Operative treatment of nonunions about the elbow

Surgical Outcomes of Olecranon Osteotomy Approach Combined With Submerged Kirschner Wires and Plate Fixation for Duckerley IIIB Distal Humeral Coronal Shear Fractures

OBJECTIVE

Duckerley type IIIB distal humerus fractures are rare and complex injuries that pose significant challenges in both diagnosis and treatment. Currently, no consensus exists on the fixation method, with existing approaches often struggling to handle small fragments and associated with issues like elbow instability. The purpose of this study is to evaluate the surgical outcomes of submerged Kirschner wires combined with plate or submerged screw fixation technique for the treatment of Duckerley type IIIB distal humerus fractures.

METHODS

A retrospective analysis was conducted on 10 patients with Duckerley type IIIB distal humerus fractures who were treated at our hospital from February 2017 to April 2021. The treatment involved applying buried Kirschner wires combined with microplate or buried screw fixation technique through the olecranon osteotomy approach. The study included six males and four females, with a mean age of 51.4 ± 15.34 years (ranging from 22 to 69 years). During the follow-up, the elbow range of motion, Mayo Elbow Performance Score (MEPS), American Shoulder and Elbow Surgeons (ASES) score, and complications were assessed.

RESULTS

All 10 patients received regular clinical and imaging follow-up for a mean of 39.7 ± 8.8 months (range: 25-50 months). Postoperative incision healing was good for all patients, and no neurovascular injuries were noted. Two patients developed elbow pain. At the last follow-up before the internal fixation removal operation (9.6 ± 1.9 months), X-ray and CT findings confirmed bony healing, and no internal fixation loosening and breakage occurred in any of the patients, except for one case in which there was displacement of the Kirschner wires. The mean range of motion of the elbow before the internal fixation removal operation was extension 15.0° ± 21.6°, flexion 129.5° ± 28.1°, pronation 83.0° ± 9.2°, and supination 81.5° ± 8.0°. The MEPS score was 83.0 ± 8.3, and the ASES was 83.6 ± 7.8. At the last follow-up, the mean range of motion of the elbow was extension 10.0° ± 21.9°, flexion 133.5° ± 16.0°, pronation 88.0° ± 11.2°, and supination 85.0° ± 9.5°. The MEPS score was 84.6 ± 7.6, and the ASES was 84.1 ± 7.4.

CONCLUSIONS

The treatment of Duckerley type IIIB low distal humerus fractures using submerged Kirschner wires combined with plate or submerged screw fixation technique has satisfactory advantages in terms of fracture reduction, maintenance of the position of internal fixation, and postoperative recovery.

Strain reduction screws for nonunions following fixation around the elbow - A case series and review of the literature

Background

Nonunions following fracture fixation result in significant patient morbidity and financial burden. Traditional operative management around the elbow consists of removal of metalwork, debridement of the nonunion and re-fixation with compression, often with bone grafting. Recently, some authors in the lower limb literature have described a minimally invasive technique used for select nonunions where simply placing screws across the nonunion facilitates healing by reducing inter-fragmentary strain. To our knowledge, this has not been described around the elbow, where traditional more invasive techniques continue to be employed.

Aims

The aim of this study was to describe the application of strain reduction screws for management of select nonunions around the elbow.

Methods & Results

We describe 4 cases (two humeral shaft, one distal humerus and one proximal ulna) of established nonunion following previous internal fixation, where minimally invasive placement of strain reduction screws were used. In all cases, no existing metal work was removed, the nonunion site was not opened, and no bone grafting or biologic stimulation was used. Surgery was performed between 9 and 24 months after the original fixation. 2.7 mm or 3.5 standard cortical screws were placed across the nonunion without lagging. Three fractures went on to unite with no further intervention required. One fracture required revision fixation using traditional techniques. Failure of the technique in this case did not adversely affect the subsequent revision procedure and has allowed refinement of the indications.

Conclusion

Strain reduction screws are safe, simple and effective technique to treat select nonunions around the elbow. This technique has potential to be a paradigm shift in the management of these highly complex cases and is the first description in the upper limb to our knowledge.

Distal humerus nonunion: evaluation and management

Despite recent improvements in surgical implants and techniques, distal humerus nonunion does occur between 8% and 25% of the time.

Careful identification and improvement of any modifiable risk factors such as smoking, metabolic disorders, immunosuppressant medications, poor nutritional status and infection is mandatory.

