Extensile Posterolateral Novel Approach Through the Anconeus Muscle for an Atypical Coronal Shear Fracture of the Capitellum with Associated Lateral Epicondyle and Olecranon Fractures: A Case Report

Objective To report a new surgical approach(modified anconeus flap approach)in which the anconeus and part of triceps are reflected in the treatment of distal intercondylar humerus fracture(AO type C). Methods To design the modified anconeus flap approach, the anatomy of the distal tendon of the triceps brachii and the anconeus was studied using 15 cadaveric adult specimens(30 sides). The new surgical approach was compared with the triceps-reflecting anconeus pedicle(TRAP)approach in terms of the area of exposure at the distal humeral articular surface. Furthermore, the new surgical approach was applied in 16 patients who had been treated for intercondylar humerus fracture(AO type C)from May 2005 to May 2013. The clinical outcomes were evaluated using the Mayo elbow performance score(MEPS)and Broberg-Morrey scoring systems. Results The blood supply and innervation of the anconeus was interrupted minimally during incision along the radical edge of triceps tendon. The area of exposure at the distal humeral articular surface provided by the part triceps and anconeus reflecting approach and the medial humerus approach was 42. 66% ±0. 03% at the elbow flexion from 0° to 50°. This was significantly smaller than that provided by the TRAP approach(46. 11% ± 0. 03%)(P< 0. 05). Of the 16 patients, 15 obtained complete follow-ups from 6 months to 4 years(average, 16. 5 months). The mean MEPS at the last follow-up was 90. 5 points(range, from 82 to 93 points), with 10 excellent and 4 good cases and one poor case. The Broberg & Morrey score system showed 11 patients with no articular cartilage degeneration(level-0), 3 patients with level-1 degeneration, and 2 patients with level-2 degeneration. Conclusion The modified anconeus flap approach proposed in the present study provides clear surgical vision and needs no olecranon osteotomy or olecranon dissection or ablation of the major triceps brachii tendon for intercondylar humerus fractures, thereby leading to early active motion and satisfactory clinical outcomes. Key words: Humeral fractures; Autopsy; Therapies, investigational; Surgical approach

Background and aim of the work:Monteggia-like lesions are complex and rare elbow injuries. A detailed classification and a proper surgical treatment can provide quite good functional and radiological outcomes. The aim of this retrospective study was to evaluate the mid-term results of Monteggia-like lesions surgical treatment. The other purpose was to investigate whether the complexity of ulna and radius fractures could be prognostic factors of insufficient functional results.Methods:Seven women and five men, with a mean age of 59,25 years who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QUICK-DASH) score were used for evaluation at a mean of 17,5 months postoperatively (12-26). The range of movement (ROM), patients’ satisfaction and neurological symptoms were also investigated. Osteolysis, implant loosening and heterotopic ossification were graded. Pearson’s test was used to correlate the different classification systems used (AO/OTA, Bado and Jupiter, PURCCS, Mason) with MEPS and QUICK-DASH score.Results:The mean MEPS was 84,92 (65 to 100). The mean QUICK-DASH score was 18,75 (0 to 34,1). The mean active pronation and supination was 72,5° and 59,17°, respectively. The mean active ROM of the elbow was 101,43°. Heterotopic ossifications were absent in six cases but were found in six. No statistically significant correlation was found between the analyzed variables.Conclusions:Quite good functional results can be obtained in Monteggia-like lesions if injury pattern is recognized and each component of the injury is addressed. Further studies are needed to determine any prognostic factors. (www.actabiomedica.it)

