Triceps-reflecting Anconeus Pedicle Approach Research Articles

Percutaneous elevation of radial head fractures without fixation - a promising technique.

The aim of the study is to describe the surgical technique and to report the outcomes of triceps reflecting anconeus pedicle (TRAP) approach for intercondylar fractures of the humerus. Twenty two patients with intercondylar fractures of the humerus were operated on by open reduction via the TRAP approach and internal fixation with dual precontoured locking plates. Data were collected on union time, postoperative complications, range of motion (ROM), triceps power, and objective clinical measurement. All fractures were united with a mean union time of 16.5 weeks (range 12-22). All patients had good-to-excellent Mayo Elbow Performance (MEP) score results with a mean ROM of 118.2 degrees (range 90-135). Triceps power was grade 5 in 16 patients and grade 4 in 6. There were 3 transient ulnar nerve palsy and 1 heterotopic ossification. TRAP approach is safe and effective in terms of utility for articular reduction, restoration of elbow motion, and triceps function for intercondylar fractures of the humerus.

Evaluation of outcome in arc of motion of elbow after arthrolysis in post-traumatic stiff elbow through posterior triceps reflecting anconeus pedicle approach

Background: The elbow is a synovial hinge joint, with a high chance of stiffness. A stiff elbow is an elbow with a loss of extension of >30° and flexion of <120 which can result due to post-traumatic events around elbow. Surgical intervention is required if conservative treatment fails. The arthrolysis of the elbow by posterior approach has been reported less widely. Aims and Objectives: This study aims at reporting the arc of motion of the elbow after arthrolysis by posterior approach by TRAP approach. Material and Methods: This study was done on 26 patients with post-traumatic elbow stiffness through posterior triceps reflecting anconeus pedicle graft approach. The mean age of patients in our study is 30.8, ranging from 15 to 54 years. After surgery, patients were reviewed to assess arc of motion and fixed flexion deformity (FFD) improvement, MAYO and oxford score. Results: Our study showed increase in arc of motion from 50.7° to 90.7°, FFD decrease from 31.3° to 18.2° and MAYO score which had a pre-operative mean of 77.3, increased to 90 postoperatively with excellent result in 18 cases (69.2%) and good in eight cases (30.8%). Oxford score had an improvement from 21.8 to 40.3 showing satisfactory result in 11 cases. Conclusion: The approach described in our study is ideal for posterior bony blocks with maintaing intact extensor mechanism and less chance of neurovascular damage. Stability of the joint is maintained with feasability to do ulnar nerve transposition.

A Study comparing Olecranon osteotomy with Triceps reflecting anconeus pedicle approach (TRAP) for internal fixation of supracondylar and intercondylar fractures of the humerus

Objective: To evaluate the outcome of the Olecranon osteotomy approach and TRAP (triceps reflecting anconeus pedicle) approach and comparing them, attributable to Mayo Elbow Performance Score, range of motion, duration of fracture union and duration of surgery. Studydoneat: Government Medical College, Ratlam, MP, India Method and Material: The study is a retrospective randomized control trial on patients with intercondylar and supracondylar fractures of humerus admitted and operated in Department of Orthopaedics, Government medical college and District Hospital, Ratlam from July 2019 to September 2020. Total of 30 patients was included in the study, 15 in each group viz. Group-A operated by TRAP approach and Group-B operated by olecranon osteotomy approach. Results: The difference in Mean duration for fracture union was not statistically significant, in group-A was 12.21 ± 1.621 weeks, while it was 13.46 ± 2.307 weeks in group-B. Duration of surgery was statistically significantly different, more in group B (1.42 ± 0.14 hours) compare to group-A (1.21 ± 0.21 hours). Comparison between ranges of motion of both groups was assessed by Average of extension lag, the mean elbow arc of motion and average of flexion. No significant difference was found between the parameters. The average of extension lag was 11.96 ± 9.26 degree in group-A and it was 16.77 ± 10.31 degree in group-B. The mean elbow arc of motion in group A was 98.34 ± 24.17degrees and in group B was 91.25 ± 21.84 degrees. Average flexion was 109.71 ± 16.65 degrees and 111.47 ± 20.37degrees in group-A and group-B respectively. The average Mayo Elbow Performance Score in group-A was 86.93 ± 12.42 and in group-B was 83.48 ± 15.93. P-value was >.05 show that there was no statistically significant difference between two groups Mayo elbow score. Finally, 25 patients (83.33%) out of 30 showed good and excellent results and hence concluding that there is no statistically significant difference between these two modalities when it comes to outcome. Conclusion: TRAP approach is comparatively better than osteotomy approach in terms of stable fracture fixation and better outcome, with the advantage of intact olecranon. However the approach demands fast rehabilitation. Design: Prospective randomized control trial

Clinical comparison of management of intra-articular distal humerus fractures with two surgical approaches; TRAP vs Olecranon osteotomy

Background: The aim of this study is to evaluate and compare the functional outcomes of patients with intra-articular distal humerus fractures treated with triceps-reflecting anconeus pedicle (TRAP) and olecranon osteotomy. Methods: Thirty three patients with intra-articular distal humerus fractures were retrospectively analysed. TRAP approach was used in 17 patients (10 males, 7 females; mean age 35.9 years, range 17-70), and olecranon osteotomy in 16 patients (11 males, 5 females; mean age 34.4 years, range 18-62). Fractures were classified using the AO/ASIF classification. Functional results were evaluated with the Mayo elbow performance score (MEPS) and the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score. Results: The overall mean arc of elbow motion was 108° (range 70°-140°) in the TRAP group, whereas that of the olecranon osteotomy group was 102° (range 70°-130°). There were no significant differences noted between the two groups in terms of mean MEPS and DASH scores (p=0.318, p=0.236, respectively). The overall complication rate was 41.17% in the TRAP group and 56.25% in the olecranon osteotomy group. Conclusion: Intra-articular distal humerus fractures mandates surgical fixation for best functional outcomes. Both TRAP and olecranon osteotomy approaches can be used in the treatment of intra-articular distal humerus fractures. Both approaches yields no significant difference in clinical and functional results for intra-articular distal humerus fracture management.

