Pronation-supination Arc Research Articles

Residual Elbow Instability Treated with a Submuscular Internal Joint Stabilizer: Prospective and Consecutive Series with a Minimum Follow-Up of 12 Months.

Background: The management of residual elbow instability is a challenging and compelling issue for treating physicians. To overcome inherent drawbacks of dynamic external fixators, the internal joint stabilizer (IJS) has been developed, achieving successful results, but it can sometimes cause local tenderness or anesthetic concerns in the subcutaneous layer. In addition, a bulky anconeus can pull the hardware away from the axis of rotation with an increase in the lever arm and potential issues. To address these issues, an alternative approach has been recently described in which the internal device is covered by the anconeus muscle, becoming submuscular, rather than subcutaneous. The aim of this study was to evaluate the effectiveness of this alternative approach to the IJS application in maintaining a concentric elbow during and after device removal in both acute and chronic scenarios. Methods: Prospective data collection was performed with consecutive patients who had residual elbow instability treated with an IJS (Skeletal Dynamics, Miami, FL) covered by the anconeus from January 2022 and with a minimum follow-up of 12 months. Results: At a medium follow-up of 16 months, the 16 patients selected had a mean arc of flexion-extension of 123° (range: 0-140°) and a mean pronation-supination arc of 150° (range: 80-80°). The mean MEPS and DASH scores were 90.3 ± 6.2 and 6.3 ± 5.3, respectively. At the last follow-up, elbow stability and concentric reduction were confirmed with radiographic and clinical examinations. Conclusions: With a minimum follow-up of 12 months, the present study supports the safety and efficacy of the internal device in a submuscular layer. The clinical outcomes and the rate of recurrent instability are comparable to those achieved with a classic subcutaneous position. Similarly, the complication rate is not affected, and removal surgery is no more aggressive than the classic approach.

Surgical Treatment and Outcomes of Trans-Ulnar Basal Coronoid Fracture-Dislocations

Trans-ulnar fracture-dislocations of the elbow are complex injuries that can be difficult to classify and treat. Trans-ulnar basal coronoid injuries, in which the coronoid is not attached to either the olecranon or the metaphysis, present substantial challenges to achieve anatomic reduction and stable internal fixation. The purpose of this study was to analyze the outcome of surgical treatment of trans-ulnar basal coronoid fracture-dislocations. Between 2002 and 2019, 32 consecutive trans-ulnar basal coronoid fracture-dislocations underwent open reduction and internal fixation (ORIF) at our institution. Four elbows were lost to follow-up within the first 6 months after surgery and were excluded. Among the 28 elbows remaining, there were 13 females and 15 males with a mean age of 56 (range 28-78) years at the time of injury. The mean clinical and radiographic follow-up times were 37 months and 29 months, respectively. Radiographs were reviewed to determine rates of union, Hastings and Graham heterotopic ossification (HO) grade, and Broberg and Morrey arthritis grade. Union occurred in 25 elbows. Union could not be determined for 1 elbow at most recent follow-up and the remaining 2 elbows developed nonunion of the coronoid. Complications occurred in 10 elbows (36%): deep infection (4), ulnar neuropathy (2), elbow contracture (2), and nonunion (2). There were reoperations in 11 elbows (39%): irrigation and débridement with hardware removal (4), hardware removal (2), ulnar nerve transposition (2), contracture release with HO removal (2), and revision ORIF with iliac crest autograft (1). At most recent follow-up, the mean flexion-extension arc was 106° (range 10-150°), and the mean pronation-supination arc was 137° (range 0-170°). The mean Quick Disabilities of Arm, Shoulder, and Hand score was 11 (range 0-39) points with a mean Single Assessment Numeric Evaluation-Elbow score of 81 (range 55-100) points. At final radiographic follow-up, 16 elbows (57%) had HO (8 class I and 8 class II), and 20 elbows (71%) had arthritis (8 grade 1, 6 grade 2, and 6 grade 3). Trans-ulnar basal coronoid fracture dislocations are severe injuries associated with high rates of reoperation, heterotopic ossification, and post-traumatic arthritis. However, the majority of elbows achieve union, a functional range of motion, and reasonable patient reported outcome measures. Over the study period, surgeons were more likely to utilize multiple deep approaches and separate fixation of the coronoid (either with lag screws or anteromedial plates) to ensure anatomic reduction.

Osteoarthritis of Proximal Radioulnar Joint: Computed Tomography-Based Assessment and Associations with Clinical Findings.