A recent computed tomography scan is paramount to determine the nonunion pattern, assess residual bone stock, identify previously placed hardware, and determine whether there is evidence of osteoarthritis or malunion of the articular surface.

Internal fixation is the treatment of choice in the majority of patients presenting with reasonable bone stock and preserved articular cartilage; total elbow arthroplasty is an appealing alternative for elbows with severe destruction of the articular cartilage or severe bone loss at the articular segment, especially in older, female patients. Internal fixation requires not only achieving a stable fixation, but also releasing associated elbow contractures and the liberal use of bone graft or substitutes.

Although reported union rates after internal fixation of distal humerus nonunions are excellent (over 95%), the complication rate remains very high, and unsatisfactory results do occur.

Cite this article: EFORT Open Rev 2020;5:289-298. DOI: 10.1302/2058-5241.5.190050

Surgical Technique: Treatment of Distal Humerus Nonunions

BACKGROUND

Open reduction and internal fixation of distal humerus fractures is standard of care with good to excellent outcome for most patients. However, nonunions of the distal humerus still occur. These are severely disabling problems for the patient and a challenge for the treating physician. Fortunately, a combination of standard nonunion techniques with new plate designs and fixation methods allow even the most challenging distal humeral nonunion to be treated successfully.

QUESTIONS/PURPOSES

The purpose of this manuscript is to describe our current technique in treating distal humeral nonunion as it has evolved over the last four decades. We have now follow-up on 62 treated patients.

METHODS

A few key steps are essential to obtain bone healing while regaining or preserving elbow motion. These include careful planning, extensile exposure, release of the ulnar nerve, capsular release and mobilization of the distal fragment, debridement, and finally stable fixation after alignment with application of bone graft.

RESULTS

The vast majority of distal humeral nonunions can be treated successfully with open reduction and internal fixation.

CONCLUSION

Important components of the treatment plan are careful preoperative planning, extensile approach, debridement, and solid fixation with-locking-plates and liberal use of bone graft.

Valgus Instability of the Elbow Due to Medial Epicondyle Nonunion: Treatment by Fragment Excision and Medial Collateral Ligament Reconstruction

Background: The medial epicondyle nonunion becomes symptomatic valgus instability with medial elbow pain and joint instability due to dysfunction of the medial collateral ligament (MCL), thus requiring surgical treatment. The purpose of the present study is to report the clinical result of the fragment excision and ligament reconstruction by free tendon graft in the treatment of symptomatic medial epicondyle nonunion.

Methods: A retrospective study of five consecutive patients was performed. All five patients had signs and symptoms of valgus instability of the elbow. The mean period of nonunion was 25 years, and their injuries progressed asymptomatically until symptoms developed in adulthood after a second injury.

Results: All patients were treated by fragment excision and MCL reconstruction. At the final follow-up, no patients exhibited pain or instability. The mean joint range of motion was 0o of extension and 138o of flexion, with an MEPS of 100 points in all patients.

Conclusions: By ligament reconstruction for MCL insufficiency and removing the bone fragments avoided irritation by the bone fragments, pain and instability disappeared, good range of motion was restored, and excellent outcomes were achieved in all patients. We believe that fragment excision and MCL reconstruction should be considered as the treatment option for symptomatic medial epicondyle nonunion of the humerus.

The posttraumatic stiff elbow: an update

Posttraumatic elbow stiffness is a disabling condition that remains challenging to treat despite improvement of our understanding of the pathogenesis of posttraumatic contractures and new treatment regimens. This review provides an update and overview of the etiology of posttraumatic elbow stiffness, its classification, evaluation, nonoperative and operative treatment, and postoperative management.

Distal humerus fractures nonunion with elbow stiffness in working adults: Can triple tension band technique and Lambda Plate(®) be a standby solution?

BACKGROUND

Distal humerus fracture nonunion and associated elbow stiffness are two intermingled orthopaedic challenges for working adults. This prospective study aimed to evaluate the short-term results of the triple tension band and Lambda plate in managing both problems.

METHODS

The study included fourteen cases. The mean age was 35.7 ± 8.5 years (range 25-49). Eight cases were males. Initial management was conservative in three cases. Three cases had a history of infected nonunion. Eight cases had initially OTA type C injuries and six cases had type A injuries. All cases had olecranon osteotomy, triple tension band, Lambda plating, and autogenous bone grafting. Five cases had ulnar nerve anterior transposition. Evaluation of the cases was objectively via Mayo Elbow Performance (MEP) score and subjectively through Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The average follow-up period was 23.7 ± 5.3 months. All cases had a solid bony union in a mean of 16.4 ± 2.1 weeks and the final range of motion averaged 100 ± 19.6°. MEP and DASH scores had significant improvement at the final follow-up periods (P = 0.001). Cases with transposed ulnar nerve had significantly less MEP scores (P = 0.028) and more DASH scores (P = 0.013).