Background Elbow joint dislocation accounts for 11%-28% of elbow trauma and is commonly seen in sports injury. The dislocation can be anatomically classified into simple type (no intraarticular fractures) and complex type (complicated with distal humeral fractures, radial head fractures, proximal ulna and/or coronal process fractures) . The simple type of elbow dislocation is more common than the complex type, and it does not mean less damage. The anatomical study , injury mechanism and clinical feature indicate extensive damage to the surrounding soft tissue after elbow joint dislocation. O 'Driscoll et al. expatiate the classic simple type of elbow dislocation mechanism in detail. The elbow joint undergoes axial stress combined with supination and valgus stress. These lead to annular soft tissue injury starting with lateral collateral ligament (LCL) from the anterior joint capsule to the medial collateral ligament (MCL) of anterior and posterior bundles, causing the posterolateral instability and dislocation of elbow joint. With improper treatment, these acute elbow instabilities cause incomplete healing of lateral collateral ligament complex (LCLC) which may develop into chronic elbow instability. The most common one is posterolateral rotatory instability (PLRI) . However, due to the limited awareness and knowledge among most doctors for the elbow joint dysfunction caused by such ligament injuries, the missed diagnosis or the failure of timely and effective treatment will seriously affect the life quality of patients. Currently, the treatment of PLRI is mainly surgical with repair or reconstruction of LCLC. Methods 1. Clinical data:From June 2013 to December 2017, 20 patients with PLRI caused by simple elbow dislocation were admitted into our hospital continuously, among which 11 patients underwent open reduction and LCLC repair, and 9 patients received conservative treatment of external fixation with hinged brace. There were 9 cases of male and 2 cases of female with an average age of 29.4 years (19-52 years) . 9 cases had the dominant elbow affected. Causes of injury: 7 cases of sports injury; 2 cases of traffic injury; 1 case of high fall injury; 1 case of fall damage. Among them, 2 cases were combined with the avulsion fracture of external humeral epicondyle. In the control group, there were 6 males and 3 females with an average age of 28.2 years (17-45 years) . 6 cases had the dominant elbow affected. Causes of injury: 4 cases of sports injury; 1 case of traffic injury; 2 cases of fall injury; 2 cases of fall damage. The diagnosis of PLRI was made based on patient's medical history, physical examination, preoperative X-ray and MRI examination. 2. Surgical methods:Modified Kocher approach was adopted on the lateral side of elbow joint. A 6-8 cm oblique incision was made across humeroradial joint and radial head along the lateral epicondyle of humerus. The gap between extensor carpi ulnaris muscle and anconeus was cut open through the entrance between brachioradialis muscle and triceps muscle, and the common extensor tendon was carefully lifted to fully expose the insertion point of LCLC. Lateral axial test and lateral drawer test were performed during the operation, and the radial head was found unstable with subluxation in posterior and lateral position. A suture anchor was placed in the origin of external epicondylar ligament of humerus. According to the method of Kim et al., the lateral ulnar collateral ligament (LUCL) and LCL were respectively repaired by Mason Allen method with two sutures. 3. Postoperative management:In the operation group, the elbow joint was immobilized in 90° of neutral flexion within 1 week of operation , and the hinged brace was adopted 1 week after operation. Passive flexion and extension started within 3 weeks, and the range of motion was controlled from 30° of elbow extension to 90° of elbow flexion. The rehabilitation training including active and passive flexion and extension began 3 weeks later , and the range of motion was gradually increased to normal (0-150°) 6 weeks after operation. The brace was removed 6-8 weeks postoperatively, and the elbow joint was restored to normal 3 months after surgery. In the control group, the elbow joint was immobilized with plaster in 90° of neutral flexion. 3 weeks later, the plaster was changed into hinged brace for progressive functional exercise. 4. Postoperative evaluation:During postoperative follow-up, VAS score and Mayo elbow performance score (MEPS) were used to evaluate elbow function before and after treatment. Pain (45 points) , range of joint motion (20 points) , joint stability (10 points) and daily life function (25 points) were evaluated according to MEPS: ≥90 points were considered excellent, 75-89 points were considered good, 60-74 points were considered moderate and <60 points were considered poor. 5. Statistical methods:The SPSS19.0 statistical software was used to analyze and process the data in this study,±s was used to represent measurement data, and percentage was used to represent counting data. A P value of <0.05 was considered statistical difference, and t or χ2 test was used for comparison between groups. Results 1. Clinical efficacy analysis:All patients were followed up for an average of 11.8 months (6-24 months) . The excellent and good rates of operation group and control group were 100% and 77.78%, respectively, and the difference was statistically significant. 2.VAS scores and MEPS scores before and after treatment in the two groups.The VAS scores of patients in the two groups decreased significantly after the treatment, but symptoms alleviated more significantly in the operation group. The difference of post-operated VAS scores between the two groups was statistically significant. The MEPS scores of operation group increased significantly after the treatment, and the difference was statistically significant compared with that of the control group.3. Complications in the two groups after the treatment:In the operation group, 11 patients had no wound infection, nerve injury or reoperation, and only 1 patient had slight heterotopic ossification. In the control group, 2 patients showed slight heterotopic ossification, and 1 patient had elbow stiffness. Conclusions The correct diagnosis of acute posterolateral rotatory instability of elbow is critical for the selection of treatment option. The LCLC repair with active functional exercise is preferred for restoring normal function and elbow stability. Key words: Elbow; Lateral collateral ligament complex; Posterolateral rotatory instability

