Comparing internal and external stabilization for traumatic elbow instability: a systematic review

Background

Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS.

Methods

A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment.

Results

The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals.

Discussion

The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.

The Internal Joint Stabilizer of the Elbow: A Systematic Review of the Clinical and Biomechanical Evidence

Purpose

The goal of surgical management for unstable elbow injuries is the restoration of joint concentricity and stability. After internal fixation, concerns may exist regarding instability or durability of the fixation construct. Historically, these scenarios were treated with options such as transarticular pinning or external fixation. Recently, an internal joint stabilizer (IJS) that allows postoperative mobilization was introduced. Our objective was to systematically review the literature to aggregate the clinical and biomechanical evidence for the IJS of the elbow.

Methods

A systematic review of the PubMed and Google Scholar databases was performed, following the PRISMA guidelines. The search results were narrowed from 2015 through 2023 to coincide with the inception of the device being reviewed.

Results

A total of nine retrospective reports on the IJS (N = 171) cases at a mean follow-up of 10.8 months were included. The pooled rate of implant failure was 4.4%, and recurrent instability was 4.1%. Additionally, the we included seven case reports and two biomechanical reports.

Conclusions

The aggregate literature describes satisfactory clinical outcomes with low rates of recurrent instability and device failure for the IJS of the elbow. The limited biomechanical investigations conclude efficacy for stability profiles.

Clinical relevance

Across a spectrum of unstable elbow cases, the IJS prevented recurrent instability during the early postoperative period. Notably, the device requires an additional procedure for removal, and the long-term impact of the retained devices is currently unclear.

Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study

PURPOSE

Elbow dislocations are at risk for persistent instability and stiffness of the joint. Treatment with a hinged external fixation provides elbow joint stability, and allows early mobilization to prevent stiffness. Mounting a hinged elbow fixator correctly, however, is technically challenging. The low incidence rate of elbow dislocations with persistent instability suggests that centralization would result in higher surgeon exposure and consequently in less complications. This study aimed to investigate the results of treatment of elbow dislocations with a hinged elbow fixator on the rate of complications, range of motion, level of pain and restrictions in activities of daily living.

METHODS

A retrospective observational cohort study in a level I trauma center, in which the majority of patients was treated by a dedicated elbow surgeon, was performed. All patients of 16 years or older treated with a hinged external elbow fixator between January 1, 2006 and December 31, 2017 were included. The fixator could be used (1) for the treatment of persistent instability in acute/residual simple and complex dislocations or (2) as revision surgery to treat joint incongruency or a stiff elbow. Patient and injury characteristics, details on treatment, complications, secondary interventions, and range of motion were extracted from the patients' medical files.

RESULTS

The results of treatment of 34 patients were analyzed with a median follow-up of 13 months. The fixator was removed after a median period of 48 days. Fixator-related complications encountered were six pintract infections, one redisclocation, one joint incongruency, one muscle hernia, and one hardware failure. The median range of motion at the end of follow-up was 140° flexion, 15° constraint in extension, 90° pronation, and 80° supination.

CONCLUSION

A hinged elbow fixator applied by a dedicated elbow surgeon in cases of elbow instability after elbow dislocations can result in excellent joint function. Fixator-related complications are mostly mild and only temporary.

[External fixator of the elbow]

AIM OF SURGERY

The placement of an external elbow fixator can be statically carried out as temporary stabilization or as a hinged movement fixator. As a hinged movement fixator a functional follow-up treatment is possible due to control of the joint guidance and reduction of the compromising forces on the osteoligamentous structures.

INDICATIONS

As a temporary stabilization of the elbow, the external fixator is used as a damage control method. As a movement fixator it is used as an additional protection and movement control after complex osteoligamentous interventions and persisting tendency to dislocation of the joint and also as a standalone procedure. In some cases, the procedure is also used in distraction arthrolysis of stiff elbows and as a salvage procedure in patients with relevant comorbidities as part of fracture treatment.

CONTRAINDICATIONS

Inexperience in relation to the procedure as well as a local acute infection at the level of the intended pin locations should specifically be mentioned as contraindications. In addition, compliance and patient understanding of the procedure are essential for the success of treatment.

SURGICAL TECHNIQUE

Soft tissue preparation for pin placement should be preferred over percutaneous incisions to enable a safe bone exposure. Knowledge of the course of neurovascular structures (particularly the radial nerve) is essential. When placing a hinge, knowledge of the position and detection of the idealized center of rotation is of fundamental importance.

POSTOPERATIVE MANAGEMENT

The type of postoperative management required essentially depends on the underlying injury. When placing a hinged fixator, the aim is to enable movement as early as possible. Nevertheless, blocking of the hinged fixator may be useful for a short period of time. Adequate pin care over the duration of the treatment is essential in order to prevent complications.

