Elbow Instability Research Articles

Новые подходы к лечению детей с посттравматическими контрактурами локтевого сустава

Abstract. Introduction Post-traumatic elbow contracture is a severe disabling condition of childhood that interferes with both physical and psychic aspects for the child. A high rate of poor results encourages surgeons seek for better surgical treatments. Current diagnostic modalities were practical to get the clinical picture of the contracture mechanogenesis and determine the treatment strategy. The goal of the study was to review long-term results of new surgical techniques developed for post-traumatic elbow contractures in children. Material and methods The inpatient records of 102 pediatric patients with post-traumatic elbow contractures operated on with the technique offered were reviewed. All patients underwent conventional radiological, ultrasound and MSCT examinations. Results Based on the pathobiomechanics of the injured elbow a mobilization technique was developed to ensure complete bone realignment, relieve pain and allow early exercises for the joint. Postoperative lavage of the joint cavity, intra-articular administration of corticosteroids and polyvalent enzymes in the early postoperative period facilitated improved long-term outcomes of elbow contractures. All patients reported good results. Discussion Tenotomies of the lateral ligaments can be added to arthrotomy and reconstruction of articular surfaces for temporary instability of the joint to restore movement in the elbow joint in severe cases. Post-traumatic elbow contractures are accompanied by impaired biomechanics. MSCT and 3D reconstruction of bone structures is the gold standard in the diagnosis of post-traumatic elbow contractures. Conclusion Bone impingements are to be addressed and an extended mobilization of the capsular ligamentous complex be provided for complete movement recovery through partial elbow instability to be temporarily ensured. Prolonged lavage of the elbow joint can be used to prevent adhesions and allow early elbow exercises and provide improved outcomes.

Ultrasound assessment of the posterolateral elbow ulnohumeral gap in normal subjects with and without posterolateral drawer testing

Posterolateral rotator instability (PLRI) is the most common pattern of recurrent elbow instability, and current imaging to aid PLRI diagnosis is limited. Thus, we sought to define use of ultrasound (US) to determine normal lateral ulnohumeral joint measurements, with and without posterolateral drawer testing to provide an insight into how US may aid diagnosis. Sixty elbows were evaluated in thirty healthy volunteers. The lateral ulnohumeral gap (LUHG) was measured with US in the resting position while the posterolateral drawer stress test maneuver was applied. Joint laxity was calculated as the difference between maximum stress and average rest measurements. Two independent readers assessed each elbow with comparison performed between stress and rest positions. Differences in the LUHG were evident between stress and rest conditions (reader 1: P<.0001 and reader 2: P=.0002). At rest, median LUHG values were 2.31 mm and 2.05 mm for readers 1 and 2 respectively, while at stress 2.88 mm and 2.9 mm for readers 1 and 2. Median joint laxity was 0.8 mm for reader 1 and 1.1 mm for reader 2. Pearson correlation was r=0.457 (absolute intraclass correlation coefficient [ICC]=0.608) while under stress and r=0.308 (absolute intraclass correlation coefficient [ICC]=0.417) at rest. Median joint laxity demonstrated a Pearson correlation of r=0.161 and absolute intraclass correlation coefficient [ICC]=0.252. This study demonstrates a dynamic US assessment for PLRI, which aimed to assess the usefulness and feasibility of a laxity measurement after the application of a posterolateral drawer stress maneuver in a healthy population. Although establishing concordance between readers in measuring an LUHG under stress, the utility of a laxity measurement alone is not clear as correlation of measurements is not excellent; hence, an upper limit of normal for the ulnohumeral gap under stress may be more useful. Further evaluation of this technique is required in patients with PLRI.

Acute Radial Head Resection for Fracture: are We Likely to Miss an Essex-Lopresti Injury?