BackgroundStandard plate fixation can be used to treat intraarticular olecranon fractures with satisfactory functional recovery, but its use is accompanied by implant related complications. This retrospective study reports on the functional outcome of intraarticular olecranon fractures treated with a central tension plate with sharp hook.MethodsA retrospective review of any patient with an olecranon fracture from August 2007 to December 2008 was conducted. Patients were considered for inclusion in the study if they were treated surgically with a central tension plate with sharp hook. Patients with pathological fractures or previous fractures of the proximal ulna were excluded. The quality of reduction was evaluated using postoperative imaging. The functional recoveries of the affected upper limbs were evaluated postoperatively at regular intervals using the Mayo Elbow Performance (MEP) score and Disability of the Arm, Shoulder and Hand questionnaire (DASH).ResultsTwenty six patients met the study criteria and were included in analysis. There were ten Type IIA, nine Type IIB, four Type IIIA and three Type IIIB fractures according to the Mayo classification system. Thirteen patients exhibited other concomitant fractures at the time of surgery: one patient with a coronoid fracture, two with a fracture of the radial head, and ten with fractures in other bones. Postoperative radiographic assessment revealed an anatomical or nearly anatomical reduction of all olecranon fractures treated. All olecranon fractures healed at an average of 14 weeks (range, 9 to 32 weeks). The patients were followed up for 42 months (range, 32 to 54 months). The mean DASH score was 8.5 (range, 0 to 31.7). The mean MEP score was 93.6 (range, 75 to 100). Based on the MEP score, all patients achieved good or excellent outcomes. No symptomatic plate removal was performed at the time of last follow-up.ConclusionThe central tension plate with sharp hook closely contours to the osteology of the proximal ulna. Treating intra-articular olecranon fracture with this new plate can achieve good to excellent functional outcome with a high union rate and a low incidence of hardware related complications.

Dislocations of components, loosening of the stem, overstuffing and removal in up to 24 % of common radial head prostheses (RHP) after implantation in complex elbow injuries signal the need for improvement. The latest biomechanical evidence shows advantages for monopolar designs. Clinical results after primary and secondary implantation of the newly designed press-fit monobloc monopolar RHP in cases of complex elbow injury are evaluated. Twenty-nine patients [median age 60 years (29-86)] were followed up retrospectively for a median of 25 months (7-54) post-operatively. Subjective parameters, the Mayo Elbow Performance Score (MEPS), the Broberg and Morrey score (BMS), latest radiographs and complications were evaluated. MEPS and BMS averaged 87.2 ± 12.9 and 81.1 ± 11.9 points, respectively. No case of implant loosening was observed; the RHP had to be removed in one case (3 %). The overall complication and revision rate was higher after secondary (53 %) than after primary (19 %) implantation. Satisfactory clinical results and low short-term removal rates emphasise the practicality of monobloc monopolar RHP. Differentiated treatment of complex elbow fracture-dislocations is compulsory to avoid the need for secondary RHP implantation which carries a higher complication rate.

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow

Background Distal biceps tendon (DBT) rupture is not one of the most common upper limb injuries. Surgical intervention is recommended for these injuries to restore muscular strength and functionality. Multiple different techniques are documented in the literature, however there is no definitive consensus on the most effective surgical treatment. The objective of this study was to assess the functional results of patients who underwent repair of DBT utilizing cortical button fixation procedures. Methods This study is a retrospective single-unit case series consisting of 54 patients who underwent DBT repair at Heartlands Hospital in Birmingham, United Kingdom. The patients' functional outcomes was assessed by the Mayo Elbow Performance Score (MEPS). Results The mean age was 51±11.01 years. Patients were operated on 4.72±7.083 days after the injury. The mean pain Visual Analogue Scale (VAS) 6 months after the surgery was 0.54±0.50. At 6 months follow-up, the average extension deficit was 2.69° (0-10), flexion 132° (120-140), supination76° (50- 85), and 77° for pronation (78-95). Patients were followed up routinely for 6 months. Mayo Elbow Performance (MEP) Score was utilized to assess the functional outcome and the mean MEP score was 91.43±8.26 which showed excellent functional outcomes for the cohort. Conclusion DBT repair with cortical button fixation yielded favorable functional outcomes at 6 months, notably restoring supination strength. This approach offers anatomical reinsertion while minimizing nerve damage risk.

Background: Intra-articular distal humerus fractures are rare but complex injuries that present major surgical challenges. Stable fixation and early mobilisation are essential to avoid stiffness and restore elbow function. Dual plating has emerged as the standard of care, but evidence from Indian centres remains limited. Methods: This prospective study included 20 adult patients (≥18 years) with closed intra-articular distal humerus fractures (AO/OTA Type B and C) treated with dual plating at a tertiary care centre between February 2023 and February 2025. The posterior approach was used in 70% of cases, while olecranon osteotomy was required in 30%. Patients underwent structured rehabilitation with early mobilisation. Functional outcomes were assessed using the Mayo Elbow Performance Score (MEPS) at 6 weeks, 12 weeks, and 6 months. Radiological union and complications were documented. Statistical analysis employed one-way ANOVA for MEPS progression and Chi-square testing for AO type versus outcome. Results: The mean age was 46.5 years, with 55% males. AO Type B fractures accounted for 55% and Type C for 45%. Mean MEPS improved from 68.2 at 6 weeks to 84.3 at 6 months (p &lt; 0.001). At 6 months, 30% achieved excellent, 40% good, 20% fair, and 10% poor outcomes. Union was achieved in 90% of patients within a mean of 14.4 weeks. Complications included infection (20%), delayed union (15%), non-union (10%), implant failure (10%), and transient nerve palsy (10%). No significant association was found between AO type and functional outcome (p = 0.758). Conclusion:Dual plating for intra-articular distal humerus fractures provides stable fixation, high union rates, and satisfactory functional outcomes irrespective of fracture type. Early rehabilitation remains crucial to optimise recovery.

The purpose of the current study was to investigate the long-term outcomes of radial head arthroplasty in complex elbow injuries through radiographic analysis and functional correlation. We evaluated 24 radial head arthroplasties in 24 consecutive patients with complex elbow fracture dislocation. All patients were treated with a single type of modular monopolar prosthesis containing smooth stem in press-fit implantation. Clinical survey using the Mayo Elbow Performance Score (MEPS), self-reported scales of shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the visual analog scale (VAS) at more than 10-year follow-up were reported and compared to 2-year outcomes. Periprosthetic osteolysis was measured in the 10 zones of prosthesis-cortical interface with a modified radiolucency score, which was calibrated by each prosthesis size. Pearson correlation analysis was performed to detect the association between periprosthetic radiolucency and clinical assessment. At the final follow-up, MEPS, QuickDASH score and VAS score averaged 82.5 ± 15, 14.1 ± 14.3 and 1.6 ± 1.2 respectively. A decline in functional status was noted, with decreased mean MEPS and increased mean QuickDASH and VAS scores as compared to the 2-year results while the difference was insignificant. Periprosthetic osteolysis was more prevalent around stem tip of zone 3 and zone 8. The final and 2-year radiolucency scores averaged 7.4 ± 4.2 and 2.6 ± 2.3 respectively with significant difference. Pearson correlation analysis indicated that the difference between radiolucency scores and clinical outcomes in MEPS/QuickDASH/VAS was −0.836, 0.517 and 0.464. Progression of periprosthetic osteolysis after postoperative 10 years is more prevalent around the stem tip with moderate to high correlation to clinical outcomes. Sustained follow-up is warranted to justify subsequent surgery for revision or implant removal.

Olecranon fracture is relatively common and accounts for approximately 40% of elbow joint fractures. It is an intra-articular fracture, so the aim of treatment is anatomic reduction, stable fixation and early mobilization. Tension band wiring (TBW) may be a popular and widely practiced method using either single knot or two knots techniques. Now two knots TBW are widely accepted by AO foundation as well as various countries. But single knot technique is commonly practiced in Bangladesh. The present study was done to see the clinical, radiologi- cal and functional outcome of two knots Tension band wiring (TBW) in Mayo type IIA olecranon fracture. This observational study was carried out by the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh. A total of 32 patients with Mayo type IIA olecranon fractures were treated with two knots TBW, out of which 30 cases had completed at least 24 weeks of follow-up and analyzed for final functional outcome with Mayo Elbow Performance Score (MEPS). The mean age was 32.58±14.21 years and the male to female ratio was 2.6:1. The mean radiological union time was 8.15±2.25 weeks. In 6 (18.75%) cases, it took 6 weeks, in 18 (56.25%) cases, it took 8 weeks and in 8 (25.0%), it took 12 weeks. Complications were found in 21.9% of patients. At first follow-up after the operation showed that 21 (70.0%) had moderate pain and the final follow-up showed 21 (70.0%) had no pain. The mean arc of elbow motion at first follow-up and final follow-up were 61.090±16.2340 and 122.820±15.2870, respectively. The mean functional score at 1st follow-up was 6.75±5.63 and the last follow-up was 24.76±1.69. The mean total Mayo Elbow Performance Score (MEPS) scores at first and last follow-up were 40.65±14.48 and 94.13±8.35, respectively. Excellent and good outcomes were found among 21 (70.0%) and 9 (30.0%) patients, respectively. Two knots TBW technique is safe regarding overall complication rate, pain status and excellent outcome. BSMMU J 2022; 15(2): 90-95

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.

