Broberg and Morrey score and MEPI score. RESULTS Surgical fixation with headless screw guaranteed complete healing of all shear fractures examined, no loss of reduction were reported. ROM assessment showed good results with an average arc of 113.1°. Excellent to good Broberg-Morrey and MEPI score were reported. No cases of avascular necrosis nor post-traumatic osteoarthritis resulted in our series. Complications occurred in 16.6% of the patients. CONCLUSION Coronal shear fracture represents a challenging injury to treat. Anatomical reduction and the use of cannulated self-tapping headless screws from posterior provide a stable fixation, high union rates and good elbow function, with a low cartilage damage and risks of necrosis over 2 years of follow-up. LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Luigi Tarallo
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy.
| | - Michele Novi
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Giuseppe Porcellini
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Andrea Giorgini
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Gianmario Micheloni
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - Fabio Catani
- Orthopaedic and Traumatology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
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Shah NV, Hayes WT, Wang H, Hordines JC, Karakostas JE, Paxinos O, Koehler SM. A pilot biomechanical study comparing a novel, intramedullary Nail/Plate construct to standard Dual-Plate fixation of intra-articular C2.3 distal humerus fractures. Injury 2020; 51:2148-2157. [PMID: 32605784 DOI: 10.1016/j.injury.2020.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The gold-standard treatment for intra-articular distal humerus fractures (DHFs) is dual-plate/dual-column fixation, though optimal orientation is not yet established. With a superior method not yet identified, we propose a load-sharing construct, combining absolute stability (extramedullary plate fixation) for distal articular fragments and relative stability (load-sharing intramedullary nail) for the metaphyseal segment. The purpose of this pilot study was to evaluate the biomechanical performance of a novel implant compared to orthogonal dual-plating. MATERIALS AND METHODS Ten fresh-frozen matched-pairs of human cadaveric upper extremities with no prior elbow pathology/surgery were used. Pairs were randomized into two groups: Dual-Plate (medial and posterolateral) or novel Nail/Plate (cross-locked medial nail and posterolateral plate). AO/ASIF type 13-C2.3 multifragmentary fractures with simulated metaphyseal comminution. Biomechanical testing included stiffness (MPa) and load to failure (Newtons) in axial (100 cycles at 3 Hz at 20 N increments from 20 to 100 N) and coronal (varus/valgus; 4,000 cycles from 50N-100 N at 3 Hz) planes. Failed specimens were not analyzed and mechanisms were identified. For all failures, mechanisms were identified and reviewed by three consultant surgeons for revision vs. immobilization, to attempt to recreate a real-world scenario. All outcomes were compared between groups. RESULTS During stiffness testing, zero Nail/Plate specimens failed, but two (20%) Dual-Plate specimens failed (mechanisms: fracture diastasis; bone collapse and intussusception into osteotomy, yielding articular congruency loss). For remaining samples, Nail/Plate (n = 10) coronal (varus/valgus) stiffness was comparable to Dual-Plate (n = 8) constructs (41.5 vs. 39.0 MPa, p = 0.440). Remaining Dual-Plate constructs had greater axial overall stiffness than Nail/Plate (118.3 ± 48.3 vs. 95.6 ± 34.7 MPa, p = 0.020). Failure loads were comparable between Nail/Plate and Dual-Plate constructs (1,327.8 vs. 1,032.4 N, p = 0.170). Individual nail yield strength ranged from 1,101.1-1,124.4 N (n = 2). In review of all failures, the most common overall mechanism was fracture/osteotomy site posterolateral plate bending. Revision recommendation rate was comparable between constructs (Nail/Plate, 22.2% vs. Dual-Plate, 44.4%, p>0.05). CONCLUSIONS The novel Nail/Plate construct demonstrated non-inferior coronal (varus/valgus) stiffness, despite producing lower axial stiffness than orthogonal dual-plating, potentially due to the load-sharing cross-locked design. Considering comparable biomechanical performance, with no failures and comparable recommendations for revision, this novel construct warrants further evaluation as an alternative to the gold-standard, dual-plate fixation method for intra-articular distal humerus fractures. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Westley T Hayes
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Hanbin Wang
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - John C Hordines
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Jonathan E Karakostas
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA
| | - Odysseas Paxinos
- Orthopaedic Department, 251 Hellenic Air Force Hospital, Athens, Greece
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, 450 Clarkson Ave, MSC 30, Brooklyn, NY 11203, USA.