Although many studies have focused on the degenerative changes of the ulnohumeral and radiohumeral joints in osteoarthritis (OA) of the elbow, the proximal radioulnar joint (PRUJ), which facilitates the pronation and supination motions of the forearm, has not been comprehensively evaluated. To assess the prevalence of PRUJ OA in patients diagnosed with OA of the elbow using computed tomography (CT) images and to establish an association between the CT findings and clinical manifestations. Cross-sectional study; Level of evidence, 3. Between 2010 and 2022, a total of 85 consecutive patients who were scheduled to undergo osteocapsular arthroplasty for OA of the elbow and had undergone preoperative CT imaging were included in the study. As a control group, 85 patients who underwent CT scans of the elbow for reasons other than OA of the elbow were selected and matched to patients in the OA group. CT findings of OA in the PRUJ, including osteophytes, joint space narrowing, subchondral cysts, and loose bodies, were evaluated. Inter- and intraobserver agreement analyses for CT findings were performed. The relationship between the CT findings of OA in the PRUJ and OA of the elbow classification systems (Broberg-Morrey, Hasting-Rettig, and Kwak) as well as clinical manifestations (range of motion [ROM], Mayo Elbow Performance Score, and visual analog scale for pain) were evaluated. Patients in the OA group showed osteophytes in the radial notch (81.2%), osteophytes in the radial head (45.9%), joint space narrowing (54.1%), loose bodies (25.9%), and subchondral cysts (23.5%) involving the PRUJ. Both the interobserver (κ = 0.866) and intraobserver agreements (κ = 0.933) for CT findings of PRUJ OA were almost perfect. The CT findings of PRUJ OA were associated with the severity of OA of the elbow in Cochran-Armitage Trend analysis (with Brogberg-Morray, r = -2.624, P = .011; with Hasting-Rettig, r = -3.421, P = .002; with Kwak, r = -2.266, P = .032). The presence of radial notch osteophytes restricted ROM in the flexion-extension arc and pronation-supination arc (P = .009 and P < .001, respectively). PRUJ OA could be identified using CT imaging and showed radial notch osteophytes, joint space narrowing, loose bodies within the joint space, and subchondral cysts. PRUJ OA was related to overall OA of the elbow and may contribute to reduced ROM in the elbow joint. Therefore, preoperative evaluation of PRUJ OA can aid in the surgical planning of osteocapsular arthroplasty for OA of the elbow.

Ulnohumeral Cross-Pinning in the Management of Traumatic Elbow Instability

Traumatic elbow instability (subluxation and dislocation) represents a challenging clinical entity that can be complicated by persistent intraoperative instability after attempted stabilization or recurrent postoperative instability. Both static and dynamic supplemental stabilization procedures have been described for cases where fracture fixation and ligament repair fail to restore stability. There is a paucity of prior studies involving ulnohumeral cross-pinning (UCP), which is a type of static supplemental stabilization. Our purpose was to assess complications and outcomes after UCP. We reviewed all surgical cases involving primary and revision UCP for traumatic elbow instability at a single center from 2017-2023. Baseline demographics were recorded. Outcomes including radiographs, range of motion, patient-reported outcome measures, and surgical complications were analyzed. Fourteen patients undergoing UCP were included with a mean follow-up of 27 months. Five cross-pinnings (36%) were performed during revision procedures. Mean visual analog scale (VAS) pain, Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and the Single Assessment Numeric Evaluation (SANE) scores were 2.4, 34, and 69, respectively. The mean flexion-extension and pronation-supination arcs were 114° and 140°, with 85% achieving at least a 100° arc for flexion and forearm rotation. Five patients (36%) had complications, all of which required reoperation. Two complications involved postoperative instability: one radial head subluxation and one radial head dislocation. Both occurred in revision UCP cases indicated for recurrent postoperative instability. Ulnohumeral cross-pinning for persistent and recurrent elbow instability results in maintained ulnohumeral joint alignment, functional arcs of elbow range of motion, and acceptable patient-reported outcome measures, particularly in the setting of a primary procedure indicated for persistent intraoperative instability. Ulnohumeral cross-pinning is a reasonable supplemental stabilization procedure for complex elbow instability. Therapeutic IV.

Clinical Outcomes and Management Strategies for Capitellum and Trochlea Fractures: A Systematic Review.