Given the current available evidence, surgical treatment of radial head fracture with acute resection is controversial. The aim of this study was to determine whether acute resection of the radial head for a radial head fracture leads to longitudinal forearm instability due to a missed Essex-Lopresti injury. A retrospective review was conducted of radial head resections performed for acute radial head fractures at two Level I trauma centers from 2000 to 2018. A total of 11 patients met inclusion criteria. Our primary outcome was a missed Essex-Lopresti injury at time of final clinical follow-up. Long-term telephone follow-up was attempted for QuickDASH, pain scores, and satisfaction scores. Of the 11 radial head fractures in this study, intraoperative radial pull tests were performed and normal in 6 patients. No patient was found to have a missed Essex-Lopresti injury at a mean of 36.2 months' clinical follow-up after radial head resection. At a mean telephone follow-up of 12.6 years in available patients, mean QuickDASH was 3.4, mean satisfaction was 9.75 out of 10, and no further complication or reoperation was reported. Our findings challenge the dogma that the radial head cannot be safely excised in the setting of acute fracture, even with elbow instability and/or wrist pain, particularly when intraoperative longitudinal stability is assessed by a stress maneuver.

Clinical and radiological outcomes of autologous humeral bone grafting for radial head reconstruction: a minimum 2-year follow-up.

The aim of this prospective study was to assess the clinical and functional results of radial head reconstruction with an autologous bone graft from distal humerus in 12 patients, with a follow-up for a period of 24months. From March 2017 to June 2018, we surgically treated 12 patients using an autologous bone graft from the lateral distal metaphysis of the homolateral humerus. Patients were divided into two groups: -Group A consisted of patients with previous failed ORIF for radial head fracture. Patients underwent revision surgery at an average time of 7months (between 6 to 8months) from the first surgery. All the patients reported pain during the elbow range of motion with no gross clinical signs or instability of the joint. They all presented standard X-ray and CT-scan of the elbow suggestive of non-union fracture. None of them presented osteoarthritic modification at the time of surgery. -Group B consisted of patients reporting acute irreparable radial head fractures. Patients were evaluated clinically at 6-, 12-, and 24-months duration according to Disabilities of the Arm. Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and Visual analogue score for pain (VAS);, range of motion (ROM) was evaluated at 6 and 24months after surgery. Plain radiographs on anteroposterior and lateral views of the elbow were evaluated at final follow-up. In both, groups (A and B) patients showed a significant improvement with regards to VAS, MEPS, and DASH at each follow-up (p < 0.05). X-rays showed complete bone healing in all patients with no sign of mobilisation or loosening of the screws. One case in group A presented asymptomatic partial ossification of LUCL. No cases of fracture or residual pain at the donor site. Furthermore, no other complications such as infection, wound issues, elbow instability, elbow stiffness, ulnar neuritis, graft non-union were reported. Distal humerus bone graft should be considered a reliable option for the treatment of acute fractures that are unrepairable fractures or revision surgery for failed ORIF of the radial head, especially among young patients where prosthesis may be reserved as a salvage procedure, and radial head resection is a damaging and is not considered desirable. Level IV - Prospective Case Series.

Internal bracing in the treatment of elbow instabilities

AbstractInternal bracing is an augmentation of ligament repair or reconstruction using a non-absorbable suture tape. The suture reinforcement of the ligament is intended to absorb the forces applied to the joint while the ligament repair or reconstruction underneath is healing. The rigidity of the construct is expected to improve primary stability, which should facilitate and accelerate postoperative mobilization and rehabilitation. Nevertheless, internal bracing is a novel treatment and data is limited. Therefore, this review describes the surgical techniques and provides an overview of the current literature regarding acute and chronic instabilities of the medial and lateral elbow treated with internal bracing.

