Comprehensive review of surgical approaches to the elbow

Surgical Treatment of Coronoid Fracture With Elbow Varus Posteromedial Rotatory Instability: An Instructional Review

Varus posteromedial rotatory instability (VPMRI) of the elbow is one of the complex elbow instability. The primary sites of injury encompass fractures of the anteromedial coronoid process and injuries to the lateral collateral ligament of the elbow. Some patients may present with involvement of the medial collateral ligament of the elbow. Owing to its distinctive injury mechanism and imaging characteristics, this condition is infrequent in clinical practice and susceptible to misdiagnosis and missed diagnosis. Literature reviews indicate that conservative management of VPMRI is associated with numerous complications, such as persistent pain, traumatic arthritis, and chronic elbow instability. Consequently, surgical intervention has emerged as the recommended treatment modality. Nonetheless, the lack of systematic research on VPMRI in clinical practice has been inconclusive regarding the optimal internal fixation techniques and surgical approaches. Therefore, investigating the treatment modalities, surgical techniques, and internal fixation strategies for VPMRI associated with coronoid fractures holds substantial importance for informing clinical management. In this review, we systematically synthesize the existing literature on coronoid fractures with VPMRI for offering a valuable reference for future clinical treatment.

Effectiveness of supracondylar dome osteotomy in reducing lateral condylar prominence and enhancing functional outcomes in pediatric cubitus varus: a retrospective study

BACKGROUND

Cubitus varus, a common complication of pediatric supracondylar humerus fractures, presents with internal rotation, extension, and varus angulation. While primarily considered a cosmetic concern, it can lead to significant complications, including chronic pain, ulnar nerve palsy, and posterolateral elbow instability. This study evaluates the effectiveness of supracondylar dome osteotomy in decreasing lateral condylar prominence and improving functional outcomes in patients with cubitus varus.

METHODS

This retrospective cohort study analyzed 65 patients under 18 who underwent dome-shaped corrective osteotomy between 2017 and 2022 at the Hospital and Rehabilitation Center for Disabled Children, Nepal. Inclusion criteria comprised patients with cubitus varus deformity greater than 10 degrees and at least six months post-trauma. Outcomes were assessed using the Mayo Elbow Performance Score (MEPS), Lateral Condylar Prominence Index (LPI), and radiological measurements of carrying angle (CA).

RESULTS

The mean age at surgery was 11.77 years (± 3.76), with an average time since injury of 54.15 months (± 31.76). Post-operatively, the radiological carrying angle improved from 23.90° (± 8.84) varus to 5.14° (± 7.64) valgus. The LPI changed from 0.58 (± 16.68) preoperatively to -3.18 (± 16.39) post-operatively. MEPS improved from 89.54 (± 6.66) to 95.23 (± 5.26). Significant improvements in LPI were observed in patients older than 12 years (p = 0.00) and patients with radiological CA less than 20° (p = 0.02) and with a clinical CA less than 20°(p = 0.04).

CONCLUSIONS

Supracondylar dome osteotomy effectively reduces lateral condylar prominence in cubitus varus, particularly in post-pubertal patients and cases with radiological carrying angles less than 20 degrees. The procedure demonstrates good functional outcomes with acceptable complication rates, making it a viable surgical option for treating cubitus varus deformity.

Treatment of Ulnar Coronoid Process Fracture Using the Anterior Neurovascular Interval Approach: A Retrospective Clinical Study with Short- to Mid-term Follow-up

OBJECTIVE

Numerous surgical techniques for addressing ulnar coronoid process fractures are available; however, a consensus on the optimal approach remains elusive. This study aimed to use the anterior neurovascular interval approach for the surgical management of ulnar coronoid process fractures and to evaluate its clinical outcomes over short- to mid-term follow-up.

METHODS

This retrospective clinical study included 20 patients with ulnar coronoid process fractures who were treated using the anterior neurovascular interval approach between January 2018 and December 2022. Participants comprised 16 males and four females, aged between 20 and 64 years (mean, 34.3 ± 12.44 years). Clinical and radiological evaluations were based on elbow joint range of motion (ROM), Visual analogue scale (VAS), and Mayo elbow performance score (MEPS). A paired t-test was used to compare the pre-operative and final follow-up VAS and MEPS scores.

RESULTS

The follow-up duration for all patients was at least 12 months (average, 12.65 ± 1.60 months). At the final follow-up, measurements of elbow ROM included a mean extension of 2.85 ± 3.17°, mean flexion of 135 ± 7.25°, mean pronation of 86.4 ± 4.56°, and mean supination of 84.85 ± 5.54°. All participants reached their target MEPS, with an average score of 97.25 ± 4.72 points, and the final mean VAS score was 0.2 ± 0.52 points. The VAS score was significantly lower and MEPS score was higher at the final follow-up than those before surgery (p < 0.05). Throughout the follow-up period, all the fractures united, and the stability of the affected elbows was satisfactory.

CONCLUSION

Employing the anterior neurovascular interval approach for open reduction and internal fixation to manage coronoid process fractures effectively facilitates anatomical restoration and robust fixation of ulnar coronoid process fractures.

Role of Intraoperative Documentation: Avoidable Ulnar Nerve Injury During Implant Removal

Injuries to the ulnar nerve during open reduction and internal fixation of distal humerus fractures are a well-known phenomenon. However, ulnar nerve injury during implant removal has not been well documented. We performed implant removal in a united distal humerus fracture with the aim of improving the elbow's range of motion. Even with proper surgical precautions in place, the ulnar nerve was damaged during dissection. This report aims to provide insight into this rare phenomenon, and the reasons for this injury are examined retrospectively. The importance of operation notes, the surgical approach, anterior transposition of the nerve, and how this and other factors could have helped the surgeons avoid this complication have also been highlighted.