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30
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Kumbaraci M, Basa CD, Turgut A. Analysis of Factors Affecting Return to Work After Surgical Treatment in Patients with AO Type C Distal Humerus Fractures. Indian J Orthop 2020; 55:680-687. [PMID: 33995873 PMCID: PMC8081785 DOI: 10.1007/s43465-020-00260-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study is to evaluate the functional results of distal humerus fractures which were treated by open reduction and fixation with pre-contoured angular stable plates in young patients, and investigate whether the patients could return to their pre-injury work and patients' financial conditions while they were not working. MATERIALS AND METHODS The data of 48 patients, ages between 18 and 55 years, working in a job and having AO/OTA type C distal humerus fracture were retrospectively evaluated. Mayo Elbow Performance Score (MEPS) was used to determine functional results. Postoperative radiographs were evaluated to determine the rate of union, degenerative changes, malunion and heterotopic ossification. Financial outcome form was constituted by the authors and the patients asked whether she/he could return to their pre-injury works after treatment finished and the financial status of the patients during the treatment and after the treatment. RESULTS The mean flexion-extension arc was 114° ± 12°(range 85°-135°) and the mean MEPS score was 85 ± 11(range 65-100). The average time to return to work was 6.5 ± 2.4 months (3-12 months). AO type C2 and C3 fractures and heterotopic ossification negatively affected the functional results and also adversely affected the patients' return to their pre-injury works. 38 (79%) patients returned to pre-injury work and 29 (76%) of them started to work at the same position before the fracture occured. Nine of 38 patients (24%) had to change their positions. Among the 48 patients, 10 patients (21%) could not return to the same work, 7 of them found light duty and 3 of them had not been to work. CONCLUSION Although the functional results of surgical treatment of intra-articular distal humerus fractures are good, at the end of the treatment, especially heavy workers may have difficulties in returning to their former works.
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Affiliation(s)
- Mert Kumbaraci
- Orthopaedic and Traumatology Department, Orthopaedic Surgeon Tepecik Training and Research Hospital, Yenisehir, 35110 Izmir, Turkey
| | - Can Doruk Basa
- Orthopaedic and Traumatology Department, Orthopaedic Surgeon Tepecik Training and Research Hospital, Yenisehir, 35110 Izmir, Turkey
| | - Ali Turgut
- Orthopaedic and Traumatology Department, Orthopaedic Surgeon Tepecik Training and Research Hospital, Yenisehir, 35110 Izmir, Turkey
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Yoshii Y, Teramura S, Oyama K, Ogawa T, Hara Y, Ishii T. Development of three-dimensional preoperative planning system for the osteosynthesis of distal humerus fractures. Biomed Eng Online 2020; 19:56. [PMID: 32660498 PMCID: PMC7359224 DOI: 10.1186/s12938-020-00801-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To reproduce anatomical reduction and appropriate implant placement/choices during osteosynthesis for elbow fractures, we developed a 3D preoperative planning system. To assess the utility of 3D digital preoperative planning for the osteosynthesis of distal humerus fractures, we evaluated the reproducibility of implant reduction shapes and placements in patients with distal humerus fractures. METHODS Twelve patients with distal humerus fractures who underwent osteosynthesis using 3D preoperative planning were evaluated. Reduction shapes were evaluated by the angle between the diaphysis axis and a line connecting the vertices of the medial epicondyle and the lateral epicondyle (epicondyle angle), and the angle between the diaphysis axis and the articular surface (joint angle) in the coronal plane, and the distance between the anterior diaphysis and the anterior articular surface in the sagittal plane (anterior distance) based on 3D images of the distal humerus. In addition, the implant positions were evaluated by the positions of the proximal and posterior edge of the plate, and the angle of the plate to the epicondyle line. The reproducibility was evaluated by intra-class correlation coefficients of the parameters between pre- and postoperative images. RESULTS The intra-class correlation coefficients were 0.545, 0.802, and 0.372 for the epicondyle angle, joint angle, and anterior distance, respectively. The differences in the measurements between the preoperative plan and postoperative reduction were 2.1 ± 2.1 degrees, 2.3 ± 1.8 degrees, and 2.8 ± 2.0 mm, for the epicondyle angle, joint angle, and anterior distance, respectively. The intra-class correlation coefficients were 0.983, 0.661, and 0.653 for the proximal and posterior plate positions, and the angle to the epicondyle, respectively. The differences in the measurements between the preoperative plan and postoperative reduction were 3.3 ± 2.1 mm, 2.7 ± 1.7 mm and 9.7 ± 9.8 degrees, for the plate positions of proximal and posterior edge, and the angle of the plate to the epicondyle line, respectively. There were significant correlations for the epicondyle angle, joint angle, and plate positions. CONCLUSIONS 3D preoperative planning for osteosynthesis of distal humerus fracture was reproducible for the reduction shape of the coronal view and the plate positions. It may be helpful for acquiring practical images of osteosynthesis in distal humerus fractures. LEVEL OF EVIDENCE Level III, a case-control study.