Elbow Instability

The stability of the elbow is based on a combination of primary (static) and secondary stabilizers (dynamic). In varus stress, the bony structures and the lateral ulnar collateral ligament (LUCL) are the primary stabilizers, and in valgus stress, the ulnar collateral ligament (UCL) is the primary stabilizer. The flexor and extensor tendons crossing the elbow joint act as secondary stabilizers. Elbow instability is commonly divided into acute traumatic and chronic instability. Instability of the elbow is a continuum, with complete dislocation as its most severe form.Posterolateral rotatory instability is the most common elbow instability and can be detected at imaging both in the acute as well as the chronic phase. Imaging of suspected elbow instability starts with radiographs. Depending on the type of injury suspected, it is followed by magnetic resonance imaging (MRI) or computed tomography evaluation for depiction of a range of soft tissue and osseous injures. The most common soft tissue injuries are tears of the LUCL and the radial collateral ligament; the most common osseous injuries are an osseous LUCL avulsion, a fracture of the coronoid process, and a radial head fracture.Valgus instability is the second most common instability and mostly detected in the chronic phase, with valgus extension overload the dominant pattern of injury. The anterior part of the UCL is insufficient in valgus extension overload due to repetitive medial tension seen in many overhead throwing sports, with UCL damage readily seen at MRI.

Radial Head Arthroplasty for Acute Complex Elbow Instability: A Prospective Long-Term Comparative Cohort Study of Two Implant Designs

The objective of this study was to prospectively compare the long-term clinical and radiological outcomes of two radial head replacement (RHR) designs in the context of complex acute elbow instability.

Medial Ulnar Collateral Ligament Repair With Internal Brace Augmentation: Results in 40 Consecutive Patients.

Background:Medial ulnar collateral ligament (MUCL) repair has been proven to be effective in nonprofessional overhead-throwing athletes, with faster and higher rates of return to play (RTP) than the more traditional Tommy John reconstruction. Biomechanical studies and clinical data suggest that MUCL repair augmented with a collagen-coated internal brace may be an effective treatment option in this patient population.Purpose:To evaluate the functional outcomes of young nonprofessional athletes who underwent MUCL repair with internal brace augmentation for medial elbow instability. The hypothesis was that these patients will have high rates of RTP and improved functional outcomes.Study Design:Case series; Level of evidence, 4.Methods:Nonprofessional overhead athletes treated with MUCL repair with internal brace augmentation between 2015 and 2017 were prospectively evaluated for a minimum of 1 year. Preoperatively, all patients had evidence of medial elbow pain caused by MUCL insufficiency, as confirmed by signal changes on magnetic resonance imaging and valgus instability on arthroscopic examination. These findings did not allow them to participate in their chosen sport or profession, and each patient had failed nonoperative treatment. Postoperative outcomes were evaluated using the Overhead Athlete Shoulder and Elbow Score of the Kerlan-Jobe Orthopaedic Clinic. Complications were recorded and detailed.Results:A total of 40 nonprofessional overhead athletes were included in this study (35 men and 5 women; mean age, 17.8 years [range, 14-28 years]). The mean follow-up time was 23.8 months (range, 12-44 months). The mean postoperative Kerlan-Jobe Orthopaedic Clinic score was 92.6 (range, 64-100). Overall, 37 athletes (92.5%) returned to play or profession at the same level or higher at a mean time of 6.9 months (range, 2-12 months). Three patients did not RTP: 1 was limited by a concomitant medical diagnosis, and the other 2 chose not to resume athletics after the procedure but remained symptom free.Conclusion:In the nonprofessional athlete, primary MUCL repair with internal brace augmentation is a viable alternative to traditional repair techniques or reconstruction, allowing for a rapid RTP and promising functional outcomes.

Tratamiento de la inestabilidad aguda compleja de codo con fijador interno IJS-E System

IntroductionTreatment of acute complex fracture-dislocation of the elbow has been associated with a high rate of complications. Internal Joint Stabilizer of the Elbow (IJSE) device appears as a valid option to optimize and improve our results. Material and methodsWe present a retrospective case series of five patients treated at our institution with IJS-E System (Skeletal DynamicsR) from February 2019 to 2020. Our inclusion criteria was: patients over 18 years old surgically treated with IJS-E due to persistent elbow instability despite of a suitable osteoligamentous surgical repair. ResultsWe obtained a total of five patients (4 males and 1 female) with an average age of 37.4 years old (24-71). The Injury pattern was posterolateral instability, TTIE in all cases. The mean final postoperative MEP score was 94 points (85-100) and the postoperative DASH score was 11.78 points (4.2-20.6) with an average follow-up of 9.8 months (6-12). We described a final arc of motion of 134° with a range of flexionbetween 120° and 140° and a mean lack of extension of 12° (5°-20°), with a complete arc of pronosupination. As complications we found one case of heterotopic ossfication and one case of elbow stiffnes. However, no complications device-related or articular incongruence were reported during follow-up. ConclusionsThe IJS-E device appears as an effective alternative instead of external fixation. Nevertheless, a high rate of reoperation up to 100% is associated with IJS-E. A larger series, longer follow-up and prospective studies are needed to define properly his role in the surgical treatment of acute elbow instability.