Capitellum and trochlea fractures, also referred to as coronal shear fractures of the distal humerus, are infrequent yet challenging intra-articular fractures of the elbow. There are a variety of surgical approaches and fixation methods with often variable outcomes. This systematic review investigates interventions, outcomes and complications of capitellum and trochlea fractures. A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the clinical outcomes of capitellum and trochlea fractures managed surgically. Data on patient demographics, surgical approach, implant usage, postoperative outcomes and complications were compiled. Forty-one studies met the inclusion criteria with a total of 700 patients. Surgical interventions primarily utilized either the lateral (79%) or antero-lateral (15%) approaches with headless compression screws as the most common fixation method (68%). Clinical outcomes were measured using the Mayo Elbow Performance Index (MEPI) with a mean score of 89.9 (±2.6) and the DASH score with a mean of 16.9 (±7.3). Elbow range of motion showed a mean flexion of 126.3° (±19.4), extension of 5.71° (±11.8), pronation of 75.23° (±12.2), and supination of 76.6° (±9.8). The mean flexion-extension arc was 113.7° (±16.9), and the mean pronation-supination arc was 165.31° (±9.41). Complications occurred in 19.8% of cases, with re-interventions required in 8.3% of cases, mainly due to symptomatic implants and elbow stiffness requiring surgical release. Other complications included implant removal (10.4%), overall reported stiff elbows (6%), nerve palsies (2%), non-union (1.5%), and infection (1.2%). The treatment of capitellum and trochlea fractures yields satisfactory outcomes but has a considerable rate of complications and reoperations primarily due to symptomatic implants and elbow stiffness. There is noteworthy variability in the achieved range of motion, suggesting unpredictable outcomes. Deficits in functionality and range of motion are common after surgery, especially with more complex injury patterns.

Locking plate fixation in comminuted coronoid fractures with partial loss of the articular cartilage – Of basal-1 type according to the O'Driscoll classification –

BackgroundWe have attempted to restore the arc of motion by considering trochlear-coronoid articulation as a complete circle during fixation of the coronoid, even for comminuted coronoid fractures with partial loss of articular cartilage (CCFPLAC), using various kinds of locking plates. Herein, we report the radiological and clinical outcomes after fixation of the basal-1 type of CCFPLAC (O'Driscoll classification) using our method. MethodsThirty-one patients diagnosed with CCFPLAC were admitted between January 2012 and December 2020. Sixteen of these patients met the inclusion/exclusion criteria and were enrolled in this study. Surgically, the lost area (defect of articular cartilage) was never compressed or minimized, but the original height and shape of the coronoid were preserved as is. Provisionally, a few K-wires were used to maintain the original shape and position of the CCFPLAC, and various kinds of locking plates/screws were used to fix the fragment anatomically and firmly. If needed, the plate was bent to ensure stable compression of the coronoid according to its size. In a few cases, locking plates were adjusted by cutting extra screw holes. ResultsAmong the 16 patients, the mean age was 46.2 years, and the male:female ratio was 10:6. The mean follow-up period was 3.63 years. 8, 6, and 2 patients were designated as group 1 (isolated CCFPLAC), 2 [CCFPLAC in type 4 (terrible triad) injury), and 3 (CCFPLAC in type 5 posterior olecranon fracture-dislocations), respectively. Complete union was achieved after a mean of 8.94 weeks. The mean flexion-extension and pronation-supination arcs were 127.19 ± 4.46° and 135.31.59 ± 8.06°, respectively, which were significantly different from those on the contralateral (normal) side (p < 0.001); however, the arcs were within the functional ranges for ordinary daily living. Additionally, the functional status was satisfactory in all patients. However, Mayo Elbow Performance Score and the degree of arthritis were statistically poor in group 2. ConclusionsCCFPLAC of the basal-1 type (O'Driscoll classification) can be treated satisfactorily if already designed and widely distributed locking plates are properly manipulated to maintain the original geometry of the coronoid according to the individual joint characteristics. Level of evidenceLevel IV, Retrospective case series

Clinical outcomes of olecranon sled fixation in patients with Mayo type II olecranon fractures