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Affiliation(s)
- Yuichi Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan.
| | - Shin Teramura
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan
| | - Kazuki Oyama
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan
| | - Takeshi Ogawa
- Department of Orthopaedic Surgery, University of Tsukuba Hospital, Tsukuba, Ibaraki, 305-8576, Japan
| | - Yuki Hara
- Department of Orthopaedic Surgery, University of Tsukuba Hospital, Tsukuba, Ibaraki, 305-8576, Japan
| | - Tomoo Ishii
- Department of Orthopaedic Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan
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Goetti P, Behrends DA, Gallusser N, Terrier A, Becce F, Vauclair F. Predrilled locking compression plate is more accurate than tension band wiring in restoring articular geometry of the ulnar greater sigmoid notch after olecranon Chevron osteotomy. Injury 2020; 51:1597-1602. [PMID: 32430193 DOI: 10.1016/j.injury.2020.04.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/14/2020] [Accepted: 04/25/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The olecranon Chevron osteotomy (OCO) is commonly used to approach complex intra-articular fractures of the distal humerus. Predrilled tension band wiring (TBW) has historically been used to fix OCO. However, clinical outcomes are burdened by secondary loss of reduction and up to 21.3% non-union rates. The biomechanical stability of anatomic locking compression plate (LCP) was reported to be superior to TBW in olecranon fracture fixation. We hypothesised that this implant may also be superior to TBW in the anatomic reconstruction of the articular surfaces of the ulnar greater sigmoid notch after OCO by predrilling the holes of the angular stable plate with the threaded drill guide prior to osteotomy. MATERIALS AND METHODS Lateral standardised and calibrated radiographs of twenty synthetic ulnar bones were obtained using a custom-made holder prior to preparation by a senior orthopaedic trauma surgeon. Ten specimens were then predrilled using the threaded drill bit guide of an olecranon LCP, while the other ten samples were predrilled with two 1.6 mm Kirschner wires. A distal "V" OCO was performed using a 0.6 mm oscillating saw. After repositioning and fixation with the corresponding device, lateral radiographs were repeated. Two independent observers used the TraumaCad planning software to document the articular geometry of the ulnar greater sigmoid notch pre- and postoperatively. The diameter of the best-fitting circle (diameter), the distance between the tip of the coronoid and the olecranon processes (distance) and the maximum articular depth were measured. RESULTS With the TBW technique, after OCO and fixation, all three postoperative measurements were significantly (p≤0.001) different from preoperative measurements. The diameter and distance increased by a mean of 1.5±0.5 mm and 0.9±0.3 mm, respectively, while the depth decreased by a mean of 0.2±0.1 mm. In contrast, no significant differences between pre- and postoperative measurements were observed with the LCP technique (p≥0.13). Inter and intra-observer measurement reliability was strong to very strong (intraclass correlation coefficients≥0.793) for all three variables. CONCLUSION Our study reveals that the predrilled LCP technique is more accurate than the predrilled TBW in restoring the anatomic articular geometry of the ulnar greater sigmoid notch after OCO.
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Affiliation(s)
- Patrick Goetti
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Dominique Andre Behrends
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Nicolas Gallusser
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Alexandre Terrier
- Laboratory of Biomechanical Orthopedics, Ecole Polytechnique Fédérale de Lausanne, Station 19, 1015 Lausanne.
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Frédéric Vauclair
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
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Marcoin A, Eichler D, Kempf JF, Clavert P. Biomechanical model of distal articular humeral fractures-influence of bone density on the fracture threshold. Int Orthop 2020; 44:1385-1389. [PMID: 32474717 DOI: 10.1007/s00264-020-04624-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/12/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Working hypothesis: The distal humeral bone density influences supracondylar fracture threshold. The aim of this study was first to develop a reproducible model of intra-articular distal humeral fractures and second to establish a relationship between bone mineral density (BMD) and the fracture threshold of the humerus. MATERIALS AND METHODS An original model of the fracture was developed using ten sawbones. After obtaining a reproducible and clinically relevant fracture model, we tested 21 cadaveric distal humeri for which the BMD was known with a stainless-steel custom-made proximal ulna jig. Fractures were created using a servo hydraulic-testing machine in axial compression to simulate a fall onto an outstretched hand. Fracture lines, load to failure, and rigidity of the bone were recorded based on the stress-strain curves. RESULTS The fracture generation was reliable, reproducible, and clinically relevant (type B2). A significant correlation between the BMD and the fracture threshold was found. Mean threshold was 901.86 N/m2. Mean distal humerus BMD was 0.9097 g/cm2 (r = 0.7321). CONCLUSIONS We developed a reproducible articular fracture of the distal humerus model and found a correlation between the fracture threshold and bone mineral density.
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Affiliation(s)
- Axel Marcoin
- CHU Maison Blanche, 45 Rue Cognacq Jay, 51092, Reims, France
| | | | - Jean-François Kempf
- Shoulder and Elbow Department, CCOM-CHU Strasbourg, 10 avenue Achille Baumann, 67400, Illkirch-Graffenstaden, France
| | - Philippe Clavert
- Laboratoire iCube-GEBOAS, CNRS UMR 7357, Equipe 12 Matériaux Multi-échelles et Biomécanique, Institut d'Anatomie Normale, Faculté de médecine, 67085, Strasbourg, France.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Fortis-Olmedo IO, Avalos-Arroyo G, Romo-Rodríguez R. [Complex elbow fracture]. Acta Ortop Mex 2019; 33:329-332. [PMID: 32253857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Elbow fractures are secondary to low or high energy trauma affecting the distal humerus, olecranon, radial head or a combination of the above. Complex fractures of the elbow complicate the reduction and its subsequent fixation representing a real challenge for the orthopedic surgeon. It is essential the use of diagnostic aids such as computerized axial tomography for diagnosis and subsequent treatment. Currently new trends in the fixation of the same and the various implants with which it is counted, can improve improve the patients prognosis. We present two clinical cases of complex elbow fractures treated by osteosynthesis.