Results of Medial and Lateral Elbow Collateral Ligaments Reconstruction with the “Box-Loop” Technique in Eleven Consecutive Cases of Complex Chronic Elbow Instability

Results of Medial and Lateral Elbow Collateral Ligaments Reconstruction with the “Box-Loop” Technique in Eleven Consecutive Cases of Complex Chronic Elbow Instability

Lateral Elbow Laxity Is Affected by the Integrity of the Radial Band of the Lateral Collateral Ligament Complex: A Cadaveric Model With Sequential Releases and Varus Stress Simulating Everyday Activities

Background: An elongation of the radial lateral collateral complex (R-LCL) can provoke symptomatic minor instability of the lateral elbow leading to lateral elbow pain. Biomechanical models investigating the effects of elongation and partial or complete lesions of the R-LCL on lateral elbow stability are lacking. Purpose: To evaluate how partial and complete R-LCL release affects radiocapitellar joint stability in a setting of controlled varus load and progressive soft tissue release. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric specimens were obtained and mounted on a custom-made support to control elbow flexion and extension and to allow for controlled varus loading. Stress tests were performed on all intact specimens under gravity load alone, a 0.5-kg load applied to the hand, and a 1-kg load applied to the hand. After load application, anteroposterior radiographs were obtained. The following release sequence was applied to all specimens: release of the anterior half of the common extensor origin, pie crusting of the R-LCL, and R-LCL release. After each release, stress tests and radiographs were performed. The varus joint angulation of the elbow (α) was measured by 2 examiners as the main outcome parameter. Results: Significant changes in α from the initial condition occurred after each release, and a significant effect of varus load on α was documented for all release steps. A significant effect of the releases on α could be documented for all identical varus load conditions. A linear regression model was generated to describe the effect of varus load on α. Conclusion: Varus loads simulating everyday activities produce changes in the varus joint angulation of the elbow already in the intact specimen, which are linearly dependent on the applied moment and persist after release of the lateral stabilizing structures. With progressive load, a pie crusting of the R-LCL is the minimal procedure able to provoke a significant change in the varus joint angulation, and a complete R-LCL release produces additional increase in the varus joint angulation in all testing conditions. Clinical Relevance: These findings confirm the role of the R-LCL as static lateral stabilizer, supporting a pathological model based on its insufficiency and culminating with a symptomatic minor instability of the lateral elbow.

Novel Radiographic Indexes for Elbow Stability Assessment: Part A\u2014Cadaveric Validation