BackgroundTension band wiring and plate fixation are common internal fixation methods used for olecranon fractures, but complications and reoperations are common. The purpose of this study is to investigate the clinical outcomes of displaced olecranon fractures treated with olecranon sled internal fixation. MethodsThe data of 39 patients with olecranon fractures treated with olecranon sled in the Department of Traumatology of Beijing Jishuitan Hospital between May 2018 and April 2020 were retrospectively analyzed. There were 17 males and 22 females; the mean age was 44.0 ± 15.8 (range, 18–68 years). Preoperative olecranon fractures were classified according to the Mayo classification: 24 cases were type IIA and 15 cases were type IIB. Elbow range of motion (extension and flexion) and forearm rotation (protonation and supination) were observed at the last follow-up. The Mayo elbow performance score (MEPS), Disabilities of the arm, shoulder and hand (DASH) and visual analogue scale (VAS) scores were used to evaluate elbow function and pain, and complications were also recorded. ResultsThirty-nine patients were followed up for 33.6 ± 8.3 months (range, 25–51 months) after the operation. At the last follow-up, the mean flexion-extension arc was 137° ± 15° (range, 60°–160°), and the mean pronation-supination arc was 178° ± 4° (range, 160°–180°). The mean MEPS was 94.9 ± 9.9 (range, 50.0–100.0). The mean DASH score was 5.4 ± 4.3 (range, 0–18.3). The mean VAS score was 0.4 ± 0.8 (range, 0–3). Seven patients developed olecranon skin irritation, and 3 of them had the internal fixation device removed. Two patients developed heterotopic ossification, of whom 1 patient suffered elbow stiffness. ConclusionOlecranon sled internal fixation has good clinical outcomes in the treatment of Mayo type II olecranon fractures with a low rate of reoperations.

A clinical review of elbow ligament repairs and reconstructions in the acute and chronic settings

BackgroundThe ligamentous and osseous structures of the elbow joint are the major contributors to its inherent stability and damage to any of these structures can result in elbow instability. The aim of this study is to present objective and subjective outcomes following ligament repairs and/or reconstructions for acute elbow instability and chronic elbow instability. MethodsThis study included patients who underwent an elbow ligament repair and/or reconstruction for acute or chronic elbow instability. We performed a comprehensive retrospective data analysis of the patient's files, followed by a clinical examination and X-ray of these patients. ResultsWe identified 12 acute stabilizations and 22 stabilizations for chronic instability. Patients who underwent a stabilization for chronic instability had statistically significant improvements in their preoperative flexion and extension; 14.8 ± 6.4° and 5.9 ± 2.5°. Patients with chronic instability achieved better extension-flexion and pronation-supination arcs compared with their acute instability counterparts and this reached statistical significance. When the elbow pain and function scores were compared, we found stabilizations in the acute setting had better outcomes. There were two cases of postoperative instability, one in the acute instability group and one in the chronic instability group. ConclusionThis study provides evidence for elbow ligament repairs and reconstructions in both acute and chronic settings. It is an effective way of stabilizing the elbow joint in chronic instability patients, and results in an improvement in their overall range of motion. These patients achieved a greater range of motions compared with their acute instability counterparts.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating roomfor stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Certain fracture patterns in children/adolescents would be better called 'Barton equivalent' fractures.

We have encountered consecutive children/adolescents with a volar Barton fracture (VBF) pattern without involving the physis. These were managed by buttress plating; thus, we would like to report the radiological and clinical outcomes through retrospective case series and suggest the revisiting of the 'VBF category' in this population. We screened children/adolescents with a diagnosis of trauma to the bony structures in the wrist from 2008 to 2019. Of these patients, 16 who met our inclusion/exclusion criteria were investigated. At the final follow-up performed at least 2 years postoperatively, radiologic and clinical outcomes were evaluated. The mean age at the time of injury was 12.88 years old. At the final follow-up, the volar tiltings, radial inclinations and ulnar variances were 10.13°, 20.88° and -0.50 mm, respectively. None of these radiologic parameters were significantly different from the contralateral values, except the radial inclination. The mean visual analog scale score was 0.38. The mean range of motion arcs were 136.56° and 157.81° in the flexion-extension and pronation-supination arcs, respectively, and the grip strength was 22.00 kg. The mean modified Mayo Wrist Score was 92.8. The radiologic and clinical outcomes compared with the contralateral side were not significantly different from those in a previous report. A VBF pattern without involving the physis in the child/adolescent population was treated satisfactorily by buttress plating. Thus, including the previously reported 'SH-II in sagittal plane' injuries, the current injury pattern would be better called a 'Barton equivalent' fracture. Level of Evidence: Level IV, retrospective case series.

Minimally invasive percutaneous screw internal fixation under robot navigation for the treatment of a hamate bone fracture

