Biomechanical comparison of elbow stability constructs

Patterns of management for post-traumatic elbow stiffness: A comparative study of open and arthroscopic approaches

Background

Post-traumatic elbow stiffness (PTES) often results in significant functional impairment. Open elbow arthrolysis (OEA) and arthroscopic elbow arthrolysis (AEA) are two surgical management options. This study aimed to compare the incidence, demographics, and treatment patterns of patients with PTES undergoing OEA and AEA from 2014 to 2023.

Methods

A retrospective analysis was conducted using the TriNetX database. Patients diagnosed with elbow stiffness (ICD-10 codes M25.621, M25.622, M25.629) were included. Rates of OEA (CPT 24149, 24006) and AEA (CPT 29837, 29838) were identified. Demographic characteristics and simultaneous surgical procedures were assessed.

Results

A total of 30,624 patients were diagnosed with PTES, with 848 undergoing OEA (2.8%) and 361 undergoing AEA (1.2%). The mean age for OEA patients was 44.3 ± 17.6 years, while AEA patients had a mean age of 37.9 ± 18.9 years. OEA was more common in males (61.2%) and non-Hispanic/Latino patients (68.3%). AEA showed higher rates in younger patients and non-Hispanic/Latino individuals (72.7%).

Discussion

The study highlights a preference for OEA in older patients with complex conditions, while AEA is more common in younger patients. Despite the growing trend toward minimally invasive techniques, OEA remains prevalent. Further research is needed to understand the drivers of these trends.

Residual Elbow Instability Treated with a Submuscular Internal Joint Stabilizer: Prospective and Consecutive Series with a Minimum Follow-Up of 12 Months

Background: The management of residual elbow instability is a challenging and compelling issue for treating physicians. To overcome inherent drawbacks of dynamic external fixators, the internal joint stabilizer (IJS) has been developed, achieving successful results, but it can sometimes cause local tenderness or anesthetic concerns in the subcutaneous layer. In addition, a bulky anconeus can pull the hardware away from the axis of rotation with an increase in the lever arm and potential issues. To address these issues, an alternative approach has been recently described in which the internal device is covered by the anconeus muscle, becoming submuscular, rather than subcutaneous. The aim of this study was to evaluate the effectiveness of this alternative approach to the IJS application in maintaining a concentric elbow during and after device removal in both acute and chronic scenarios. Methods: Prospective data collection was performed with consecutive patients who had residual elbow instability treated with an IJS (Skeletal Dynamics, Miami, FL) covered by the anconeus from January 2022 and with a minimum follow-up of 12 months. Results: At a medium follow-up of 16 months, the 16 patients selected had a mean arc of flexion-extension of 123° (range: 0-140°) and a mean pronation-supination arc of 150° (range: 80-80°). The mean MEPS and DASH scores were 90.3 ± 6.2 and 6.3 ± 5.3, respectively. At the last follow-up, elbow stability and concentric reduction were confirmed with radiographic and clinical examinations. Conclusions: With a minimum follow-up of 12 months, the present study supports the safety and efficacy of the internal device in a submuscular layer. The clinical outcomes and the rate of recurrent instability are comparable to those achieved with a classic subcutaneous position. Similarly, the complication rate is not affected, and removal surgery is no more aggressive than the classic approach.

The internal joint stabilizer for elbow instability: current concepts

The management of residual elbow instability is challenging in both acute and chronic injuries. Among the available devices, the hinged external fixator provides an additional joint stabilization while allowing an early motion, but it is clumsy and associated to high rate of pin track complications. To address these issues, an internal joint stabilizer (IJS) has been recently developed. An easier recreation of the axis of rotation coupled to the reduced lever arm of the hinge is the root of the consistent and satisfactory results thus far observed. In addition, the device is more comfortable for the patients being an internal stabilizer. Nonetheless, a second surgery for the device removal is necessary, of which the timing is still not standardized. This current concepts paper describes literature regarding outcomes of the IJS focusing on the rate of maintained radiographic joint reduction, the resultant range of motion, and the associated complication profile.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow

PURPOSE

To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting.

METHODS

This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up.

RESULTS

Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69).

CONCLUSIONS

This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

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.