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Affiliation(s)
- I O Fortis-Olmedo
- Hospital ABC The American British Cowdray Medical Center. Ciudad de México. México
- Hospital Shriners para niños,. Ciudad de México. México
| | - G Avalos-Arroyo
- Hospital General Regional Núm. 1, Instituto Mexicano del Seguro Social (IMSS). Querétaro, Qro. México
| | - R Romo-Rodríguez
- Cirugía de Mano y Microcirugía, Hospital ABC The American British Cowdray Medical Center. Ciudad de México. México
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Yu X, Xie L, Wang J, Chen C, Zhang C, Zheng W. Orthogonal plating method versus parallel plating method in the treatment of distal humerus fracture: A systematic review and meta-analysis. Int J Surg 2019; 69:49-60. [PMID: 31362124 DOI: 10.1016/j.ijsu.2019.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/23/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This systematic review and meta-analysis was performed to investigate the outcomes of orthogonal plating method and parallel plating method in the treatment of distal humerus fracture from the current literatures. METHODS The electronic literature database of Pubmed, Embase, and Cochrane library were searched in November 2018. The data operation time, union time, Mayo Elbow Performance Score (MEPS), range of motion (ROM) of elbow, arc of elbow flexion, arc of elbow extension, rate of excellent and good results and complications (including heterotopic ossification, transient ulnar nerve neuropathy and ankylosis) were extracted. Stata 14.0 software was used for our meta-analysis. RESULTS A total of 8 studies including 6 RCTs and 2 cohort studies met our inclusion criteria. This meta-analysis showed that there was no significant difference between the two groups regarding operation time, MEPS, ROM of elbow, arc of elbow flexion, arc of elbow extension and rate of excellent and good results at final follow-up (P = 0.50, P = 0.39, P = 0.87, P = 0.18, P = 0.58 and P = 0.59 respectively). However, the present meta-analysis demostrated that parallel plating method had significantly shorter union time than orthogonal plating method (P = 0.018). As for the complications (heterotopic ossification, transient ulnar nerve neuropathy and ankylosis), there was no significant difference between the two groups (P = 0.89, P = 0.08 and P = 0.29 respectively). CONCLUSION Our meta-analysis suggested that both orthogonal plating and parallel plating method could achieve satisfactory outcomes with the similarly low complications in the treatment of distal humerus fracture. More RCTs are required for further research.
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Affiliation(s)
- Xianbin Yu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Linzhen Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jinwu Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chunhui Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chuanxu Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Wenhao Zheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
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Lustenberger T, Leonardy R, Marzi I, Frank J. Outcome after surgical treatment of complex elbow fractures: a single-center follow-up study. Eur J Trauma Emerg Surg 2019; 46:1445-1449. [PMID: 31115614 DOI: 10.1007/s00068-019-01157-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/16/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Elbow injuries present particular challenges for the treating surgeons. The aim of the present study was to evaluate the postoperative outcome after surgical treatment of complex elbow fractures. PATIENTS AND METHODS Retrospective analysis with subsequent clinical follow-up examination of all patients with complex elbow fractures admitted to our level I trauma center over a 6-year period. The patients were stratified into three groups: single fractures of the proximal forearm (olecranon fractures type Mayo IIB, radial head fractures type Mason II-IV), distal humerus fractures (AO type C1-3), and combined injures. The clinical examination included the range of motion, grip strength measured with a Jamar dynamometer, DASH and MEP score. RESULTS Overall, 39 patients with complex elbow fractures were included in the study. Twelve patients presented with a distal, intra-articular humerus fracture, 16 patients had an isolated proximal forearm fracture and 11 patients suffered multiple fractures. The functional scores showed good overall results, with a median DASH score of 6.7 points and median MEP score of 85.0 points. The median extension deficit in the elbow joint was 15.0° (mean 16.2° ± 12.8°), the median flexion deficit was 5.0° (9.8° ± 12.3°) and the median pronation/supination (overall rotation) deficit was 5.0° (16.7° ± 23.6°). Patients with intra-articular distal humerus fractures showed a significantly increased extension and flexion deficit compared to the other groups. CONCLUSION The surgical treatment of complex elbow fractures was associated with good to excellent clinical results. However, distal intra-articular humerus fractures presented the most prominent loss of elbow motion in the follow-up examination.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| | - Raphael Leonardy
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Johannes Frank
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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Zarezadeh A, Mamelson K, Thomas WC, Schoch BS, Wright TW, King JJ. Outcomes of distal humerus fractures: What are we measuring? Orthop Traumatol Surg Res 2018; 104:1253-1258. [PMID: 30352777 DOI: 10.1016/j.otsr.2018.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 08/03/2018] [Accepted: 08/23/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We evaluate the most common outcome measures used in distal humerus fracture studies in order to suggest standardization for future research. MATERIALS AND METHODS A systematic review identified articles assessing the outcomes of acute distal humerus fractures from 2006 to 2016 from PubMed and Web of Science databases. The inclusion criterion was studies reporting on the outcomes of treatment of acute distal humerus fractures. Review articles, meta-analyses, studies with<5 patients, technique articles, biomechanical studies, and those focusing on one complication/outcome were excluded. Patient demographics and all outcome measures were reviewed. Journal and demographic factors were then compared. RESULTS One-hundred-nine of 2158 articles met inclusion criteria. The median number of fractures per study was 35. Mean patient age was 55.0 years. Average follow-up was 35 months. Range-of-motion and strength measurements were reported in 90% and 17% of studies, respectively. Twenty patient-reported outcome instruments were used. The most commonly reported measures were MEPS, DASH, VAS pain, and Quick DASH scores. An average of 1.9 outcome measures were reported per study. A journal impact factor of≥1.5 was associated with more reported outcome measures. Articles including elbow arthroplasty were associated with higher impact factor journals, more outcome measures, and longer follow-up. Level of evidence was not associated with the number of reported outcome measures. DISCUSSION The current distal humerus fracture literature inconsistently reports outcome measures. More outcome measures were reported in higher impact journals. Future distal humerus fracture studies should include MEPS, DASH or Quick DASH, and VAS Pain scores to allow for appropriate cross-study comparison. LEVEL OF EVIDENCE IV, Systematic review.