PurposeHamate fractures are rare fractures of the wrist and there is still no consensus on the optimal treatment for these fractures, especially hook of hamate fractures. Herein, the authors present a case study of a series of patients who were treated with closed reduction and minimally invasive percutaneous fixation under robot navigation.MethodsThis retrospective study reviewed 14 patients who had nondisplaced or minimally displaced hamate fractures on computerized tomography images and were treated using the treatment in our centre from November 1, 2019, to October 31, 2022. At the final follow-up, the flexion-extension and radial-ulnar range of motion of the wrist were measured, and the grip strength and pinch strength were measured. The pain of the wrist was assessed using the visual analogue scale (VAS). The Mayo wrist score reflected the recovery of the wrist.ResultsThe mean total operative duration was 40.1 min. All the fractures showed union at a mean of 3.0 months. At a mean follow-up of 23.3 months (range 6–36 months), the mean VAS score was 0.7, the average Mayo wrist score was 95, and the mean pinch strength and grip strength were 11.3 and 38.7 kg, respectively. The flexion-extension arc was 138.3°, the mean radial and ulnar deviation arc was 63.8°, and the mean pronation-supination arc was 172.3°. And the time of return to the original occupation was mean 4 months (3~6 months). There were no complications, such as infection or nerve paralysis.ConclusionsThis study suggests that nondisplaced or minimally displaced hamate hook fractures can be successfully treated by closed reduction and internal fixation with a headless compression screw with the assistance of robot navigation, and the small fragment of fracture can be accurately fixed with minimal iatrogenic injury.

Comparing the outcomes of tripod technique and locked plate fixation for the treatment of Mason type 3 radial head fractures.

In this study, we aimed to compare functional outcomes and complication rates of tripod technique and locked plate fixation used in Mason type 3 radial head fractures. Between January 2012 and December 2019, a total of 27 patients (16 males, 11 females; median age: 43.2 years; range, 20 to 68 years) with Mason type 3 radial head fractures were retrospectively analyzed. The patients were divided into two groups according to fixation method used. Group 1 consisted of 12 patients who were treated with tripod technique, and Group 2 consisted of 15 patients who were treated with locked plate fixation. Operation time, follow-up period, length of hospital stay, union time, Disabilities of Arm, Shoulder and Hand (DASH) scores, range of motions and complications were recorded. The median time to bone union was 46.7 days in Group 1, which was significantly shorter than Group 2 (p<0.001). The median forearm pronation-supination arc was 123.75° (range, 30° to 180°) in Group 1 and was 94° (range, 45° to 180°) in Group 2. There was no significant difference in the forearm rotation between the groups. The median elbow flexion-extension arc was 99.17° (range, 65° to 130°) in Group 1 and was 80.33° (range, 30° to 130°) in Group 2. No statistically significant difference was found in the flexion-extension and pronation-supination arc degrees. There was no significant difference in the postoperative DASH scores between the groups (p=0.464). Our study results demonstrate that comparable results can be achieved in both techniques regarding functional outcome and range of motion. With a shorter union time and less complication rates, the tripod technique should be considered as the primary treatment method for the comminuted radial head fractures without a metaphyseal defect.

Primary Hinged External Fixator for Complex Fracture Dislocations of the Elbow (Systematic Review/Meta-Analysis)

Background High-energy and fracture dislocations with compromise of the medial and lateral ligamentous complex, the joint capsule, and potentially the tertiary stabilizers (i.e., the flexor pronator, extensor supinator masses, and brachialis) often demonstrate residual instability after osseous and ligamentous stabilization. The optimal management of a complex elbow injury should results in restoring joint stability and its full range of motion. However, this is often difficult to achieve by surgical means and a marked restriction of movement remains a frequent con- sequence of severe elbow injury. Aim of the Study The aim of this study is to discuss the results of using a lateral hinged external fixator as an adjunct stabilizer in the treatment of a variety of acute destabilizing elbow injuries as a primary method of fixation not only in chronic or complicated cases. Patients and Methods Types of studies: Randomized controlled trials, including cluster RCTs, controlled (non-randomized) clinical trials or cluster trials, prospective and retrospective comparative cohort studies, and case-control or nested case-control studies. Types of participants: Only studies on human subjects with acute complex elbow fracture dislocation treated by hinged elbow external fixator. Types of interventions: Surgical treatment of acute complex elbow fracture dislocation with hinged external fixation of elbow. Types of outcome measures: Operative details, intra and postoperative complications and final clinical outcome. Literature searches will be conducted using the following databases:” PubMed, Ovid, Web of Science, ScienceDirect, Scopus, Cochrane Library, Google Scholar, Medline” using the following Keywords: acute complex elbow fracture dislocation, hinged external fixator, unstable elbow, terrible triad and long term for published studies from 2010-2021. Results Regarding studies done on the use of a lateral hinged external fixator on the elbow for complex fracture dislocation which are numerous in the last 11 years, we have reviewed the most applicable studies in our review. Regarding the mean flexion-extension arc and pronation-supination arc, the results were 121.5 º and 81 º respectively. Regarding the complications, wound infection was found in 10 patients out of 69 cases (14.4%) including pin tract infection and ORIF wound infection. Secondary humeral and ulnar shaft fractures were found in 3 patients out of 69 cases (4.3%) as a recognized complication of the shanz screws application in both humerus and ulna. Another complication founded was elbow joint incongruity in 5 patients among 69 cases (7.2%) which leads to series consequences like arthritis, progressive pain and instability. Instability as a postoperative complication was found in 1 patient out of 69 cases (1.4%) which shows the huge effect of adding a hinged external fixator to the ORIF construct. In fact, this was the only reason to add a hinged external fixator in the past where it was used in cases of recurrent and chronic instability. Non union was found in 2 patients out of 69 patients (2.8%) while heterotrophic calcification was found in 8 patients out of 69 cases (11.5%). Iordens et al in 2015 was the only paper to calculate the quick-dash score where among 27 patients the score were 30 at 6 weeks and 7 at 1 year. Regarding the mayo elbow performance score (MEPS), among the 69 patients 21 patients (30.4%) were not affiliated while the score was poor in 1 patient (1.4%), fair in 7 patients (10.1%), good in 18 patients (26%) and excellent in 22 patients (31.8%) which shows that above 50% of cases where good to excellent showing the effect of early protected range of motion gained by the addition of a hinged external fixator. Conclusion The best management for complex elbow fracture dislocations is still controversy but the additional use of a hinged external fixator to the ORIF repair shows better outcomes as described.