CONCLUSIONS

The prescribed technique could be a good alternative to the known traditional methods with the advantages of: good exposure for arthrolysis; rigid and stable internal fixation even with low bone quality or small-sized distal fragments; and secure early rehabilitation.

Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union

BACKGROUND

Hyperbaric oxygen therapy (HBOT) consists of intermittently administering 100% oxygen at pressures greater than one atmosphere absolute (ATA) in a pressure vessel. This technology has been used to treat a variety of diseases and has been described as helping patients who have delayed healing or established non-union of bony fractures. This is an update of a Cochrane Review first published in 2005, and previously updated in 2008.

OBJECTIVES

The aim of this review is to assess the evidence for the benefit of hyperbaric oxygen treatment (HBOT) for the treatment of delayed bony healing and established non-union of bony fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2012), the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7), MEDLINE (1946 to July Week 1 2012), EMBASE (1974 to 2012 July 16), CINAHL (1937 to 17 July 2012), the Database of Randomised Controlled Trials in Hyperbaric Medicine (accessed July 2012), the WHO International Clinical Trials Registry Platform (17 July 2012) and reference lists of articles.

SELECTION CRITERIA

We aimed to include all randomised controlled trials comparing the clinical effects of HBOT with no HBOT (no treatment or sham) for healing of bony fractures and fracture non-unions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened electronic search results, and all three authors independently performed study selection. We planned independent data collection and risk of bias assessment by two authors using standardised forms.

MAIN RESULTS

No trials met the inclusion criteria. In this update, we identified three ongoing randomised controlled trials. Among the eight excluded studies were three randomised trials comparing HBOT with no treatment that included patients with fractures. One of these trials had been abandoned and the other two did not report on fracture healing outcomes.

AUTHORS' CONCLUSIONS

This systematic review failed to locate any relevant clinical evidence to support or refute the effectiveness of HBOT for the management of delayed union or established non-union of bony fractures. Good quality clinical trials are needed to define the role, if any, of HBOT in the treatment of these injuries. There are three randomised controlled trials underway and we anticipate these will help provide some relevant clinical evidence to address this issue in the future.

WITHDRAWN: Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union

BACKGROUND

Hyperbaric oxygen therapy (HBOT) consists of intermittently administering 100% oxygen at pressures greater than one atmosphere absolute (ATA) in a pressure vessel. This technology has been used to treat a variety of diseases and has been described as helping patients who have delayed healing or established non-union of bony fractures.

OBJECTIVES

The aim of this review was to assess the evidence for the benefit of hyperbaric oxygen treatment (HBOT) for the treatment of delayed bony healing and established non-union of bony fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2008), the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (OVID 1966 to April week 3, 2008), CINAHL (OVID 1982 to April week 3, 2008), EMBASE (OVID 1980 to week 17 2008), the locally developed Database of Randomised Controlled Trials in Hyperbaric Medicine (available at www.hboevidence.com) from inception to May 2008, and reference lists of articles.

SELECTION CRITERIA

We aimed to include all randomised controlled trials that compared the effect of HBOT with no HBOT (no treatment or sham).

DATA COLLECTION AND ANALYSIS

We planned independent data collection by two authors using standardised forms.

MAIN RESULTS

No trials met the inclusion criteria. We excluded one trial that compared HBOT with no treatment because no clinical outcomes were reported.

AUTHORS' CONCLUSIONS

This systematic review failed to locate any relevant clinical evidence to support or refute the effectiveness of HBOT for the management of delayed union or established non-union of bony fractures. Good quality clinical trials are needed to define the role, if any, of HBOT in the treatment of these injuries.

Spontaneous displacement of olecranon fracture through geode salvaged by elbow replacement

We present a case of pathological fracture of olecranon through a giant geode. Fracture was initially undisplaced and was treated conservatively. It later progressed to a transolecranon dislocation as a result of a pseudarthrosis at the fracture site. The patient presented 4 years later when she developed symptoms of ulnar nerve palsy. She was treated by a total elbow arthroplasty with ulnar nerve transposition. The current report highlights this unusual case and reviews the relevant literature.