IntroductionElbow bony stability relies primarily on the high anatomic congruency between the humeral trochlea and the ulnar greater sigmoid notch. No practical tools are available to distinguish different morphotypes of the proximal ulna and herewith predict elbow stability. The aim of this study was to assess inter-observer reproducibility, evaluate diagnostic performance and determine responsiveness to change after simulated coronoid process fracture for three novel elbow radiographic indexes.MethodsTen fresh-frozen cadaver specimens of upper limbs from human donors were available for this study. Three primary indexes were defined, as well as two derived angles: Trochlear Depth Index (TDI); Posterior Coverage Index (PCI); Anterior Coverage Index (ACI); radiographic coverage angle (RCA); olecranon–diaphisary angle (ODA). Each index was first measured on standardized lateral radiographs and subsequently by direct measurement after open dissection. Finally, a type II coronoid fracture (Regan and Morrey classification) was created on each specimen and both radiographic and open measurements were repeated. All measurements were conducted by two orthopaedic surgeons and two dedicated musculoskeletal radiologists.ResultsAll three indexes showed good or moderate inter-observer reliability and moderate accuracy and precision when compared to the gold standard (open measurement). A significant change between the radiographic TDI and ACI before and after simulated coronoid fracture was observed [TDI: decrease from 0.45 ± 0.03 to 0.39 ± 0.08 (p = 0.035); ACI: decrease from 1.90 ± 0.17 to 1.58 ± 0.21 (p = 0.001)]. As expected, no significant changes were documented for the PCI. Based on these data, a predictive model was generated, able to identify coronoid fractures with a sensitivity of 80% and a specificity of 100%.ConclusionNew, simple and easily reproducible radiological indexes to describe the congruency of the greater sigmoid notch have been proposed. TDI and ACI change significantly after a simulated coronoid fracture, indicating a good responsiveness of these parameters to a pathological condition. Furthermore, combining TDI and ACI in a regression model equation allowed to identify simulated fractures with high sensitivity and specificity. The newly proposed indexes are, therefore, promising tools to improve diagnostic accuracy of coronoid fractures and show potential to enhance perioperative diagnostic also in cases of elbow instability and stiffness.Level of evidenceBasic science study.Clinical relevanceThe newly proposed indexes are promising tools to improve diagnostic accuracy of coronoid fractures as well as to enhance perioperative diagnostic for elbow instability and stiffness.

Open Reduction and Internal Fixation of Pediatric Medial Epicondylar Humeral Fractures in the Prone Position.

Fracture of the medial epicondyle is a common pediatric injury, with an estimated annual incidence of 40 to 60 per 100,000 people per year1-3. Medial epicondylar fractures are associated with elbow dislocation in about 60% of cases, and ulnar nerve dysfunction is reported to occur nearly 10% of the time2,4. No standard of care for medial epicondylar fracture exists, as similar outcomes have been demonstrated in observational studies with both operative and nonoperative treatment5,6. Increasingly, however, these injuries are being treated with surgical intervention, which in most cases consists of a single screw affixing the osseous piece back to its donor site on the humerus7-9. There is broad consensus on the absolute indications for operative treatment, including an open fracture and an incarcerated epicondylar fragment1,10-13. The relative indications are more controversial and include ulnar nerve dysfunction, elbow instability, increased fragment displacement, and high-level throwing or upper-extremity weight-bearing athletes2,9,14-16. The patient is placed in the prone position with the operative arm on a radiolucent arm board. A milking maneuver with an Esmarch bandage is utilized. A posteromedial incision is made over the medial epicondyle. The ulnar nerve is protected posteriorly. The fracture is easily reduced under minimal tension, and then 1 or 2 guidewires from the 4.0-mm cannulated screw kit are placed to fix the fragment. The central guidewire is overreamed, and then a partially threaded 4.0-mm screw is placed in a relative posterior-to-anterior trajectory within the medial column of the elbow. Nonoperative treatment includes immobilization in a long arm cast until fragment healing. Complications associated with nonoperative treatment include nonunion and late instability. Supine positioning is a reasonable alternative to the prone position described here. In that case, the fracture is fixed with the arm in external rotation of the shoulder and with the elbow extended. Prone positioning for operative treatment of medial epicondylar fractures is preferred because the tension from the flexor pronator mass associated with supine positioning is negated, facilitating an easier fracture reduction and improved anatomic reduction. To our knowledge, there are currently no Level-I or Level-II prospective studies reporting on the outcomes of operative versus nonoperative treatment of medial epicondylar fractures. A systematic review of retrospective results suggested no difference in pain or clinical outcomes, but >9-times greater odds of union with operative treatment5,6. Expectations following operative treatment of a medial epicondylar fracture have been explored in multiple studies. Generally, return to full levels of activity and near-normal range of motion of the elbow have been demonstrated by most. Minor rates of range-of-motion limitation, including extension deficit (4% with deficit up to 20°) are reported in some studies8. In the setting of preoperative instability, the expectation is that elbow stability will be achieved by operative treatment7,8. Perform and document an accurate preoperative neurovascular examination of the arm.Test the shoulder in internal rotation prior to prone positioning.Protect the ulnar nerve during surgical fixation and drilling.Confirm that the screw trajectory is relatively posterior to anterior and only in the medial column of the elbow.