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Affiliation(s)
- Ali Zarezadeh
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Kelly Mamelson
- College of Medicine, Florida State University, Tallahassee, FL, USA
| | - W Christian Thomas
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA.
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Tunalı O, Erşen A, Pehlivanoğlu T, Bayram S, Atalar AC, Demirhan M. Evaluation of risk factors for stiffness after distal humerus plating. Int Orthop 2018; 42:921-6. [PMID: 29392385 DOI: 10.1007/s00264-018-3792-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE In distal humerus fractures, the goal is to achieve a functional range of motion of 30°-130° which is not always possible. The aims of the study were to evaluate the functional results after distal humerus fracture operation and to investigate the risk factors for stiffness. METHODS Between 2005 and 2014, 75 patients with the mean age of 37.8 years (17-80) underwent open reduction and plate fixation for distal humerus fractures. Range of motion (ROM), Mayo elbow performance scores, and quick DASH scores were used for functional evaluation. Patients were divided into two groups according their ROM. Group 1 had > 100° of extension-flexion ROM and group 2 had < 100°. Older age (> 60), AO type C2-3 fracture, open fracture, longer injury-surgery interval, type of plating, and presence of olecranon osteotomy were investigated as risk factors for poor outcome. RESULTS At a mean follow-up of 25 months (6-80), 40 patients were in group 1 and 35 patients were in group 2. Group 1 had significantly better functional scores than group 2. AO type C2 and C3 fracture (odds ratio (OR) 16.6, p < 0.0001) and injury-surgery interval longer than 7 days (OR 2.59, p 0.047) were found as significant risk factors for stiffness. CONCLUSIONS Patients who had distal humerus fracture should be informed about the risk of elbow stiffness especially in AO type C2-C3 fractures and surgical treatment should be planned without any delay.
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Abstract
Background: Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation. Methods: A literature search was performed and the authors’ personal experiences are reported. Results: This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate orientation, transposition of the ulnar nerve and the role of elbow arthroplasty. Conclusion: Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes.
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Affiliation(s)
- James C Beazley
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Njalalle Baraza
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Robert Jordan
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
| | - Chetan S Modi
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, CV2 2DX, Coventry, UK
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Atalar AC, Tunalı O, Erşen A, Kapıcıoğlu M, Sağlam Y, Demirhan MS. Biomechanical comparison of orthogonal versus parallel double plating systems in intraarticular distal humerus fractures. Acta Orthop Traumatol Turc 2017; 51:23-28. [PMID: 27965047 PMCID: PMC6197297 DOI: 10.1016/j.aott.2016.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/09/2016] [Accepted: 11/07/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In intraarticular distal humerus fractures, internal fixation with double plates is the gold standard treatment. However the optimal plate configuration is not clear in the literature. The aim of this study was to compare the biomechanical stability of the parallel and the orthogonal anatomical locking plating systems in intraarticular distal humerus fractures in artificial humerus models. METHODS Intraarticular distal humerus fracture (AO13-C2) with 5 mm metaphyseal defect was created in sixteen artificial humeral models. Models were fixed with either orthogonal or parallel plating systems with locking screws (Acumed elbow plating systems). Both systems were tested for their stiffness with loads in axial compression, varus, valgus, anterior and posterior bending. Then plastic deformation after cyclic loading in posterior bending and load to failure in posterior bending were tested. The failure mechanisms of all the samples were observed. RESULTS Stiffness values in every direction were not significantly different among the orthogonal and the parallel plating groups. There was no statistical difference between the two groups in plastic deformation values (0.31 mm-0.29 mm) and load to failure tests in posterior bending (372.4 N-379.7 N). In the orthogonal plating system most of the failures occurred due to the proximal shaft fracture, whereas in the parallel plating system failure occurred due to the shift of the most distal screw in proximal fragment. CONCLUSION Our study showed that both plating systems had similar biomechanical stabilities when anatomic plates with distal locking screws were used in intraarticular distal humerus fractures in artificial humerus models.
