Modified paratricipital approach without mobilization of the ulnar nerve prevents postoperative ulnar neuropathy in distal humerus fractures

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.

Management of type 13C2 distal humerus fractures by olecranon osteotomy approach versus triceps sparing approach-our experience with sixty cases

BACKGROUND

Intercondylar humerus fractures (AO type 13C), though less common (less than 1%), are increasing over the last few years. Open reduction and internal fixation (ORIF) of these fractures are now well recognised and preferred management. These fractures are principally approached from posterior side and various posterior approaches have been mentioned. Triceps sparing is a relatively newer approach for fixation of these fractures. Here, we are ascertaining the outcomes of triceps sparing approach and olecranon osteotomy approach and also investigating the preferred approach in various age groups.

MATERIALS AND METHODS

A level III non-randomized retrospective comparative study was conducted with a total of 60 patients belonging to AO type 13C2 in the age group of 16-70 years, operated upon during the period of September 2013 to March 2019. They were analysed for various outcome measures and complications. MEPS and DASH were used to determine outcome.

RESULTS

Out of a total of 60 patients (mean age 37.52 years), 28 were in olecranon osteotomy (OO) group and 32 were in the triceps sparing (TS) group. The mean operative time for group OO was 93.11 ± 8.78 minutes compared with group TS where it was 77 ± 4.64 minutes and the difference was statistically significant. Similarly, blood loss was 224 ± 46 ml in group OO compared with 197 ± 39 ml in group TS and it was also statistically significant. The average MEPS score was slightly better in the group TS (86.56 ± 10.66) compared with group OO (83.57 ± 10.96), though not statistically significant. Similarly, DASH score was 35.72 ± 8.35 in group TS and 35.32 ± 8.89 in group OO. The MEPS score was excellent (≥ 90) in 12 patients of group OO and 16 patients of group TS, good (75-89) in 11 patients of each group and fair (60-74) in 5 patients of each group. The patients in the age group of ≥ 60 years tend to have inferior functional outcomes, though not statistically significant, when treated with triceps sparing approach compared with olecranon osteotomy approach.

CONCLUSION

In conclusion, we found that, compared with the olecranon osteotomy technique, better results though not statistically significant, can be expected with triceps sparing approach while treating type C2 distal humerus fractures in younger patients without significantly compromising the articular reduction or impairing stability of fracture fixation.

Paratricipital approach for distal humerus fractures

OBJECTIVE

To report functional outcomes in a case series of distal shaft and distal humeral fractures (AO type 12 and 13) managed with open reduction and internal fixation using paratricipital approach.

METHODS

Patients who were intervened between May 2006 and December 2015 were included in the analysis. The Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand (DASH) score and the visual analogue scale (VAS) were used for functional assessment.

RESULTS

Twelve patients were included in this case series, eight (67%) of them were women. The average age was 46 (SD 22). Regarding the type of fracture, three (25%) were classified as 12A1, two (17%) as 12B1, two (17%) as 12B2, three (25%) as 13C1 and two (17%) as 13C2. At most recent average follow-up of 3, 4 years (DS 1,62), the results were: elbow range of flexion-extension 138,3º (SD 15,18), MEPS reached 85,8 (DS 11,7), DASH of 11,8 (SD 10,6) and the mean VAS 1,3 (SD 1,1). At the final evaluation, all fractures had healed. One case presented radial nerve neuropraxia, three cases paresthesias at the ulnar nerve territory, and all of these evolved positively and spontaneously.

CONCLUSIONS

In our experience, posterior paratricipital approach is useful and safe for managing the open reduction and internal fixation. It may provide preservation of the triceps and promote an earlier rehabilitation. Functional outcomes were satisfactory in this case series.

Surgical approaches for open reduction and internal fixation of intra-articular distal humerus fractures in adults: A systematic review and meta-analysis

BACKGROUND

A number of surgical approaches have been described for open reduction and internal fixation (ORIF) of intra-articular distal humerus (IDH) fractures in adults. However, there is no consensus as to which approach is better in terms of functional outcomes and complications. The purpose of this study was to determine whether the functional outcomes and types and rates of complications are influenced by the choice of surgical approach for ORIF of IDH fractures (AO/OTA types 13 B & C).

METHODS

A systematic review of literature was performed using the PubMed, EMBASE and Cochrane Database of Systematic Reviews databases. Studies, both prospective and retrospective and comparative or non-comparative, dealing with surgical approaches for ORIF of IDH fractures in adult patients were included. Conference abstracts, studies looking primarily at the results of internal fixation rather than the surgical approach, those including extra-articular distal humeral fractures, pediatric distal humeral fractures (<18 years of age), delayed unions, non unions, malunions, cadaveric studies, pathological fractures and studies with <10 patients were excluded. Studies that looked at surgical modalities other than internal fixation (for e.g. total elbow arthroplasty) for intra-articular distal humerus fractures or those that did not report a validated functional outcome scoring system were also excluded.

RESULTS

11 studies were included in the qualitative analysis, of which 5 were comparative studies and 6 were non-comparative. Quantitative analysis was performed on two sets of two studies, each set comparing the Bryan and Morrey or the triceps-split approach to the olecranon osteotomy approach, and revealed no significant differences in the Mayo Elbow Performance Score, range of motion and rates of complications. The overall methodological quality of the studies included in the review was low.

CONCLUSIONS

High-quality evidence on surgical approaches for ORIF of IDH fractures in adults is lacking. Evidence from low-quality studies indicates that there is no difference in the functional outcomes or complication rates when comparing the Bryan and Morrey or triceps-split to the olecranon osteotomy approach. Future research in the form of high-quality randomized controlled trials is needed to determine which approach is superior in terms of functional outcomes and complications.