Intraoperative visualization of the posterolateral ulnohumeral joint space is reliable to indicate overlengthening in radial head arthroplasty

INTRODUCTION

Avoiding overlengthening in radial head arthroplasty (RHA) is essential for the prognosis of the elbow joint. An overlengthening from 2 mm is visible due to widening of the anterolateral ulnohumeral joint space but intraoperatively, this particular joint space is difficult to visualize. The commonly used Kocher approach allows visualization of the posterolateral joint space without additional instruments or further surgical release of the already unstable elbow. The aim of our study was to investigate whether the visualization of the posterolateral joint space is also a reliable method to indicate overlengthening in RHA.

MATERIAL AND METHODS

RHA was performed in five human cadaveric specimens with the forearm, wrist, and hand intact. The lateral ligament complex was detached and an anatomic transosseous refixation was performed. Six stages of implantation heights were documented: native joint (1), RHA at the anatomic height (2), + 2 mm (3), + 4 mm (4), + 6 mm (5) and - 2 mm (6). Macroscopic measurement and digital image analysis of the posterolateral and anterolateral ulnohumeral joint spaces were performed.

RESULTS

All stages of overlengthening showed a significant increase in posterolateral and anterolateral joint space widening (p < 0.05). The posterior and anterior joint space showed excellent intraclass correlation.

CONCLUSION

Visualization of the posterolateral aspect of the ulnohumeral joint space is a reliable indicator for overlengthening in RHA without further compromising an already unstable elbow. Correlation to the findings of the anterolateral ulnohumeral joint space in different implants leads to the assumption that visualization of either the anterior or posterior ulnohumeral joint space is universally applicable to determine overlengthening in RHA, regardless of the type of the radial head implant.

Functional Outcome of Complex Elbow Fracture Managed With the Boyd Approach

INTRODUCTION

The Boyd approach allows excellent access to the elbow and is used to treat complex elbow injuries using a single incision approach.

MATERIALS AND METHODS

In this study, we retrospectively evaluated 16 patients with complex elbow injuries treated with open reduction and internal fixation using the Boyd approach between 2016 and 2018.

RESULTS

All fractures were well united in anatomical position. Postoperatively, the range of motion was not significantly different between the affected and unaffected elbows. The mean Mayo Elbow Performance Index score was 95 ± 5 (range 90 to 100). All study participants had satisfactory results and recovered to full activity. There was no incidence of posttraumatic arthritis of the elbow joint or synostosis of the radius and ulna.

CONCLUSION

Thus, according to our study, the Boyd elbow approach is a safe and effective method of treating elbow injuries.

Management of the stiff elbow: a literature review

The elbow is prone to stiffness due to its unique anatomy and profound capsular reaction to inflammation. The resulting movement impairment may significantly interfere with a patient's activities of daily living. Trauma (including surgery for trauma), posttraumatic arthritis, and heterotopic ossification (HO) are the most common causes of elbow stiffness. In stiffness caused by soft tissue contractures, initial conservative treatment with physiotherapy (PT) and splinting is advised. In cases in which osseous deformities limit range of motion (e.g. malunion, osseous impingement, or HO), early surgical intervention is recommended. Open and arthroscopic arthrolysis are the primary surgical options. Arthroscopic arthrolysis has a lower complication and revision rate but has narrower indications. Early active mobilization using PT after surgery is recommended in postoperative rehabilitation and may be complemented by splinting or continuous passive motion therapy. Most results are gained within the first few months but can continue to improve until 12 months. This paper reviews the current literature and provides state-of-the-art guidance on the management regarding prevention, evaluation, and treatment of elbow stiffness.

Outcomes of the Posterior Approach for the Treatment of Radial Head Fractures and Associated Elbow Injuries: A Retrospective Observational Study

BACKGROUND

The lateral approach to the radial head remains the routinely used approach for surgical fixation or replacement despite the risk of injury to lateral soft tissue structures. Multiple approaches are required when dealing with complex elbow injuries involving other bony and soft tissue structures which lead to greater soft tissue dissection, prolonged immobilization, and a higher rate of elbow stiffness. This article utilizes a single posterior approach involving the Boyd interval in the surgical management of radial head fractures with an associated elbow injury.

METHODS

Thirteen patients with radial head fractures and related elbow injuries treated with the posterior approach to the elbow were retrospectively analyzed. All patients were operated on by a single surgeon and followed up for a minimum of 18 months postoperatively. Functional evaluation of the patients was performed at the final follow-up which comprised a range of movements of the elbow, visual analogue scale (VAS), Disability of Arm, Shoulder, and Hand (QuickDASH), and the Mayo Elbow Performance Score (MEPS).

RESULTS

The mean VAS score was 2.16, QuickDASH score, and Mayo elbow score were 7.15 ± 2.96 and 78.46 ± 8.26 respectively. The flexion-extension arc of the elbow was 128.46 ± 4.27 degrees and the supination-pronation arc was 133.92 ± 4.04 degrees at one-year follow-up. Two patients developed early postoperative complications (elbow stiffness and ulnar nerve neuropraxia) and recovered spontaneously. No patients developed neuropraxia of the posterior interosseous nerve (PIN).

CONCLUSION

The single incision posterior (Boyd) approach to the elbow offers complete access to the radial head, olecranon, coronoid, and lateral ligamentous structures in complex elbow injuries and provides good functional outcomes in our small observational study.