Background: Internal fixations for olecranon fractures, like tension band wiring and plates, have some complications such as prominence of the devices, neurovascular injuries, superficial infection, and skin irritation. In this study, a new triceps aponeurosis tongue shape flap technique was used to solve the problem in patients with olecranon fracture fixation. Materials and methods: Nine patients with olecranon fractures were evaluated. After fixation by tension band wiring and plate, the free aponeurosis triceps muscle in a tongue-shaped flap was used and rotated 180° to cover the whole the pin wire or plate. The surgeon then began to suture it to the anconeus, extensor carpi ulnaris and flexor carpi ulnaris muscles, fully around, with absorbable sutures. The follow-up time was eight weeks and a Mayo elbow performance score (MEPS) was filled for all patients. Results: Nine patients were analysed. Two cases were male and seven was female. The meanage was 49.11±10.37 years. Extension was full in six patients and was 170 in three. Flexion was full in all patients. No complications were recorded. The MEPS results showed that it was good and excellent in all the patients (number for patients was in the range of 80-95). Conclusion: According to results of present study, this technique can help to surgical fixation of olecranon fractures with different devices to have fewer complications, especially prominence of fixator systems and with this method tension band wiring can be remained as a gold standard in olecranon fracture fixation.

Introduction: Tension Band Wiring (TBW) is a common fixation method for olecranon fractures. This study aims to evaluate the functional outcomes of patients treated with TBW, using the Mayo Elbow Performance Score (MEPS). Methods: Thirty patients with olecranon fractures were randomly selected for operative treatment, meeting the inclusion criteria. They were followed up for six months, with outcomes assessed using the Visual Analogue Scale (VAS) and MEPS at the final follow-up. Results: Among the 30 patients evaluated, males comprised 70%, and 30% were females. The olecranon of the right side was more commonly injured (56.67%). The mean age of participants was 34.10 years (range 18-64 years). Most fractures resulted from fall injuries (46.67%), followed by Road Traffic Accidents (43.33%). The most frequent fracture type was Mayo Type 2 (56.67%), followed by Type 3 (43.33%). The mean time from injury to surgery was 3.93 days, and the average union time was 7.57 weeks. At three months, the mean VAS score was 1.20, improving to 0.63 at six months. The mean MEPS at three months was 84.83, increasing to 92.33 at six months. At the final follow-up, 20 patients had excellent outcomes, 8 had good outcomes, and two had fair outcomes. Conclusions: Open reduction and internal fixation with TBW leads to excellent functional outcomes, supporting its continued use as the gold-standard technique based on solid biomechanical principles.

To asses physical function and quality of life after distal biceps tendon repair and compare suture anchor and cortical button fixation. Secondarily, we assessed the impact of other factors: acute repair, graft use, concomitant arm conditions, contralateral rupture, and complications. We approached all 50 patients that underwent distal biceps tendon rupture repair (2009-2016) to participate in our study and complete a questionnaire including: patient demographics, QuickDASH, Quality of life EQ-5D-5L, pain score, and Mayo Elbow Performance score (MEPS). In total, 37 (76%) of 49 alive patients participated in our study. All were men, with a median age of 47years. Median follow-up was 34months (range 8-100months). On average, we found perfect upper extremity (QuickDASH, median: 0, IQR 0-7.9; 53% had no [QuickDASH = 0] upper extremity disability) and elbow function (MEPS, median: 100, IQR 100-100; 83% had perfect [MEPS > 90] clinical elbow function), perfect quality of life (EQ-5D-5L, median: 1, IQR 0.85-1; 59% had perfect [EQ-5D-5L = 1] quality of life), and no pain (median 0, IQR 0-0; 68% had no pain). We found no difference in upper extremity (QuickDASH: anchor, median 1.1, IQR 0-6.8; endobutton, median 0, IQR 0-9.1, p = 0.972) and elbow (MEPS: anchor, median 100, IQR 100-100; endobutton, median 100, IQR 100-100, p = 0.895) function, quality of life (EQ-5D-5L: anchor, median 1, IQR 0.85-1; endobutton, median 1, IQR 0.84-1, p = 0.507), and pain score (anchor, median 0, IQR 0-0.5; endobutton, median 0, IQR 0-0, p = 0.742) when comparing the anchor to endobutton fixation technique. Overall, patients have excellent outcome after distal biceps tendon rupture repair. There was no difference in patient-reported outcome measures between suture anchor and endobutton fixation. Level III, retrospective comparative study.

Arthroscopic Management of Mason Type II- Radial Head Fractures Using Percutaneous K-wires (SS-53)