RESULTS

Good functional results have been reported for the treatment of unstable elbows after primary and secondary placement of a hinged external fixator. Good functional scores and improvement in the range of motion were also recorded in the context of an arthrolysis (additive for open arthrolysis or distraction arthrolysis); however, in contrast a significant number of complications associated with this surgery are likely to emerge. As a definitive salvage procedure, satisfactory results were obtained in a small case series of a selected older patient group with relevant comorbidities.

An X-ray-free method to accurately identify the elbow flexion-extension axis for the placement of a hinged external fixator

PURPOSE

Identifying the elbow flexion-extension (F-E) movement axis is important for placing a hinged elbow external fixator. An X-ray fluoroscopy-based method is widely used in clinical practice, exposing the patient and surgeons to high doses of radiation. Additionally, the accuracy and repeatability of the fluoroscopy-based method are very low and affected by subjective factors.

METHODS

To solve this problem, an X-ray-free method based on kinematics analysis was proposed to identify the elbow F-E movement axis, and a navigation system was built to guide the placement of the elbow external fixator.

RESULTS

Our X-ray-free navigation method is more repeatable than the current X-ray fluoroscopy method used clinically. Both our algorithm and the NIST (National Institute of Standards and Technology) algorithm showed high accuracy and repeatability to identify the axis.

CONCLUSIONS

The method proposed in this study is very promising to avoid a large dose of X-ray radiation and increases the repeatability and performance of identifying the elbow F-E movement axis for the placement of the hinged elbow external fixator.

Conceptual design and implantation of an external fixator with improved mobility for knee rehabilitation

A hinged external fixator is used to allow early knee rehabilitation in case of injury or trauma, as an alternative approach to immobilization. It is mainly adopted for the treatment of dislocations, which involve tearing of the ligaments, and it basically consists of two links connected to each other by a revolute joint. Each link is fixed to the femur and tibia via pin fixation, and the revolute joint is approximately aligned to the knee flexion-extension (FE) axis. The advantage in its implantation is to protect ligament reconstruction, while allowing for an aggressive rehabilitation. Traditional fixators only accommodate the functional flexion movement in a limited range, i.e. where the anatomical movement is closer to a planar circular trajectory. This paper presents the conceptual design and implantation procedure of a double-axis fixator, which accommodates both FE and longitudinal internal-external rotation. The procedure is based on accurate knee kinematics measurements and on computer-aided multibody simulations to assist clinicians in the implantation. An experimental test is presented using an artificial knee, and guidelines are given for in vitro studies. The proposed technique may allow for a better understanding of knee kinematics and have the potential advantage to increase the range of motion in postoperative rehabilitation.

Hinged external fixation for Regan-Morrey type I and II fractures and fracture-dislocations

Elbow fracture-dislocation is always demanding to manage due to the considerable soft-tissue swelling or damage involved, which can make an early open approach and ligamentous reconstruction impossible. The purpose of this study was to evaluate the role of elbow hinged external fixation (HEF) as a definitive treatment in patients with elbow dislocations associated with Regan–Morrey (R-M) type I and II coronoid fractures and soft-tissue damage. We treated 11 patients between 2010 and 2012 with HEF. Instability tests and standard X-ray examinations were performed before surgery and 1–3 to 3–6 months after surgery, respectively. All patients underwent a preoperative CT scan. Outcomes were assessed with a functional assessment scale (Mayo Elbow Performance Score, MEPS) that included 4 parameters: pain, ROM, stability, and function. The results were good or excellent in all 11 patients, and no patient complained of residual instability. Radiographic examination showed bone metaplasia involving the anterior and medial sides of the joint in 5 patients. HEF presented several advantages: it improves elbow stability and it avoids long and demanding surgery in particular in cases with large soft tissue damage. We therefore consider elbow HEF to be a viable option for treating R-M type I and II fracture-dislocations.

Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases

The terrible triad is an uncommon injury, which includes an elbow posterior dislocation with fractures of the radial head and coronoid process of the ulna. In addition there is rupture of the lateral and medial collateral ligaments. The short-term and long term results are historically poor, with a high rate of complications. The main objective of this study is to report the results of a multicentre study of patients who sustained the terrible triad injury focusing on surgical treatment in order to offer a standardized surgical protocol. We retrospectively review the results of surgical treatment of eighteen terrible triads from a multicentre study of 226 elbow dislocations. At an average follow up of 31.5 months postoperatively, all eighteen patients returned for clinical examination, functional evaluation, and radiographs. The mean MEPS score value was 78 (25-100), which correspond to three excellent results, ten good results, three fair results, and two poor results. Five early and three late complications were reported. This particular case of elbow dislocation is very unstable and leads to many complications. The surgeon should attempt to restore stability by preserving the radial head whenever possible or replacing it with prosthesis otherwise, by repairing the lateral collateral ligament and performing fixation of the coronoid fracture. If after anatomical restoration of stability elements, the elbow remains unstable, options include repair of the medial collateral ligament or stabilization assumed by hinged external fixator.

Hinged external fixation for complex fracture-dislocation of the elbow in elderly people

The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty.