Job N. Doornberg

Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability.

BACKGROUND The use of a metal radial head prosthesis to help stabilize an elbow with traumatic instability is appealing because internal fixation of multifragment, displaced fractures of the radial head is susceptible to either early or late failure. The newer modular prostheses are easier to size and implant, but their effectiveness has not been investigated, to our knowledge. METHODS Twenty-seven patients in whom a radial head replacement with a modular metal spacer prosthesis had been performed to treat traumatic elbow instability were evaluated with use of the Mayo Elbow Performance Index (MEPI), the American Shoulder and Elbow Surgeons Elbow Evaluation Instrument (ASES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiographs were evaluated for arthrosis, periprosthetic radiolucency, and heterotopic ossification. RESULTS Seven patients underwent one or more subsequent operations to treat residual instability, heterotopic ossification and elbow contracture, ulnar neuropathy, or a misplaced screw. In two of these patients, the prosthesis was removed as part of an elbow contracture release or to treat infection. At an average of forty months postoperatively, elbow motion in the entire group of twenty-seven patients averaged 131 degrees of flexion with a 20 degrees flexion contracture, 73 degrees of pronation, and 57 degrees of supination. Stability was restored to all twenty-seven elbows, and twenty-two patients had a good or excellent result according to the MEPI. Seventeen patients had radiographic evidence of lucency around the neck of the prosthesis that was not associated with increased pain, thirteen patients had clinically inconsequential heterotopic ossification anterior to the radial neck, and nine patients had radiographic changes in the capitellum. CONCLUSIONS An intentionally loosely placed modular metal radial head prosthesis can help to restore stability in conjunction with repair of other fractures and reattachment of the lateral collateral ligament to the epicondyle in the setting of traumatic elbow instability with a comminuted fracture of the radial head. While a prosthesis that is too large can cause problems, lucencies around the stem of the intentionally loose prosthesis and most changes in the capitellum do not appear to cause problems, at least in the short term.

Fracture of the Anteromedial Facet of the Coronoid Process

BACKGROUND Fracture of the anteromedial facet of the coronoid was recently recognized as a distinct type of coronoid fracture resulting from a varus posteromedial rotational injury force. Very few reports are available to help guide the management of these injuries. METHODS Eighteen patients with a fracture of the anteromedial facet of the coronoid process were treated over a six-year period. Twelve patients were treated for the acute fracture, and six were managed after initial treatment elsewhere. All but three patients (two with concomitant fracture of the olecranon and one with a second fracture at the base of the coronoid) had avulsion of the origin of the lateral collateral ligament complex from the lateral epicondyle. The initial treatment was operative in fifteen patients and nonoperative in three. The coronoid fracture was secured with a plate applied to the medial surface of the coronoid in nine patients, a screw in one patient, and sutures in one patient. It was not repaired in the remaining seven patients. RESULTS At the final evaluation, an average of twenty-six months after the injury, six patients had malalignment of the anteromedial facet of the coronoid with varus subluxation of the elbow, which was due to the fact that the fracture had not been specifically treated in four patients and to loss of fracture fixation in two patients. All six had development of arthrosis and a fair or poor result according to the system of Broberg and Morrey. The remaining twelve patients had good or excellent elbow function. CONCLUSIONS Anteromedial fractures of the coronoid are associated with either subluxation or complete dislocation of the elbow in most patients. Secure fixation of the coronoid fracture usually restores good elbow function.

Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy.