Dumontier group 2 radiocarpal fracture-dislocation: The results of open reduction and fixation without volar ligament repair

IntroductionThe radiocarpal fracture-dislocations are a spectrum of severe injury involving both the bony and ligamentous structures that stabilise the wrist joint. The aim of this study was to analyse the outcome of open reduction and fixation without volar ligament repair for Dumontier group 2 radiocarpal fracture-dislocation and to evaluate the incidence and clinical relevance of ulnar translation and advanced osteoarthritis. Patients and methodsWe retrospectively reviewed 22 patients with Dumontier group 2 radiocarpal fracture-dislocation treated in our institute. Clinical and radiological outcomes were recorded. Postoperative visual analogue scale (VAS) score for pain, Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH), and Mayo modified wrist scores (MMWS) were collected. Furthermore, extension‒flexion and supination‒pronation arcs were collected by reviewing chart, either. We divided the patients into two groups according to the presence or absence of advanced osteoarthritis, and presented the differences in the pain, disability, wrist performance, and range of motion between the two groups. We performed the same comparison between the patients with and those without the ulnar translation of the carpus. ResultsThere were sixteen men and six women with a median age of 23 years (range, 20‒48 years). The median follow-up period was 33 months (range, 12–149 months). The median VAS, DASH and MMWS were 0 (range 0–2), 9.1 (range, 0–65.9) and 80 (range, 45–90), respectively. The median flexion‒extension and pronation‒supination arcs were 142.5° (range, 20°‒170°) and 147.5° (range, 70°‒175°), respectively. Ulnar translation was recognised in four patients and the development of advanced osteoarthritis was noted in 13 patients during the follow-up period. However, neither was highly correlated with functional outcomes. ConclusionThe current study postulated that ulnar translation might occur following treatment for Dumontier group 2 lesions, whereas injury was predominantly caused by rotational force. Therefore, radiocarpal instability should be recognized during the operation. However, the clinical relevance of ulnar translation and wrist osteoarthritis needs to be assessed in further comparison studies.

The Clinical Outcomes of Radiocapitellar Reconstruction With Radiocapitellar Arthroplasty: A Systematic Review and Meta-Analysis.

Radiocapitellar arthroplasty fills a treatment void for young patients who experience isolated capitellar fractures or radiocapitellar osteoarthritis who are not candidates for total elbow arthroplasty. The outcomes of this procedure are sparsely reported. We designed a meta-analysis to determine the utility of radiocapitellar arthroplasty with respect to functional and patient reported outcomes. The PubMed database was searched for relevant studies. Only studies published in English language that assessed patient reported outcomes following radiocapitellar arthroplasty were included in this study. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses for 2020. The initial review yielded 562 studies that met the criteria. After excluding duplications and confounding factors, eight case series were identified for review. Of the eight studies, seven were eligible for inclusion in the meta-analysis for Mayo Elbow Performance Score, flexion-extension arc, and pronation-supination arc. The pooled standard mean difference was found to be statistically significant between pre-operative and post-operative outcomes for Mayo Elbow Performance Score (SMD = 3.04, 95% CI [2.40, 3.67]), flexion-extension arc (SMD = 1.28, 95% CI [0.73, 1.83]), and pronation-supination arc (SMD = 0.81, 95% CI [0.43, 1.18]). Cochran's Q-test and I2 statistics indicated statistically significant heterogeneity for Mayo Elbow Performance Score (p = .04, I2 = 54%) and flexion-extension arc (p < .01, I2 = 67%). Patients undergoing radiocapitellar arthroplasty showed statistically significant improvements in flexion-extension arc, pronation-supination arc, and Mayo Elbow Performance Scores compared to pre-operative measures.