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Affiliation(s)
- Ata C Atalar
- Istanbul University, Istanbul Medical Faculty Orthopaedics and Traumatology Department, Istanbul, Turkey.
| | - Onur Tunalı
- Istanbul University, Istanbul Medical Faculty Orthopaedics and Traumatology Department, Istanbul, Turkey.
| | - Ali Erşen
- Istanbul University, Istanbul Medical Faculty Orthopaedics and Traumatology Department, Istanbul, Turkey.
| | - Mehmet Kapıcıoğlu
- Istanbul University, Istanbul Medical Faculty Orthopaedics and Traumatology Department, Istanbul, Turkey.
| | - Yavuz Sağlam
- Istanbul University, Istanbul Medical Faculty Orthopaedics and Traumatology Department, Istanbul, Turkey.
| | - Mehmet S Demirhan
- Koç University, Medical Faculty Orthopaedics and Traumatology Department, Istanbul, Turkey.
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Kharbanda Y, Tanwar YS, Srivastava V, Birla V, Rajput A, Pandit R. Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach. Strategies Trauma Limb Reconstr 2016; 12:1-9. [PMID: 27812778 PMCID: PMC5360669 DOI: 10.1007/s11751-016-0270-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/21/2016] [Indexed: 11/27/2022] Open
Abstract
Management of extra-articular distal humerus fractures presents a challenge to the treating surgeon due to the complex anatomy of the distal part of the humerus and complicated fracture morphology. Although surgical treatment has shown to provide a more stable reduction and alignment and predictable return to function, it has been associated with complications like iatrogenic radial nerve palsy, infection, non-union and Implant failure. We in the present series retrospectively analysed 20 patients with extra-articular distal humerus shaft fractures surgically treated using the extra-articular distal humeral locking plate approached by the triceps-sparing posterolateral approach. The outcome was assessed using the DASH score, range of motion at the elbow and the time to union. The mean time to radiographic fracture union was 12 weeks.
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Affiliation(s)
- Yatinder Kharbanda
- Department of Orthopedics, Apollo Hospital, HNo299, Pocket B, DDA Flats, Sarita Vihar, New Delhi, Delhi, 110076, India
| | - Yashwant Singh Tanwar
- Department of Orthopedics, Apollo Hospital, HNo299, Pocket B, DDA Flats, Sarita Vihar, New Delhi, Delhi, 110076, India.
| | - Vishal Srivastava
- Department of Orthopedics, Dr. RML Hospital and PGIMER, New Delhi, Delhi, 110001, India
| | - Vikas Birla
- Department of Orthopedics, Apollo Hospital, HNo299, Pocket B, DDA Flats, Sarita Vihar, New Delhi, Delhi, 110076, India
| | - Ashok Rajput
- Department of Orthopedics, Dr. RML Hospital and PGIMER, New Delhi, Delhi, 110001, India
| | - Ramsagar Pandit
- Department of Orthopedics, Apollo Hospital, HNo299, Pocket B, DDA Flats, Sarita Vihar, New Delhi, Delhi, 110076, India
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Abstract
Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment.
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Affiliation(s)
- Steinitz Amir
- Department of Traumatology and Orthopedic Surgery, University Hospital Basel, Spitalstr. 21, 4031 Basel, Switzerland
| | - Sailer Jannis
- Department of Traumatology and Orthopedic Surgery, University Hospital Basel, Spitalstr. 21, 4031 Basel, Switzerland
| | - Rikli Daniel
- Department of Traumatology and Orthopedic Surgery, University Hospital Basel, Spitalstr. 21, 4031 Basel, Switzerland
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Kinaci A, Buijze GA, Leeuwen DHV, Jupiter JB, Marti RK, Kloen P. Corrective Osteotomy for Intra-Articular Distal Humerus Malunion. Arch Bone Jt Surg 2016; 4:161-5. [PMID: 27200396 PMCID: PMC4852044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 09/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND An intra-articular distal humerus malunion can be disabling. To improve function, reduce pain and/or prevent further secondary osteoarthritis an intra-articular corrective osteotomy can be considered. Herein we present the indications, practical guidelines for pre- operative planning and surgical technique. Subsequently, we provide long-term results in a small series. METHODS We included six consecutive patients operated for intra-articular distal humerus malunion. Mean follow-up was 88 months. At lastest follow up elbow function was assessed according to standardized questionnaires and classification systems. RESULTS All six patients healed their osteotomies. Three patients had a postoperative complication which were treated succesfully. Range of motion improved significantly and all patients were satisfied with the outcome. The elbow performance scores were good to excellent in all. Correlation analyses showed that age and level of osteoarthritis are very strong predictors for the long-term elbow function and quality of life. CONCLUSION An intra-articular corrective osteotomy for a malunited distal humerus fracture is a worthwhile procedure. Based on our results it should particularly be considered in young patients with minimal osteoarthritis and moderate to severe functional disability and/or pain.