Post-traumatic distal humerus non-union : Open reduction and internal fixation: long-term results

The objective of this paper is to evaluate the long-term functional results achieved after open reduction and internal fixation of 24 distal humerus non-unions. Non-unions were extra-articular-extracapsular (11 cases), extra-articular-intracapsular (8 cases) and intra-articular (5 cases). Preoperative elbow range of motion averaged 45 degrees. Time between original trauma and revision surgery averaged 14 months. Stabilisation methods varied according to type and location of the non-union. Follow-up averaged 46 months (range: 18-108). Elbow range of motion at last examination averaged 98 degrees . Flexion averaged 110 degrees and extension loss averaged 17 degrees . The disabilities of the arm, shoulder and hand (DASH) score averaged 16 points. Secondary transposition of the ulnar nerve was necessary in three cases. Sixteen patients reported no pain at last examination, seven had mild pain and one had moderate pain. Distal humerus non-unions present different characteristics; consequently, surgical treatment must be individualised for each patient. Even though they are demanding procedures, bony union and good long-term functional results were achieved.

Injuries to the proximal humerus

Five to seven percent of all fractures involve the humerus, with most occurring in ladies over the age of 60 who have osteoporosis. and suffer fractures after a simple fall. In younger individuals such fractures result from high energy injuries (road traffic accidents). Around 75% are non-displaced fractures according to Neer's classification and can be treated non-operatively. The remaining 25% require surgical intervention based on the understanding of the anatomy of the proximal, the mechanism of the injury and the quality of the patient's bone. The displaced fractures may lead to avascular necrosis, osteoarthritis, pseudoarthrosis, and reduced motion and function. Involvement of the specialist is needed at an early stage in order to restore the limb functionality and the quality of life.

Primary semi-constrained arthroplasty for chronic fracture-dislocations of the elbow

We present six patients with chronic dislocation of the elbow who were treated by primary semiconstrained total elbow arthroplasty. All were women with a mean age of 65 years (51 to 76), the mean interval between dislocation and surgery was 17 weeks (5 to 52) and the mean follow-up 58 months (24 to 123).

The most dramatic improvement was in function. The mean American Shoulder and Elbow Surgeon score was 5.2 times better (p < 0.001) and the mean total range of movement increased from 33° to 121° (p < 0.001) after operation. Three patients developed wear of polyethylene. One required revision for a periprosthetic fracture, and another required a bushing exchange.

Primary semiconstrained elbow arthroplasty provides significant, predictable functional improvement. Potential solutions for wear of polyethylene include a different operative technique or design of implant. Despite the high incidence of such wear, total elbow arthroplasty should be considered as a viable treatment option for chronic dislocation of the elbow in elderly patients.

Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union

BACKGROUND

Hyperbaric oxygen therapy (HBOT) consists of intermittently administering 100% oxygen at pressures greater than one atmosphere absolute (ATA) in a pressure vessel. This technology has been used to treat a variety of diseases and has been described as helping patients who have delayed healing or established non-union of bony fractures.

OBJECTIVES

The aim of this review was to assess the evidence for the benefit of hyperbaric oxygen treatment (HBOT) for the treatment of delayed bony healing and established non-union of bony fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group trials register (to January week 3, 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (OVID 1966 to January week 3, 2004), CINAHL (OVID 1982 to January week 3, 2004), EMBASE (OVID 1980 to February 2004), the locally developed Database of Randomised Controlled Trials in Hyperbaric Medicine (available at www.hboevidence.com) from inception to March 2004, and reference lists of articles.

SELECTION CRITERIA

We aimed to include all randomised controlled trials that compared the effect of HBOT with no HBOT (no treatment or sham).

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms attempted to extract data independently.

MAIN RESULTS

No trials met the inclusion criteria. We excluded one trial that compared HBOT with no treatment because no clinical outcomes were reported.

AUTHORS' CONCLUSIONS

This systematic review failed to locate any relevant clinical evidence to support or refute the effectiveness of HBOT for the management of delayed union or established non-union of bony fractures. Good quality clinical trials are needed to define the role, if any, of HBOT in the treatment of these injuries.