BACKGROUND Complex fractures of the distal part of the humerus can be difficult to characterize on plain radiographs and two-dimensional computed tomography scans. We tested the hypothesis that three-dimensional reconstructions of computed tomography scans improve the reliability and accuracy of fracture characterization, classification, and treatment decisions. METHODS Five independent observers evaluated thirty consecutive intra-articular fractures of the distal part of the humerus for the presence of five fracture characteristics: a fracture line in the coronal plane; articular comminution; metaphyseal comminution; the presence of separate, entirely articular fragments; and impaction of the articular surface. Fractures were also classified according to the AO/ASIF Comprehensive Classification of Fractures and the classification system of Mehne and Matta. Two rounds of evaluation were performed and then compared. Initially, a combination of plain radiographs and two-dimensional computed tomography scans (2D) were evaluated, and then, two weeks later, a combination of radiographs, two-dimensional computed tomography scans, and three-dimensional reconstructions of computed tomography scans (3D) were assessed. RESULTS Three-dimensional computed tomography improved both the intraobserver and the interobserver reliability of the AO classification system and the Mehne and Matta classification system. Three-dimensional computed tomography reconstructions also improved the intraobserver agreement for all fracture characteristics, from moderate (average kappa [kappa2D] = 0.554) to substantial agreement (kappa3D = 0.793). The addition of three-dimensional images had limited influence on the interobserver reliability and diagnostic characteristics (sensitivity, specificity, and accuracy) for the recognition of specific fracture characteristics. Three-dimensional computed tomography images improved intraobserver agreement (kappa2D = 0.62 compared with kappa3D = 0.75) but not interobserver agreement (kappa2D = 0.24 compared with kappa3D = 0.28) for treatment decisions. CONCLUSIONS Three-dimensional reconstructions improve the reliability, but not the accuracy, of fracture classification and characterization. The influence of three-dimensional computed tomography was much more notable for intraobserver comparisons than for interobserver comparisons, suggesting that different observers see different things in the scans-most likely a reflection of the training, knowledge, and experience of the observer with regard to these relatively uncommon and complex injuries.

Surgical treatment of intra-articular fractures of the distal part of the humerus: Functional outcome after twelve to thirty years

BACKGROUND The short-term results of open reduction and internal fixation of intra-articular distal humeral fractures are good to excellent in approximately 75% of patients, but the long-term results have been less well studied. This investigation addressed the long-term clinical and radiographic results of surgical treatment of intra-articular distal humeral fractures (AO Type C) as assessed with use of standardized outcome measures. METHODS Thirty patients were evaluated at an average of nineteen years (range, twelve to thirty years) after open reduction and internal fixation of a fracture of the distal part of the humerus to assess the range of elbow motion and the functional outcome. Twenty patients had an olecranon osteotomy, and all had fixation with plates and/or screws and/or Kirschner wires. No ulnar nerve was transposed. RESULTS Excluding one elbow salvaged with an arthrodesis and counted as a poor result, the average final flexion arc was 106 degrees and the average pronation-supination arc was 165 degrees. The average American Shoulder and Elbow Surgeons (ASES) score was 96 points, with an average satisfaction score of 8.8 points on a 0 to 10-point visual analog scale. The average Disabilities of the Arm, Shoulder and Hand (DASH) score was 7 points, and the average Mayo Elbow Performance Index (MEPI) score was 91 points. Including the patient with the arthrodesis, the final categorical ratings were nineteen excellent results, seven good results, one fair result, and three poor results. The presence of arthrosis did not appear to correlate with pain or predict disability or function. Subsequent procedures were performed in twelve patients (40%). CONCLUSIONS The long-term results of open reduction and internal fixation of AO-Type-C fractures of the distal part of the humerus are similar to those reported in the short term, suggesting that the results are durable. Functional ratings and perceived disability were predicated more on pain than on functional impairment and did not correlate with radiographic signs of arthrosis.

Surgical Compared with Conservative Treatment for Acute Nondisplaced or Minimally Displaced Scaphoid Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND There is a current trend in orthopaedic practice to treat nondisplaced or minimally displaced fractures with early open reduction and internal fixation instead of cast immobilization. This trend is not evidence-based. In this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute nondisplaced and minimally displaced scaphoid fractures, thus aiming to summarize the best available evidence. METHODS A systematic literature search of the medical literature from 1966 to 2009 was performed. We selected eight randomized controlled trials comparing surgical with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures in adults. Data from included studies were pooled with use of fixed-effects and random-effects models with standard mean differences and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with calculation of the I(2) statistic. RESULTS Four hundred and nineteen patients from eight trials were included. Two hundred and seven patients were treated surgically, and 212 were treated conservatively. Most trials lacked scientific rigor. Our primary outcome parameter, standardized functional outcome, which was assessed for 247 patients enrolled in four trials, significantly favored surgical treatment (p < 0.01). With regard to our secondary parameters, we found heterogeneous results that favored surgical treatment in terms of satisfaction (assessed in one study), grip strength (six studies), time to union (three studies), and time off work (five studies). In contrast, we found no significant differences between surgical and conservative treatment with regard to pain (two studies), range of motion (six studies), the rates of nonunion (six studies) and malunion (seven studies), and total treatment costs (two studies). The rate of complications was higher in the surgical treatment group (23.7%) than in the conservative group (9.1%), although this difference was not significant (p = 0.13). There was a nearly significantly higher rate of scaphotrapezial osteoarthritis in the surgical treatment group (p = 0.05). CONCLUSIONS Based on primary studies with limited methodological quality, this study suggests that surgical treatment is favorable for acute nondisplaced and minimally displaced scaphoid fractures with regard to functional outcome and time off work; however, surgical treatment engenders more complications. Thus, the long-term risks and short-term benefits of surgery should be carefully weighed in clinical decision-making.