Ulnar shortening osteotomy for posttraumatic ulnar impaction syndrome in adolescent (younger than 18 years) - Based on the Cha & Shin assessment -

PurposeWe performed ordinary ulnar shortening osteotomy (USO) in patients younger than 18 years old with secondary ulnar impaction syndrome (UIS) after traumatic events. Here, we report the clinical and radiologic outcomes with a review of the previous literature through a retrospective case series. MethodsTwenty-two adolescents treated by USOs from 2006 to 2018 were investigated. The amount of shortening was classified into three categories. The first category was for a still open physis on the medial half of the radius in those younger than 15. In this category, we osteotomized the ulna for the physis level to be left neutral or negative by 1–2 mm. The second category had no growth potency in the radius. If the patient was younger than 15, we considered only residual growth of the ulna, thus performing USO for the ordinary UV to be negative by 2–3 mm. For patients aged 15–18 years old, if growth potency was nearly absent in the ulna, we performed traditional USO with a neutral ulnar variance (UV). ResultsCategories 1, 2, and 3 for the amount of USO were determined for 4, 4, and 14 patients, respectively. All USOs properly healed without substantial complications. The mean preoperative UV was 2.91 mm, and the final value decreased to 0.23 with statistical significance (p < 0.001). The range of wrist motion was improved after USO from 133.86° and 132.73° to 154.77° and 160.68° (all, p < 0.001 in flexion-extension and pronation-supination arcs, respectively). The preoperative VAS and MMWS scores also improved from 2.77 to 75.00 to 0.18 and 88.86, respectively, at the final follow-up (all, p < 0.001). ConclusionsUIS in adolescent populations after trauma in their children/younger adolescents could be properly treated by USO. Even with an open physis at the ulna, neutral UVs could be achieved, and the clinical outcomes were satisfactory. However, long-term follow-up is still needed regarding TFCC and DRUJ status. Level of evidenceLevel IV, retrospective case series

Three-Dimensionally Planned and Printed Patient-Tailored Plates for Corrective Osteotomies of the Distal Radius and Forearm

We evaluated the 1-year postoperative clinical and patient-reported outcomes in patients who had a 3-dimensional planned corrective osteotomy of their distal radius, radial shaft, or ulnar shaft using a printed, anatomical, patient-tailored plate to determine the feasibility and effectiveness of this methodology. Simulations in computer-assisted preoperative planning of corrective osteotomies resulted in 3-dimensionally printed surgical guides, surgical models, and anatomically customized plates for application at the distal radius and forearm. Patients with malunions of the distal radius or forearm who underwent fixation with the custom-made plates were documented in our registry. Grip strength and range of motion assessments were made before surgery (baseline), as well as at 6 weeks and 3 and 12 months. Additionally, patients rated their wrist-related pain and disability using the Patient-Rated Wrist Evaluation. Fifteen patients underwent corrective surgery, and the 1-year follow-up data of 14 patients with a median age of 56 years (interquartile range, 24-64 years) were available for analysis. The median baseline Patient-Rated Wrist Evaluation score improved from 47 to 7 after 1 year. The flexion-extension arc of motion of the wrist increased from 90° at baseline to 130° at 1 year and the pronation-supination arc of motion of the wrist increased from 135° to 160° in the same time period. Differences in radiological measurements for palmar and radial inclinations, as well as for ulnar variance between the affected and contralateral wrists, were reduced with the osteotomy. In 1 case, the plate was removed 11 months after the osteotomy. No severe adverse events were reported. Three-dimensionally planned and printed patient-tailored plates offer a reliable method for correcting even complex malunions of the distal radius and forearm. Therapeutic IV.

Learning Curve Associated With Operative Treatment of Terrible Triad Elbow Fracture Dislocations.

