Unique indications for internal joint stabilizer for elbow instability

A single-surgeon experience with the internal joint stabilizer of the elbow across 56 cases

Background

Recurrent instability continues to plague outcomes of elbow trauma. Adjuvant stabilization-whether internal or external-is intended to acutely stabilize the elbow and off-load the repair construct(s) during early mobilization. Our objective was to report clinical outcomes for a single-surgeon consecutive series using the internal joint stabilizer (IJS) of the elbow. Furthermore, we intend to describe technical points that have been gleaned from the experience which may provide guidance.

Methods

A retrospective follow-up was performed for cases of elbow instability treated with the IJS (Skeletal Dynamics, Miami, Florida, USA) from 2016-2023 with a minimum requirement of 6 months of follow-up. Clinical outcomes and complications including recurrent instability were compiled.

Results

Of 87 potential cases, 56 met the inclusion criteria. Simple dislocations (30%) and terrible triad injury (21%) were the most common injury patterns. The mean Mayo Elbow Performance Score was 81 and the mean Disabilities of the Arm, Shoulder, and Hand score was 22.5. Recurrent instability occurred in 5.3% of cases. The mean time to removal was 21.1 weeks.

Discussion

Our utilization of the IJS of the elbow has evolved from simple dislocations to complex instability cases. Results demonstrated satisfactory clinical outcomes with low rates of recurrent instability and revision. The ability for early mobilization was a critical determinant for using an IJS in these cases. This advantage carried particular importance in cases that presented subacutely following an extended course of immobilization. Our protocol for removal timing is applied on a case-by-case basis and involves identification of sufficient rehabilitation and clinical stability.

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.

Management of Elbow Terrible Triad Injuries: A Comprehensive Review and Update

The "terrible triad" of the elbow, encompassing elbow dislocation, radial head fracture, and coronoid process fracture, remains a formidable challenge in orthopaedic practice. Typically, stabilizing structures in the elbow fail from lateral to medial through a posterolateral rotatory force after a fall onto an outstretched upper extremity. Surgery is often needed to repair the lateral ligamentous complex, replace or fix the radial head, possibly repair the anterior capsule or fix the coronoid, and consider medial repair or application of an internal versus external fixator. However, in some challenging cases persistent instability, complications, and loss of function may occur. Rehabilitation focuses on achieving early range of motion to prevent stiffness which can be common after these injuries. By integrating emerging approaches with established practices, this article aims to guide orthopaedic surgeons toward a fundamental understanding of terrible triad injuries and assist with informed management principles of these complex injuries.

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 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.

Improved Understanding of Traumatic Complex Elbow Instability

Recent advancements in surgical treatment have improved clinical results in complex traumatic elbow injury. There is increasing recognition that conservative treatment and inadequate surgical fixation carry high risk of substantial morbidity in many of these cases. Recent literature displays improved outcomes in complex elbow instability, in part, because of a more complete comprehension of the injury patterns and fixation methods. Prompt surgical management with stable internal fixation, which permits immediate postoperative mobilization, has been a consistent variable across the reports leading to more satisfactory outcomes. This applies to both acute and chronic cases.

Using an Internal Joint Stabilizer Through a Single Posterior Approach for Elderly Patients With Terrible Triad Injury

Introduction

Treating a terrible triad injury of the elbow remains a challenge for orthopedic surgeons, especially in elderly patients due to the poor quality of the surrounding soft tissue and bony structures. In the present study, we propose a treatment protocol using an internal joint stabilizer through a single posterior approach and analyze the clinical results.

Materials and Methods

We retrospectively reviewed 15 elderly patients with terrible triad injuries of the elbow who underwent our treatment protocol from January 2015 to December 2020. The surgery involved a posterior approach, identification of the ulnar nerve, bone and ligament reconstruction, and the application of the internal joint stabilizer. A rehabilitation program was initiated immediately after the operation. Surgery-related complications, elbow range of motion (ROM), and functional outcomes were evaluated.

Results

The mean follow-up period was 21.7 months (range, 16-36 months). ROM at the final follow-up was 130° in extension to flexion and 164° in pronation to supination. The mean Mayo Elbow Performance Score was 94 at the final follow-up. Major complications included breaking of the internal joint stabilizer in 2 patients, transient numbness over the ulnar nerve territory in one, and local infection due to irritation of the internal joint stabilizer in one.

Conclusions

Although the current study involved only a small number of patients and the protocol comprised two stages of operation, we believe that such a technique may be a valuable alternative for the treatment of these difficult cases.

Level of Clinical Evidence

4.