Pain Dominates Measurements of Elbow Function and Health Status

BACKGROUND Elbow function can be quantified with use of physician-based elbow-rating systems and health status questionnaires. Our hypothesis was that pain has a strong influence on these scores, which overwhelms the influence of objective factors such as motion. METHODS One hundred and four patients were evaluated, at a minimum of six months (average, forty-six months) after the latest surgery for an intra-articular fracture of the elbow, with use of three physician-based evaluation instruments (Mayo Elbow Performance Index [MEPI], Broberg and Morrey rating system, and American Shoulder and Elbow Surgeons Elbow Evaluation Instrument [ASES]), an upper-extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder and Hand [DASH]), and a general health status questionnaire (Short Form-36 [SF-36]). Multivariate analysis of variance and regression modeling were used to identify the factors that account for the variability in scores derived with these measures-in other words, which factors have the strongest influence on the final score. RESULTS Pain alone accounted for 66% of the variability in the MEPI scores, 59% of the variability in the Broberg and Morrey scores, and 57% of the variability in the ASES scores. Models that included other factors accounted for only slightly more variability (73%, 79%, and 79%, respectively), and those that did not include pain accounted for only 22%, 41%, and 41% of the variability. Thirty-six percent of the variability in the DASH scores could be accounted for by pain alone, and 45% could be accounted for by pain and range of motion. Models not including pain accounted for only 17% of the variability in the DASH scores. CONCLUSIONS Pain has a very strong influence on both physician-rated and patient-rated quantitative measures of elbow function. Consequently, these measures may be strongly influenced by the psychosocial aspects of illness that have a strong relationship with pain, and objective measures of elbow function such as mobility may be undervalued. It may be advisable to evaluate pain separately from objective measures of elbow function in physician-based elbow ratings.

Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch

Our goal with this study was to better define and characterize fracture-dislocations of the olecranon and to provide additional data regarding complications and elbow function after operative treatment. Twenty-six patients with fracture-dislocations of the elbow were reviewed retrospectively. Ten had anterior and 16 had posterior fracture-dislocations. Five of 10 patients with anterior injuries and all of the patients with posterior injuries had an associated fracture of the coronoid process of the ulna. One of 10 patients with anterior and 13 of 16 patients with posterior injuries had fracture of the radial head. Only one patient had a true dislocation of the ulnohumeral joint. In the other 25 patients the articular surfaces remained apposed. All 26 patients were treated operatively and followed up for at least 3 years (average, 6 years). The results were good or excellent in 21 of 26 patients according to the system of Broberg and Morrey. The five unsatisfactory results were related to inadequate fixation of the coronoid with subsequent arthrosis (three patients), proximal radioulnar synostosis (three patients), and a subsequent fracture of the distal humerus (one patient). Fracture-dislocations of the olecranon occur in anterior and posterior patterns with specific injury characteristics and pitfalls. The key to effective treatment is stable restoration of the trochlear notch.