Ligamentous Reconstruction with Semitendinosus Tendon Autograft for Posterolateral Rotatory Instability of Elbow—a Case Report with an Update of Literature Review

The elbow joint is a comparatively very stable joint owing to the adjacent osseo-ligamentous complex structural integrity around the joint. Posterolateral rotatory instability (PLRI) primarily refers to an injury of the lateral ulnar collateral ligament (LUCL) and the lateral ligamentous complex collectively referred to as the lateral collateral ligament (LCL). PLRI is often a neglected or missed injury, hence remains a relatively rare clinical entity, and reconstruction of the injured ligament is the mainstay of management. A 25-year-old male presented to the orthopedic outpatient department with complaints of post-traumatic instability with dull aching pain over the left elbow for the last 1 year. Varus stress test along with a positive pivot shift test established the clinical diagnosis of posterolateral elbow instability. The LUCL reconstruction was considered using the ipsilateral semitendinosus autograft tendon. At the final follow-up of 1.5 years, the VAS score improved from 8/10 to 1/10 during moderate activities, the Mayo elbow performance score improved from 40/100 to 85/100, and the DASH score was 10.7/100 from preoperative 52.5/100 without any clinical evidence of residual elbow instabilities. The hamstring tendon autograft is a reliable and an easily available option for reconstruction of LUCL owing to its superior inherent graft tensile strength, which helps in improving the elbow instability with minimum effect on donor site morbidities.

Abord entre le muscle ronator teres (rond pronateur) et le fléchisseur radial du carpe pour la fixation des fractures du processus coronoïde de l’ulna

BackgroundThe optimal approach for the fixation of coronoid process fractures is unknown. We present the advantages and the clinical effect of the pronator teres and the flexor carpi radialis interval approach for the treatment of ulna coronoid process fractures. MethodsThe patients who had operative treatment of closed ulna coronoid process fracture by the pronator teres and the flexor carpi radialis interval approach between January 2011 to December 2016 were studied retrospectively. Seventeen consecutive patients had received surgical fixation by screws or a mini-plate through the above approach, of whom 16 males and one female with an average age of 36.7 years (range, 21–58 years). There were 11 cases of type II and 6 cases of type III according to the O’Driscoll classification; of whom 6 patients had combined elbow dislocation, 2 patients showed elbow instability after fixation, 1 had another incision to repair the lateral collateral ligament, and received a hinged external fixator. The other patient only received a hinged external fixator for 4 weeks. Mayo Elbow Performance Score (MEPS) was used to assess the function of elbow for each patient at the final follow-up. ResultsMean follow-up was 28.7 months (range, 24–38 months). Fracture union was achieved in each patient; the average time to radiologic union was 14.2 weeks (range, 12–16 weeks). At the final follow-up, the elbow extension degree of the affected side was (3.88±2.96°), reaching 98.1% of the normal side, and the flexion degree was (131.59±4.93°), reaching 98.16% of the normal side. The forearm pronation was (82.94±3.86°), reaching 94.31% of the normal side, and the supination activity was (82.12±3.82°), reaching 93% of the normal side. According to the MEPS, the functional recovery of the injured arm was assessed as excellent in 16 cases, and good in one. None of the patients showed any neurovascular or deep infections and no heterotopic ossification was found. ConclusionsThe pronator teres and the flexor carpi radialis interval approach has the advantages of simplicity, safety, minimal invasion, excellent exposure, and good postoperative function recovery for ulna coronoid process fracture.

