Management of anteromedial coronoid fractures according to a protocol focused on instability assessment provides good outcomes with infrequent need for coronoid fixation

Abstract

Anteromedial coronoid fractures (AMCFs) are associated with persistent elbow instability and post-traumatic arthritis if managed incorrectly. It is unclear exactly which AMCFs require surgical intervention and how to make this decision. The aims of this study were to report outcomes of AMCFs managed using a protocol based on reproduction of instability using radiographic and clinical testingand to ascertain a threshold size of AMCF associated with instability. Forty-three AMCFs were studied. Thirty-two patientsformed the primary study group (group A). All were treated using a protocol in which the decision to perform coronoid fixation was based on the presence of radiographic or clinical evidence of instability. Functional outcomes (Oxford Elbow Score), radiographic outcomes, complications, and reoperations were collected, and a receiver operating characteristic curve analysis was performed to assess the optimal coronoid fracture height to recommend coronoid fixation. The results were compared with a historical group of 11 patientswith AMCFs not treated according to the protocol (group B). Of the patients, 23 had an isolated AMCF and 20 had a concurrent radial head injury. Complete nonoperative treatment of the elbow was performed in 16 patients (37%) (11 of 32 [34%] in group A vs. 5 of 11 [45%] in group B, P = .46). In 10 patients (23%), only repair of the lateral collateral ligament was performed (9 in group A and 1 in group B), whereas 8 patients (19%) underwent repair of the lateral collateral ligament and radial head fixation or replacement (6 in group A and 2 in group B). Acute coronoid fixation was performed in 9 patients (21%) (6 in group A and 3 in group B). At a mean follow-up of 20 months (range, 12-56 months), group A showed a significantly better Oxford Elbow Score (42 vs. 31, P = .02), lower complication rate (3 of 32 [9%] vs. 8 of 11 [72%], P < .001), and lower reoperation rate (1 of 32 [3%] vs. 6 of 11 [54%], P < .001) than group B. Persistent instability was found in 6 patients in group B and none in group A. The receiver operating characteristic curve analysis demonstrated 6.5 mm to be the optimal AMCF size for surgery to prevent persistent instability. Patients treated according to a protocol in which preoperative reproduction of instability determined the degree of surgical intervention had good clinical and radiographic outcomes. Our study demonstrated that AMCFs > 6.5 mm are likely to be more unstable and require intervention. If these principles are followed, a specifically defined subset of AMCFs can be treated nonsurgically without adverse outcomes.