Static progressive splinting for posttraumatic elbow stiffness

Objectives To determine the value of static progressive splinting in helping patients with posttraumatic elbow stiffness regain functional motion and avoid operative treatment for stiffness. Design Retrospective case series. Setting Level I Trauma Center. Patients and Intervention Over a 3-year period, 29 consecutive patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees) were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. Three patients were treated after the injury alone; 14 were treated after operative treatment of the initial injury, and 12 after a secondary operative contracture release for posttraumatic stiffness. Splinting was initiated on an average of 55 days (range, 15 to 200 d) after injury or operative treatment. Main Outcome Measurements Ulnohumeral range of motion before and after splint treatment. Results The flexion arc improved from 71 degrees (range, 0 to 100 degrees) before splinting to 112 degrees (range, 20 to 150 degrees) after splinting. After splinting, 3 patients had a flexion contracture greater than 30 degrees and 10 patients (34%) had fewer than 130 degrees of flexion. Only 3 patients—2 with heterotopic bone and 1 with an associated ulnar neuropathy—requested an operation to address elbow stiffness. Patients who were splinted after the initial injury (n=17, average improvementfl−ext=51±37 degrees) regained greater motion during splint wear than patients treated after elbow capsulectomy (n=12, average improvement fl−ext=22±24 degrees). Conclusions Static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate, particularly after the original injury. Operative treatment of stiffness was avoided in most patients.

Comparison of CT and MRI for Diagnosis of Suspected Scaphoid Fractures

BACKGROUND There is no consensus on the optimum imaging method to use to confirm the diagnosis of true scaphoid fractures among patients with suspected scaphoid fractures. This study tested the null hypothesis that computed tomography (CT) and magnetic resonance imaging (MRI) have the same diagnostic performance characteristics for the diagnosis of scaphoid fractures. METHODS Thirty-four consecutive patients with a suspected scaphoid fracture (tenderness of the scaphoid and normal radiographic findings after a fall on the outstretched hand) underwent CT and MRI within ten days after a wrist injury. The reference standard for a true fracture of the scaphoid was six-week follow-up radiographs in four views. A panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging. The images were considered in a randomly ordered, blinded fashion, independent of the other types of imaging. We calculated sensitivity, specificity, and accuracy as well as positive and negative predictive values. RESULTS The reference standard revealed six true fractures of the scaphoid (prevalence, 18%). CT demonstrated a fracture in five patients (15%), with one false-positive, two false-negative, and four true-positive results. MRI demonstrated a fracture in seven patients (21%), with three false-positive, two false-negative, and four true-positive results. The sensitivity, specificity, and accuracy were 67%, 96%, and 91%, respectively, for CT and 67%, 89%, and 85%, respectively, for MRI. According to the McNemar test for paired binary data, these differences were not significant. The positive predictive value with use of the Bayes formula was 0.76 for CT and 0.54 for MRI. The negative predictive value was 0.94 for CT and 0.93 for MRI. CONCLUSIONS CT and MRI had comparable diagnostic characteristics. Both were better at excluding scaphoid fractures than they were at confirming them, and both were subject to false-positive and false-negative interpretations. The best reference standard is debatable, but it is now unclear whether or not bone edema on MRI and small unicortical lines on CT represent a true fracture.

Long-term outcome of operatively treated fracture-dislocations of the olecranon

Objectives: To report the long-term results of operative treatment of anterior and posterior olecranon fracture-dislocations and compare them with the results recorded fewer than 2 years after surgery. Design: Retrospective case series with long-term evaluation. Setting: Level I trauma center. Patients and Participants: Ten patients with anterior olecranon fracture-dislocation and ten patients with posterior olecranon fracture-dislocation were evaluated after an average of 18 years (range, 11 to 28 years) after injury. Fifteen patients had an early follow-up available at an average 14 months (range, 6 to 24 months) after surgery. The average age at injury was 30 years (range, 14 to 53 years). Intervention: Treatment included plate and screw fixation (11 patients), tension band wiring (8 patients), and radiocapitellar transfixation (1 patient). Six patients had additional elbow surgery before the final evaluation. Main Outcome Measurements: Flexion arc, arthrosis, Mayo Elbow Performance Index (MEPI), Disability of Arm Shoulder and Hand questionnaire (DASH). Results: The mean arc of elbow flexion was 105 degrees (range, 15 to 140 degrees) at 1 year and 122 degrees (range 10 to 145 degrees; P = 0.01) at final evaluation. Radiographic arthrosis was observed in 14 patients (70%): severe in 3, moderate in 2, and mild in 9 patients. Five patients (25%) had ulnar nerve dysfunction at the final evaluation. The MEPI was excellent in 13 patients, good in 4, fair in 2, and poor in 1. The mean DASH score was 9 points (range, 0 to 53 points). Conclusion: The initial results of operative treatment of fracture-dislocations of the olecranon are durable over time.