Federico M. Sacchetti

Management of complex elbow instability.

Complex elbow instability is a challenging injury even for expert elbow surgeons. The preoperative radiographs should be carefully evaluated to recognize all lesions that may occur in complex elbow instabilities. Recognizing all the possible lesions is critical to achieve an optimal outcome. The most common types of injuries are as follows: (1) radial head fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation); (2) Coronoid fractures and lateral collateral ligament lesion (with or without elbow dislocation); (3) Terrible Triad; (4) Transolecranon fracture-dislocation; (5) Monteggia-like-lesions; and (6) Humeral Shear fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation). A correct evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability test under fluoroscopy. The treatment is always surgical and is challenging, and outcomes are not predictable. The goals of treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow and (3) to allow early motion. The proximal ulna must be anatomically reduced and fixed; the radial head must be repaired or replaced, and the coronoid fractures must be repaired or reconstructed. With respect of soft tissue lesions, the LUCL must be reattached with suture anchors or trans-osseous suture. The next critical step is the intra-operative assessment of elbow stability. If the elbow remains unstable, MCL repair and/or application of hinged external fixator must be considered. The most recent clinical and experimental studies have significantly expanded our knowledge of elbow instability and its management. Definite treatment protocols may improve the clinical results of such complex injuries.

Radial head, radiocapitellar and total elbow arthroplasties: A review of recent literature

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.

Hemilateral resurfacing arthroplasty in posttraumatic degenerative elbow resulting from humeral capitellum malunion

Secondary osteoarthritis, malunion, or nonunion associated with stiffness are common conditions in elbows after trauma. These conditions may be treated by various surgical methods when the elbow joint is severely compromised. In young, active patients with extensive joint destruction, interposition or distraction arthroplasty may be considered, whereas in the presence of malunited or ununited intra-articular fractures, open reduction and internal fixation can restore joint congruity. In the elderly with limited functional demand, these conditions may be treated by total elbow arthroplasty. When the lesion is only or essentially represented by malunion or nonunion of the capitellum, reconstruction can be performed as an alternative to excision of the bone fragment. Recently, Pooley has developed the hemilateral and the lateral resurfacing elbow (LRE) procedure for the treatment of osteoarthritis or early rheumatoid arthritis primarily affecting the radiocapitellar joint. We report a case of malunion of the capitellum associated with degenerative changes and stiffness of the elbow in which a hemi-LRE procedure was performed in association with extensive releases. To our knowledge, no previous report has been published on the use of hemi-LRE in posttraumatic elbow conditions.

Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: Prospective study on 76 patients

INTRODUCTION AND AIM Complex elbow instability (CEI) is one of the most troublesome pathologies that orthopaedic surgeons have to face. One of the key requirements regarding the CEI surgical treatment is an early rehabilitation programme to avoid the elbow stiffness caused by a long period of immobilisation. Although this is well known, no study has ever examined how, and to what extent, the functional range of motion (ROM) is recovered during the various stages of a prompt rehabilitation. Our aims were: (1) to prospectively analyse the pattern of ROM recovery in a series of patients with CEI who underwent early rehabilitation and (2) to identify the period of time during rehabilitation in which the greatest degree of motion recovery is obtained. MATERIALS AND METHODS A total of 76 patients (78 elbows) with CEI were followed up for 2 years. All the patients underwent anatomical and stable ostheosynthesis of all the fractures, radial head replacement in Mason III fractures, ligament injuries reconstruction and early rehabilitation that started 2 days after surgery. Two surgeons evaluated the ROM with a hand-held goniometer every 3 weeks for the first 3 months, then at 6, 12 and 24 months after surgery. RESULTS At the 3-week follow-up, the mean flexion (F), extension (E), pronation (P) and supination (S) were 113°, 29°, 60° and 62°, respectively. At the 6-week and 9-week follow-up, F, E, P and S were 119°, 23°, 70° and 69° and 123°, 24°, 72° and 71°, respectively. At the 3-month follow-up, these values were 131°, 18°, 76° and 72°, while at the 6-month follow-up they were 136°, 15°, 79° and 77°, respectively. Thereafter, the ROM improvement was not significant. DISCUSSION This study shows that the first 6 months represent the critical rehabilitation period to obtain a functional elbow; indeed, 70% of the patients recovered functional ROM between the third and sixth month, though the recovery of flexion proved to be slower than that of the other elbow movements. Thereafter, improvement continued, though at a lower rate, until the end of the first year, when approximately 80% of the patients had recovered the functional ROM. CONCLUSIONS Following CEI surgical treatment, a rehabilitation programme needs to be started promptly and continued for at least 6 months because a significant improvement of ROM occurs prevalently in this period, which should be considered the critical time period to obtain a functional elbow in a majority of patients.

Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures: A retrospective study of 15 patients followed for 29 months

Background and purpose The current surgical treatment for displaced fracture of the capitellum and trochlea is open reduction and internal fixation (ORIF), but the results are often unsatisfactory, particularly with complex fractures. Furthermore, the surgical approach, the kind of osteosynthesis, and postoperative management are controversial. We evaluated the results of internal fixation combined with hinged external fixation. Methods We analyzed 15 patients with a mean age of 47 (18–65) years. Based on the Bryan-Morrey-McKee classification, the fractures were identified as type I in 6 cases and type IV in 9. Active and passive motion was started and activities of daily living were permitted on the second postoperative day. The mean follow-up time was 29 (12–49) months. Results In 13 cases, functional range of motion was obtained within 6 weeks of surgery. At final follow-up, 14 patients had a stable, pain-free elbow with a mean active range of motion of 13° to 140°. The average score on the Mayo elbow performance score was 98. Interpretation The use of the hinged fixator allows early motion of the elbow while preserving joint stability. It may have additional value in complex articular fractures when stable internal fixation cannot be obtained with ORIF, and in the presence of severe ligamentous injuries.

Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures

Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. DOI 10.3109/17453674.2010.504612 Sir—We read with interest the article by Giannicola et al. (2010) and commend authors for their work. Coronal shear fractures of distal humerus have received much attention in recent years (Giannicola et al. 2010) and the consensus of treatment has been open reduction and internal fixation. We also experienced good results with these fractures after internal fixation and agree with literature that early mobilization after a stable fixation is the key to good functional results (Dubberley et al. 2006, Mighell et al. 2006, Ruchelsman et al. 2008, Singh et al. 2009, Ashwood et al. 2010). We also agree with Giannicola et al. that a poor osteosynthesis leads to prolonged immobilization of elbow and limits the functional results. We also understand that stable fixation is sometimes difficult to achieve but most of capitellar fractures can be fixed reasonably well to allow early mobilization (Mighell et al. 2006, Ruchelsman et al. 2008, Singh et al. 2009). It seems unreasonable to supplement internal fixation in all the cases as authors have done in their series. Supplementing stable fixations with external fixator not only increases surgical time but also subjects the patients to increased risks of complications of added surgery. We would like to ask the authors to comment on the increased cost of treatment associated with fixator used. The high rates of reoperative procedures and the discordant results for these fractures are found in largest series (28 patients) of Dubberley et al. (2006) But these fractures were treated over a period of 10 years and by different surgeons not following a uniform protocol. In series where a single protocol was followed, the results have been excellent and reproducible (Mighell et al. 2006, Ruchelsman et al. 2008, Singh et al. 2009, Ashwood et al. 2010). Authors report extrusion of Herbert screws occurred in 2 cases. What could be the reason for this fixation failure in spite of being supplemented by external fixator? Though we disagree on external fixation supplementation in all types of cases, we do congratulate the authors for extending the concept of supplementation of fixation to capitellar fractures. Further studies would be required to evaluate the efficacy and laying out specific indications for this kind of supplementation.Background and purpose The current surgical treatment for displaced fracture of the capitellum and trochlea is open reduction and internal fixation (ORIF), but the results are often unsatisfactory, particularly with complex fractures. Furthermore, the surgical approach, the kind of osteosynthesis, and postoperative management are controversial. We evaluated the results of internal fixation combined with hinged external fixation.Methods We analyzed 15 patients with a mean age of 47 (18–65) years. Based on the Bryan-Morrey-McKee classification, the fractures were identified as type I in 6 cases and type IV in 9. Active and passive motion was started and activities of daily living were permitted on the second postoperative day. The mean follow-up time was 29 (12–49) months.Results In 13 cases, functional range of motion was obtained within 6 weeks of surgery. At final follow-up, 14 patients had a stable, pain-free elbow with a mean active range of motion of 13° to 140°. The average score on the Mayo elbow pe...

Soft Tissue Constraint Injuries in Complex Elbow Instability: Prevalence, Pathoanatomy, and Classification

The types and prevalence of soft tissue constraint injuries associated with complex elbow instability have been rarely investigated. The purpose of this study was to analyze the intraoperative findings of soft tissue constraint injuries in complex elbow instability and provide a comprehensive classification of these lesions. Forty-seven patients undergoing surgery for complex elbow instability were prospectively analyzed. Ligament injuries were classified as simple or complex lesions, depending on whether the ligament was damaged at a single zone or 2 to 3 zones, including its proximal, middle, and distal portions. Posterolateral capsule injuries were classified as small or large in the presence of capsular avulsions smaller than or larger than 1 cm, respectively. The presence of lesions of the common extensor and flexor-pronator muscles were also recorded. Ligament injuries were found in 96% of patients. The lateral collateral ligament showed a simple lesion, including a proximal and distal avulsion, in 19% and 2% of patients, respectively, and a middle-zone tear in 13%. Complex lesions, including the association of a middle-zone tear with a proximal or distal avulsion, were found in 47% and 6% of patients, respectively, and a combination of proximal, distal, and middle-zone injuries in 4%. Small and large posterolateral capsule lesions were found in 49% and 17% of patients, respectively. A medial collateral ligament injury was present in 45% of patients. A high prevalence of soft tissue constraint lesions was found to be associated with complex elbow instability. Soft tissue constraint status should be carefully evaluated pre- and intraoperatively in patients with complex elbow instability. The classification reported herein may be helpful in planning the proper treatment of these complex injuries.