Purpose: To assess the outcomes of operatively treated terrible triad (TT) elbow injuries for a single surgeon at the start of clinical practice. We aimed to define postoperative patient reported outcome measures (PROMs), range of motion (ROM), and complications during the period immediately following fellowship training, in order to describe the learning process for surgical treatment of TT. Methods: All operatively treated TTs from 2017 to 2020 were included. All cases were performed by a single, fellowship-trained upper-extremity surgeon and represented a consecutive series at the start of clinical practice. Baseline demographics, injury characteristics, and surgical details were recorded for each case. PROMs [QuickDisability of arm, shoulder, and hand (DASH) and (visual analog scale) pain scale], ROM, and complications were recorded at the time of final follow-up. A perioperative glucocorticoid protocol was used in all cases without diabetes.Results: There was a total of 21 included TT cases with a mean follow-up of 20 months. The operative time averaged 89 min for the first 10 cases and 83 min for the subsequent 11 cases. The mean QuickDASH and VAS pain score at final follow-up were 19 and 2.3, respectively. The mean flexion-extension arc was 122° and two cases (9%) had < 100° arc of motion. The mean pronation-supination arc was 145°. Three cases (14%) had a postoperative complication, all of which underwent reoperation. Of the 21 included cases, these reoperations represented cases #1, #14, and #17 respectively. Conclusions: Upper-extremity surgeons at the start of clinical practice may be able to achieve outcomes similar to more experienced surgeons for operatively treated TT elbow fracture dislocations. There does not appear to be a substantial “learning curve” after fellowship training with respect to PROMs, complication rates, or operative time associated with surgical treatment of TT elbow injuries.

Does stress shielding after radial head arthroplasty affect functional outcomes?

Various complications related to the prosthesis, such as implant loosening and stress shielding phenomenon, could develop after prosthetic replacement of the radial head. Stress shielding is known to occur around rigidly fixed implants. The purpose of this study was to evaluate the clinical influence and causative factors of the stress shielding phenomenon after radial head arthroplasty (RHA). Clinical records and radiographs of 56 patients with unreconstructable radial head fractures who received radial head replacement between 2009 and 2019 were reviewed. Exclusion criteria were infection, loosening, and follow-up of less than 24months. After exclusion, 35 patients were enrolled. Patients were divided into two groups: an anatomical press-fit group (Anatomical Radial Head System; Acumed, Hillsboro, OR, USA) and a round bipolar cemented group (RHS; Tornier, Montbonnot Saint-Martin, France). Stress shielding around the prosthesis was assessed in the serial radiological examination. Clinical results were assessed using Mayo elbow performance score (MEPS), Quick Disabilities of the Arm, Shoulder, and Hand (q-DASH) score, range of motion (flexion-extension arc and pronation-supination arc), and visual analog scale score (VAS). Correlations between stress shielding phenomenon and demographic data and functional results were analyzed. At an average follow-up of 43.06 (± 14.6)months, 14 (40%) out of 35 fixed stems demonstrated stress shielding. Our results showed that the rate of stress shielding was significantly higher in cases with a bilateral ligament injury and in the anatomical press-fit group (p = 0.028 and p = 0.0091, respectively). However, stress shielding around prostheses did not affect the clinical results (p > 0.05). The stress shielding phenomenon around radial head prosthesis may vary according to prosthetic design and severity of ligament injuries. Stress shielding does not affect the mid-term outcomes in the treatment of acute fractures of the radial head. Retrospective Cohort Comparison; Treatment Study.

Olecranon With Concomitant Radial Head Fracture: A Case Series of Fifteen Patients.

IntroductionSimultaneous olecranon and radial head fractures are rare injuries and due to this factor, the outcome of the selected therapy is not widely studied. The aim of this study is to report and evaluate the functional outcome of the surgical treatment of simultaneous olecranon and radial head fractures.Materials and MethodsThis is a retrospective study of fifteen patients with concomitant olecranon and radial head fractures presenting to our orthopedic department between 2015 and 2020. Olecranon fractures were classified by Mayo classification and radial head fractures by Mason classification and were managed appropriately. Main outcome measures include range of elbow extension-flexion, pronation-supination, Broberg and Morrey rating system score, and quickDASH score.ResultsOur study included 6 females and 9 males with a mean age of 50 (r, 25–73). The mean of follow-up was 31 months (r, 3–51). Olecranon fractures were fixed with tension band with K-Wires or intramedullary compression screw or locking plate. Radial head fractures were fixed with headless compression screws or mini plate or replaced (radial head arthroplasty). Postoperatively, an average 115° extension-flexion arc and 135° pronation-supination arc was noted. The mean Broberg and Morrey rating system score was 78 and the mean quick DASH score was 25, indicating a good result. Two cases of heterotopic ossification were present and no nonunion was noted.ConclusionSurgical management of concomitant olecranon and radial head fractures with appropriate technique can result in the restoration of a functional movement arc and a satisfactory outcome.