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Affiliation(s)
- Ahmet Kinaci
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Geert A Buijze
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Diederik H van Leeuwen
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jesse B Jupiter
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rene K Marti
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Peter Kloen
- Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Abstract
Distal humerus fractures are challenging injuries for the upper extremity surgeon. However, recent techniques in open reduction internal fixation have been powerful tools in getting positive outcomes. To get such results, the surgeon must be aware of how to properly use these techniques in their respective practices. The method of fixation depends on the fracture, taking the degree of comminution and the restoration of the columns and articular surface into account. This article helps surgeons understand the concepts behind open reduction internal fixation of the distal humerus and makes them aware of pitfalls that may lead to negative results.
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Affiliation(s)
- Mark A Mighell
- The American Board of Orthopaedic Surgery, 400 Silver Cedar Court, Chapel Hill, NC 27514, USA; Department of Orthopaedic Surgery, University of South Florida, 13220 USF Laurel Drive, Tampa, FL 33612, USA; Florida Orthopaedic Institute, 13020 Telecom Parkway North, Tampa, FL 33637, USA; Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Brent Stephens
- Florida Orthopaedic Institute, 13020 Telecom Parkway North, Tampa, FL 33637, USA
| | - Geoffrey P Stone
- Florida Orthopaedic Institute, 13020 Telecom Parkway North, Tampa, FL 33637, USA
| | - Benjamin J Cottrell
- Foundation for Orthopaedic Research and Education, 13020 Telecom Parkway North, Tampa, FL 33637, USA
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Reising K, Konstantinidis L, Helwig P, Wagner FCL, Südkamp NP, Strohm PC. Minimally invasive stabilization of distal humerus fractures: a pilot study with biomechanical evaluation. Technol Health Care 2015; 22:909-13. [PMID: 25335971 DOI: 10.3233/thc-140864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fracture of the distal humerus is a fairly rare injury and makes high demands on the treating surgeon. Prerequisites for a good outcome are anatomical reconstruction and osteosynthesis stable enough for exercises. A method permitting early restoration of function is especially important for patients with osteoporosis. The extensive surgical approach necessary for open reduction is associated with a high number of wound healing disorders and infections with a frequency of 11% being reported in the literature. Although open reduction and internal fixation in double-plating technique is unavoidable for complex intraarticular fractures, an alternative, minimally invasive and, consequently, tissue-preserving procedure is desirable for simpler fractures. OBJECTVE To investigate this issue further an angular stable nail system developed for the distal radius was implanted as a stabilizer and the construct tested biomechanically as part of a feasibility study. METHODS Distal humerus fractures were stabilized by insertion of a distal radius nail, namely, the Targon DR (Aesculap, Tuttlingen) and a K-wire. To test the hypothesis six cadaveric bones fixed in formalin were tested biomechanically for displacement, implant failure, and stiffness. Displacement was determined by means of an ultrasound-based system. RESULTS An average displacement of 1.6 mm ± 0.7 was recorded at a maximum compression force of 100 N in extension and an average displacement of 1.4 mm ± 0.9 in flexion. Implant failure was not observed for any of the constructs. CONCLUSIONS The study presented here permits the conclusion that a minimally invasive procedure is possible at the distal humerus and does ensure adequate stability. Although the nail was not specifically designed for the humerus, current findings form the basis for a promising approach that will be pursued further after modification of the nail design.
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Affiliation(s)
- K Reising
- Department of Surgery, Clinic for Orthopedic and Trauma Surgery, Freiburg University Hospital, Freiberg, Germany
| | - L Konstantinidis
- Department of Surgery, Clinic for Orthopedic and Trauma Surgery, Freiburg University Hospital, Freiberg, Germany
| | - P Helwig
- Department of Surgery, Clinic for Orthopedic and Trauma Surgery, Freiburg University Hospital, Freiberg, Germany
| | - F C L Wagner
- Department of Surgery, Clinic for Orthopedic and Trauma Surgery, Freiburg University Hospital, Freiberg, Germany
| | - N P Südkamp
- Department of Surgery, Clinic for Orthopedic and Trauma Surgery, Freiburg University Hospital, Freiberg, Germany
| | - P C Strohm
- Department of Surgery, Clinic for Orthopedic and Trauma Surgery, Freiburg University Hospital, Freiberg, Germany
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Abstract
We retrospectively reviewed 89 consecutive patients (45 men and 44 women) with a mean age at the time of injury of 58 years (18 to 97) who had undergone external fixation after sustaining a unilateral fracture of the distal humerus. Our objectives were to determine the incidence of heterotopic ossification (HO); identify risk factors associated with the development of HO; and characterise the location, severity and resultant functional impairment attributable to the presence of HO. HO was identified in 37 elbows (42%), mostly around the humerus and along the course of the medial collateral ligament. HO was hazy immature in five elbows (13.5%), mature discrete in 20 (54%), extensive mature in 10 (27%), and complete bone bridges were present in two elbows (5.5%). Mild functional impairment occurred in eight patients, moderate in 27 and severe in two. HO was associated with less extension (p = 0.032) and less overall flexion-to-extension movement (p = 0.022); the flexion-to-extension arc was < 100º in 21 elbows (57%) with HO compared with 18 elbows (35%) without HO (p = 0.03). HO was removed surgically in seven elbows. The development of HO was significantly associated with sustaining a head injury (p = 0.015), delayed internal fixation (p = 0.027), the method of fracture fixation (p = 0.039) and the use of bone graft or substitute (p = 0.02).HO continues to be a substantial complication after internal fixation for distal humerus fractures.