Soft tissue constraint injuries in complex elbow instability: surgical techniques and clinical outcomes.

The surgical procedures for and outcomes of soft tissue constraint reconstruction in complex elbow instability have been rarely investigated. The purpose of this study was to analyze the clinical outcomes in a series of patients with complex elbow instability in whom the associated soft tissue constraint injures were identified and treated based on the pathoanatomic changes found intraoperatively. Forty-five patients (23 men and 22 women; mean age, 54 years) with complex elbow instability were followed prospectively. Surgical treatment included the anatomic reduction and internal fixation of any fracture and radial head replacement in Mason type III injuries. Soft tissue constraint lesions were then repaired based on the type of lesion (eg, proximal or distal ligament avulsion, middle-zone lesion, or presence of detached bony fragments). Posterolateral capsular lesions and common extensor and flexor origin injuries were also repaired. Patients were followed clinically and radiographically after a mean of 25 months. Functional range of motion was achieved in 39 (86%) patients. Average Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score; and American Shoulder and Elbow Surgeons shoulder score were 94, 5.6, and 89, respectively. At last follow-up, 42 (93%) patients showed no evidence of elbow instability, 2 (4%) patients had mild varus instability, and 1 (2%) patient had moderate posterolateral instability. The accurate identification of pathoanatomic changes of elbow soft tissue constraint lesions associated with complex elbow instability is an essential prerequisite to planning proper surgical treatment. The results of this study show that, in patients with complex elbow instability, once the fracture has been treated and each type of soft tissue constraint lesion adequately repaired, a high percentage of satisfactory functional outcomes may be achieved.

Anatomical Variations of the Proximal Radius and Their Effects on Osteosynthesis

PURPOSE In fractures of the radial head and neck requiring open reduction and internal fixation, osteosynthesis may be safely applied in a limited zone. We conducted a morphometric study of the proximal radius at the level of the safe zone to identify different morphologic types of this anatomical region. METHODS We analyzed 44 dried cadaveric radii. We measured the whole length of the radius, the length of the neck and head, and the minimum and maximum diameter of the radial head. The morphologic aspect of the neck-head curvature of the safe zone was evaluated qualitatively and quantitatively. RESULTS The proximal radius at the level of the safe zone exhibited different radii of bending. In particular, we identified a morphologic type A, which showed a flat profile (25% of cases), morphologic types B and C, which showed a low concave curvature (64%), and a marked concave curvature (11%), respectively, of the safe zone. CONCLUSIONS The profile of the proximal radius in the safe zone shows substantial morphologic variations that should be taken into account when operating on fractures of the proximal radius, to avoid malunions, pain, and stiffness of the elbow joint. A preoperative radiograph of the contralateral uninjured radius may be helpful in selecting the most appropriate internal fixation device to reconstruct the proximal radius after comminuted fractures. CLINICAL RELEVANCE Knowledge of the proper bending radius of the safe zone allows the surgeon to select the most appropriate plate, and to achieve good fracture reduction and anatomical restoration of the proximal radius.

Change in Quality of Life and Cost/Utility Analysis in Open Stage-related Surgical Treatment of Elbow Stiffness

The goals of this study were to examine the improvement in quality of life achieved after open surgical treatment of elbow stiffness and to verify the cost/utility ratio of surgery. Thirty-three patients (22 men and 11 women) underwent surgery. The etiologies of elbow stiffness were posttraumatic conditions (n=26), primary osteoarthritis (n=5), and rheumatoid arthritis (n=2). Surgery included 14 ulnohumeral arthroplasties, 6 ulnohumeral arthroplasties associated with radiocapitellar replacement, 5 ulnohumeral arthroplasties associated with radial head replacement, and 8 total elbow arthroplasties. All patients were evaluated pre- and postoperatively with the Mayo Elbow Performance Score, the Mayo Elbow Performance Index, the modified American Shoulder and Elbow Surgeons score, the Quick Disabilities of the Arm, Shoulder and Hand score, and the Short Form 36 after a mean follow-up of 26 months. Possible variables affecting clinical outcome and quality of life improvement were assessed. The cost/utility ratio was evaluated as diagnosis-related group reimbursement per quality-adjusted life year. Mayo Elbow Performance Scores and modified American Shoulder and Elbow Surgeons scores increased, on average, by 43 and 41 points, respectively (P<.0001). Quick Disabilities of the Arm, Shoulder and Hand scores decreased, on average, by 44 points (P<.0001). The improvement in the SF-36 physical and mental component summary score was 7.6 and 7, respectively (P=.0001 and .0018). The cost/utility ratio ranged between 670 and 817 Euro/quality-adjusted life year. A significant correlation was found between pain score and quality of life improvement. An inverse correlation emerged between pre- and postoperative quality of life score. The current study shows that open surgery significantly improves quality of life and elbow function. Selecting the surgical procedure that most effectively reduces pain appears to be the most relevant variable responsible for quality of life improvement. Surgery shows a satisfactory cost/utility ratio, justifying a health spending increase to reduce the social costs resulting from lingering elbow stiffness.