The pathoanatomy of lateral ligamentous disruption in complex elbow instability

We sought to determine the lateral soft-tissue injury pattern in a consecutive series of patients with elbow dislocation (10 cases) or fracture-dislocation (52 cases) that required open operative repair. Patients who were seen more than 3 months after injury or those in whom previous operative intervention had obscured the anatomy were excluded. There were 42 men and 19 women (mean age, 43 years; range, 13-82 years). One patient had bilateral injuries. The mean time to surgery was 15 days after injury, with a range from 1 to 76 days. There were associated fractures in 52 elbows: coronoid (39), radial head (36), proximal ulna (14), and distal humerus (6). Disruption of the lateral collateral ligament (LCL) complex was seen in all 62 elbows in one of six patterns of injury: proximal avulsion in 32, bony avulsion of the lateral epicondyle in 5, midsubstance rupture in 18, ulnar detachment of the LCL in 3, ulnar bony avulsion in 1, and combined patterns in 3. We found concomitant rupture of the common extensor origin in 41 cases (66%). Operative tactics included anatomic fixation of associated fractures, fixation or replacement of the radial head, and lateral soft-tissue repair. Disruption of the LCL was a universal finding in our patients. Avulsion from the distal humerus was the most common pattern, followed by midsubstance rupture; ulnar detachment or bony avulsion was rare. Disruption of the common extensor origin (a secondary constraint) was seen in 66% of cases. Repair of these lateral soft-tissue structures should be an integral part of the surgical strategy for elbow dislocations and fracture-dislocations that require operative treatment.

Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty

BACKGROUND

Under certain conditions it is standard practice to excise ununited humeral condyles during insertion of a semiconstrained total elbow prosthesis. Since the osseous origins of the common extensors and flexor-pronator muscles are lost, it has been postulated that this excision has a negative effect on strength. We are not aware of any previous study in which this issue has been investigated with use of standardized, objective testing of muscle strength.

METHODS

We used objective testing to determine the effect of condylar resection on the muscle strength of the elbow, forearm, wrist, and hand in thirty-two patients who had undergone total elbow arthroplasty. To eliminate bias, the normal, contralateral limb served as the control, and all strength values are given as a percentage of the normal side. The humeral condyles were intact in sixteen patients and had been resected in the other sixteen. Patient demographics were similar in the two groups.

RESULTS

There were no significant differences between the two groups with regard to strength of pronation (103% of the normal side in the group with intact condyles compared with 89% in the group with resection of the condyles; p = 0.40), supination (68% compared with 89%; p = 0.49), wrist flexion (66% compared with 56%; p = 0.46), wrist extension (75% compared with 65%; p = 0.40), or grip strength (83% compared with 72%; p = 0.40). There was also no difference between the two groups with regard to the Mayo Elbow Performance Score (79 points in the group with intact condyles compared with 77 points in the group with resection of the condyles; p = 0.67).

CONCLUSIONS

Condylar resection has a minimal, clinically irrelevant effect on forearm, wrist, and hand strength and no effect on the Mayo Elbow Performance Score following total elbow arthroplasty. Thus, the findings of our study support the practice of condylar resection, which simplifies total elbow arthroplasty for many conditions.

Advances in the management of humeral nonunion

Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing. Contracture release and early joint motion are necessary to optimize function. Shoulder hemiarthroplasty and semiconstrained total elbow arthroplasty are viable options for irreversible joint damage. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes.

Valgus instability of the elbow due to medial epicondyle nonunion: treatment by fragment excision and ligament repair--a report of 5 cases

We identified 5 patients with valgus instability of the elbow due to nonunion of a previous fracture of the medial epicondyle. There were 4 male patients and 1 female patient with a mean age of 35 years (range, 15-54 years). The original avulsion fracture of the medial epicondyle had occurred a mean of 10.1 years previously (range, 4 months to 25 years), and all patients had had their initial fracture treated nonoperatively. After the development of medial epicondyle nonunion, 3 patients had been treated nonoperatively and 2 had undergone unsuccessful attempts at osteosynthesis. All patients were treated with excision of the medial epicondyle, advancement of the medial collateral ligament, and fixation to the distal humerus with suture anchors. The mean Mayo Elbow Performance Score improved from 66 preoperatively to 91 postoperatively (P <.05), and all patients were satisfied with the increased stability provided by the procedure. On the basis of our experience with these 5 patients, it appears that excision of the nonunion fragment and repair of the medial collateral ligament to the distal humerus can provide satisfactory outcomes in these patients.

Fractures of the proximal ulna olecranon and coronoid fractures

Fractures of the proximal ulna present unique challenges to the surgeon because of the complexity of the elbow joint. It is important not to underestimate the potential difficulty of these cases and to give each one thorough preoperative consideration before embarking on a surgical course. The primary principles of treatment are to restore joint congruity and stability while permitting early range of motion. A logical and consistent approach, based on the fracture characteristics and concomitant injuries, should produce predictable results.