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Affiliation(s)
- A M Foruria
- Department of Orthopaedic Surgery, Shoulder and Elbow Surgery Unit, Fundación Jiménez Díaz, Avda Reyes Católicos, 2, Madrid 28040, Spain
| | - T M Lawrence
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, West Midlands CV2 2DX, UK
| | - S Augustin
- Hopital Vall d´Hebron, Passeig Vall d'Hebron, 119 to 129, 08035 Barcelona, Spain
| | - B F Morrey
- Mayo Clinic, 200 First St. SW, Rochester Minnesota 55905, USA
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Abstract
BACKGROUND Distal humeral hemiarthroplasty (DHH) is a treatment option for unreconstructable intra-articular distal humerus fractures. DHH may also be used in the setting of rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis. DHH has specific advantages over other, more common, treatment modalities: total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF). DHH is especially a reasonable option in younger patients to preserve bone stock, avoid significant weight restrictions, and limit loosening. METHODS The literature was reviewed for all cases of DHH for fracture and non-fracture indications between 1947 and 2014. Two hundred thirty-six papers were identified; 4 studies including 17 patients met criteria for non-fracture indications and 13 studies including 116 patients were identified for fracture indications. A systematic review was generated; patient indications, outcomes, and complications were recorded. RESULTS For non-fracture indications, good to excellent results were achieved in 76.5 % of patients with a mean arc of motion of 62° at mean follow up of 46.3 months. Half of the patients experienced a complication, most commonly stiffness. Loosening of the prosthesis was not noted in any patient. For fractures, good to excellent results were achieved in 67.4 % of patients with a mean arc of motion of 98.3° at a mean follow up of 42.2 months. One third of the patients experienced a complication but only 1.7 % experienced loosening of the prosthesis. CONCLUSION Here, we present the first review of the indications for DHH. DHH is a reasonable treatment option for older patients with unreconstructable intra-articular fractures of the distal humerus as well as younger patients with rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis.
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Affiliation(s)
- John Dunn
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, 5005 N Piedras, Fort Bliss, TX 79920 USA
| | - Nicholas Kusnezov
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, 5005 N Piedras, Fort Bliss, TX 79920 USA
| | - Miguel Pirela-Cruz
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79920 USA
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Linn MS, Gardner MJ, McAndrew CM, Gallagher B, Ricci WM. Is primary total elbow arthroplasty safe for the treatment of open intra-articular distal humerus fractures? Injury 2014; 45:1747-51. [PMID: 25192866 PMCID: PMC4321717 DOI: 10.1016/j.injury.2014.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/14/2014] [Accepted: 07/17/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures. METHODS Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit. RESULTS Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21° (range 5-30°) to 113° flexion (range 90-130°). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits. CONCLUSIONS TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.
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50
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Mansat P, Bonnevialle N, Rongières M, Bonnevialle P. The role of total elbow arthroplasty in traumatology. Orthop Traumatol Surg Res 2014; 100:S293-8. [PMID: 25164351 DOI: 10.1016/j.otsr.2014.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/26/2014] [Indexed: 02/02/2023]
Abstract
UNLABELLED Fractures of the distal humerus account for 5% of osteoporotic fractures in subjects older than 60 years. A history of osteoporosis, co-morbidities, and joint comminution make their management difficult. The therapeutic options are limited to functional treatments, osteosynthesis, or either partial or total arthroplasty. Functional treatment of distal humerus fractures in the elderly subject provide inconsistent results, often with persistence of pain with a stiff or unstable elbow. Osteosynthesis remains the reference treatment for these fractures, following the principle of stable and rigid osteosynthesis allowing early mobilization. However, joint comminution and a history of osteoporosis occasionally make it impossible to meet this objective, with a considerable rate of complications and surgical revisions. Total elbow arthroplasty remains an alternative to osteosynthesis with very satisfactory immediate results restoring a painless, stable, and functional elbow. These results seem reproducible and sustainable over time. The complication rate is not uncommon with an approximately 10% surgical revision rate. Elbow hemiarthroplasty remains to be validated in this indication. LEVEL OF EVIDENCE V.
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Affiliation(s)
- P Mansat
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France.
| | - N Bonnevialle
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France
| | - M Rongières
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France
| | - P Bonnevialle
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France
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