Effect of the medial collateral ligament and the lateral ulnar collateral ligament injury on elbow stability: a finite element analysis

Ligaments are the most important stabilizer of elbow. However, the stress of ligaments is hard to measure because of the complex biomechanical environment in the elbow. Our objective was to develop a human elbow finite element model and to validate it by a comparison with previous experimental data. Then several different ligaments injury conditions and elbow flexion were simulated to analyse the elbow instability and to stress the biomechanical consequences. The computational investigation of different effects of ligament constraints of elbow was studied by means of finite element analysis. The stress of the anterior bundle was almost greater than other ligaments in all conditions, which played the most important role during the elbow flexion. The posterior bundle was the secondary stabilizer during flexion after the anterior bundle. The lateral ulnar collateral ligament (LUCL) injury could result in an increase of the ulnar cartilage stress. The anterior bundle and the LUCL were recommended to be repaired in elbow joint dislocations and fractures. This study could help understand the dynamic effects of ligaments on the joint over the entire extension by investigating the tissue stress.

Complications, Reoperations, and Long-Term Outcomes after Open Reduction Internal Fixation of Mason Classification Type II and Type III Radial Head Fractures

Introduction The objectives of this study were to assess long-term outcomes, complications, and reoperations after open reduction internal fixation (ORIF) of radial head fractures.Materials and Methods 35 adult patients, who underwent ORIF of an isolated, displaced radial head fracture without elbow instability (Mason classification type II or III) at two tertiary care referral centers from 2000 to 2017, were identified. Patient satisfaction, pain, and QuickDASH scores were assessed by telephone follow-up at median 12.9 years.Results The mean age of the 35 patients in our study was 39 years, and 54% were women. The median length of clinical follow-up was 175 days. Postoperative complications occurred in 54% of patients, and reoperations in 23% of patients. Multivariable logistic regression identified fixation with plate and screws versus screws alone as a risk factor for complications and reoperations. The long-term telephone follow-up response rate was 54%. At 13-year median follow-up, the average patient satisfaction was 9.6/10, the average patient-reported pain was 0.7/10, and the average QuickDASH score was 10.5.Conclusion The long-term outcomes of ORIF of Mason classification type II and III radial head fractures are favorable; however, rates of complication and reoperation are notable and may be higher with plate-and-screw fixation.

Trans-olecranon fracture dislocations: How should we treat them?

BackgroundTrans-olecranon fracture dislocations are the least frequent complex elbow instability. Proper surgical treatment should be performed to avoid postoperative complications. MethodsA retrospective design study was performed. Patients that suffered from this injury, treated at our center from 2010 to 2016 were included. Fifteen patients were analyzed. Functional results were measured using DASH, MEPS and VAS scores. Average time from injury to first surgical treatment was 4.87 days. Radial head fracture was present in seven cases and coronoid process in three patients. Most frequent complication was hardware disturbances in five patients. Mean follow up was 3.65 years. ResultsMean range of motion (ROM) was evaluated 1 year postoperatively: 129° flexion, 6° flexion contracture, and less than 5° deficit of pronation/supination. Clinical and functional results are encouraging, DASH 36.38, MEPS 100 and VAS 0.46. ConclusionTrans-olecranon fracture dislocations could obtain functional range of movement, pain relief and good functional outcomes with a standardized protocol of surgical fixation. It is important to achieve proper ulnar fixation, focusing in reestablishing dorsal angulation, and also to treat radial head and coronoid injuries properly, if present.

Midterm Outcomes After Open Arthrolysis for Posttraumatic Elbow Stiffness in Children and Adolescents.

Background:Open arthrolysis is used for treating elbow stiffness in adults. This study evaluated the midterm outcomes after open arthrolysis in children and adolescents with posttraumatic elbow stiffness.Methods:Data of 31 children and adolescents with posttraumatic elbow stiffness following open arthrolysis with or without hinged external fixation from 2010 to 2014 were retrospectively analyzed. Their mean age was 15 (range: 6 to 19) years. At baseline and the follow-up (>4 y), we evaluated the outcomes (range of motion and Mayo Elbow Performance Index) and postoperative complications (pain, ulnar nerve symptoms, infections, and instability) and analyzed the association between outcomes and clinical variables.Results:The Mayo Elbow Performance Index improved from 67.9 (range: 35 to 95 points) to 93.7 points (range: 65 to 100 points; P<0.001). The elbow active flexion/extension arc increased significantly from 49 degrees (range: 0 to 120 degrees) to 108 degrees (range: 0 to 120 degrees; P<0.001), with a mean flexion of 123 degrees (range: 70 to 140 degrees; P<0.001) and mean extension of 15 degrees (range: 0 to 85 degrees; P<0.001) postoperatively. The increasing age at surgery was associated with improved elbow motions (P=0.004). Patients with increased preoperative serum alkaline phosphatase level demonstrated decreased arc of motion (P=0.015). Patients with extra-articular fractures had better outcomes than the other patients. At the final follow-up, 8 patients experienced recurrent contracture in the flexion arc with heterotopic ossification. Two patients had postoperative pain, 1 elbow instability, and 1 ulnar neuropathy.Conclusions:Most patients showed satisfactory functional outcomes after arthrolysis, indicating that open release with or without hinged external fixation is an effective and maintained technique for children and adolescents with posttraumatic elbow stiffness. The age at surgery, preoperative alkaline phosphatase level, and injury type should be considered to achieve good outcomes.Level of Evidence:Therapeutic level III.

Does sonography allow an objective and reproducible distinction between stable, hypermobile, and unstable elbow joints?

The diagnosis of residual or chronic elbow instability is often challenging. Sonography allows a dynamic examination of the elbow joint without any radiation exposure. The purpose of this prospective single-center study was to investigate the application of sonography for the evaluation of ligamentous instabilities of the elbow joint. Therefore, asymptomatic (stable) and acute dislocated (unstable) elbows were examined by sonography. A total of 72 elbows in 36 participants (23 women and 13 men; mean age, 40 ± 17 years [range, 18-82 years]) were examined. Group 1 (G1 [normal]) included 40 unaffected, asymptomatic elbow joints; 28 elbows belonged to 14 voluntary participants (bilateral), whereas 12 asymptomatic elbows belonged to patients who had an acute elbow dislocation (contralateral elbow). Group 2 (G2 [hypermobile]) included 20 hypermobile elbow joints in 10 participants (bilateral), and group 3 (G3 [unstable]) included 12 acute unstable elbow joints without bony lesions. Radiographic assessment included sonography of both elbow joints with standardized measurements of the neutral and stressed radiocapitellar and ulnohumeral distances (calculated as Δ values). Two investigators independently performed all measurements. Additionally, plain radiographs and magnetic resonance imaging of the affected elbow joints were obtained in G3. On the radial side, the mean radiocapitellar Δ was statistically higher in G3 (2.2 ± 1.6 mm) than in G1 (0.5 ± 0.4 mm, P < .01) or G2 (0.8 ± 0.6 mm, P < .01). G3 also showed an increased ulnohumeral Δ (2.7 ± 0.7 mm) compared with G1 (1.0 ± 0.7 mm, P < .01) or G2 (0.9 ± 0.3 mm, P < .01). No significant differences in the mean radiocapitellar Δ (P = .06) and ulnohumeral Δ (P = .26) were found between G1 and G2. Within G3, Δ was significantly higher at the affected elbow joint than at the contralateral, unaffected elbow joint (P = .04 for the radial side and P = .04 for the ulnar side). The inter-rater correlation coefficient was 0.82 for the radial side and 0.74 for the ulnar side. Patients with collateral ligament injuries, diagnosed on magnetic resonance imaging, showed higher Δ values than those with intact collateral ligaments, although no significant difference was found. Sonography of the elbow joint is a valuable imaging tool for the assessment of ligamentous instability. Nevertheless, a distinction between healthy and hypermobile elbow joints is not possible, and therefore, obtaining a complete clinical history and examination is vital. We further recommend comparing the affected elbow joint with the contralateral side to access intraindividual differences.