Articular Exposure between Triceps Reflecting Anconeus Pedicle (TRAP) Approach and Olecranon Osteotomy Approach

OBJECTIVES: To compare percentage of articular exposure of distal humerus between triceps-reflecting anconeus pedicle (TRAP) approach and olecranon osteotomy approach. MATERIAL AND METHODS: 10 fresh cadaveric elbows were randomly allocated into 2 groups. Group 1 (5 elbows) was assigned for olecranon osteotomy approach. Group 2 (5 elbows) was assigned for TRAP approach. After surgical exposures were done, the visible articular surface of distal humerus was painted with oil-based yellow color. Subsequently, all dissected elbows were disarticulated. The remaining invisible articular area was painted with oil-based blue color. A square mesh net was firmly wrapped around the painted articular surface. The number of squares was counted and calculated into percentage of articular exposure. Median was calculated and compared among both groups. RESULT: The olecranon osteotomy exposure group offers median of articular exposure at 57.69%. TRAP exposure group offers 47.45% with statistical significance in the difference between two approaches (Mann-Whitney U test, p = 0.028, 95% CI = 2.1 to 15.9) CONCLUSION: The olecranon osteotomy exposure offers more articular visualization compared with the TRAP approach with statistical significance.

Surgical treatment for distal humerus type C fractures

Distal humerus type C fracture is a rare and complicated intra-articular injury. Non-surgical treatment is difficult to achieve accurately reduction and reconstruction of articular surface, while open reduction and internal fixation is the best treatment option. Olecranon osteotomy could provide adequate surgical exposure, and is the most commonly used surgical method, but complications such as non-union osteotomy, internal fixation failure occurred. To avoid sacrificing integrity of olecranon, paratricipital approach, triceps reflecting approach, triceps reflectin ganconeus pedicle approach, triceps splitting and triceps tongue-shaped flap approach have been applied to fracture revealed. However, there is a certain contradiction of choice between surgical exposure and extension function of elbow due to limitations of different approaches. With the promotion of "double-column" theory, double plates has significant mechanical advantages over single plates. Even if parallel double-plate has more advantageous than vertical double-plate in vitro biomechanical experiments, it is not clear whether there is any difference between two methods in clinical application. Elbow arthroplasty may be the final choice for C-type fractures that could not be reconstructed on articular surface, but its long-term efficacy remains to be observed due to technical limitations.

Intra-articular fractures of the distal humerus-a review of the current practice.

Intra-articular fractures of the distal humerus are complex injuries that can considerably limit elbow function if not treated appropriately. Surgical management is indicated for most intra-articular distal humerus fractures with the goal of restoring elbow range of motion and function. Open reduction and internal fixation (ORIF) with plates and screws has been the preferred surgical option. Double plating is recommended for bicolumnar fractures and plates can be applied either parallel or orthogonal to each other. Surgical approach for ORIF of the distal humerus can be performed through an olecranon osteotomy, but other approaches that preserve the olecranon are also in use, such as the triceps-reflecting, triceps-splitting, paratricipital, and triceps-reflecting anconeus pedicle approach. The ulnar nerve is identified during the approach, followed by either in situ decompression or anterior transposition. Elbow arthroplasty has also emerged as a viable alternative to ORIF for fixation of these fractures in elderly patients with poor bone quality.

Modified anconeus flap approach for intercondylar humerus fractures

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

Triceps-reflecting anconeus pedicle approach with double precontoured locking plate fixation is efficient in the treatment of orthopaedic trauma association type C distal humerus fracture

BackgroundThe purpose of this study was to determine if the triceps-reflecting anconeus pedicle (TRAP) approach combined with the precontoured locking plate can provide acceptable clinical outcomes in the treatment of comminuted distal humerus fracture. MethodsBetween August 2008 and June 2014, 48 patients with Orthopaedic Trauma Association type C (21 with C2, 27 with C3) distal humerus fractures underwent open reduction and internal fixation with orthogonal precontoured locking plate fixation using the TRAP approach. Occurrences of bony union, implant failure, posttraumatic arthrosis, and heterotopic ossification were detected with radiography. Clinical assessment included evaluation of range of motion and determination of the pain score, Mayo Elbow Performance Index (MEPI) score, and Disability of the Arm Shoulder and Hand (DASH) score. ResultsThe fractures healed within 3 months in 25 patients (53%) and within 6 months in 23 patients (47%). The 12-month assessment revealed improved elbow movement, with the mean arc of flexion-extension of 121° (range, 100°–140°), mean arc of supination-pronation of 163° (range, 150°–180°), and mean flexion contracture of 8° (range, 0°–30°). The mean MEPI score was 81 and the mean DASH score was 11.7. ConclusionsBy retaining the intact olecranon by the TRAP approach, orthopedic surgeon can get adequate surgical exposure for fracture fixation and can use olecranon as a three-dimensional template to restore the articular fragments. The promising results in this study obtain because that precise identification of the triceps muscle allowed the determination of a proper length-tension relationship for triceps reattachment. The combination of triceps tendon repair and anconeous muscle repair ensured the strength of the extensor mechanism. Therefore, the TRAP approach in combination with the usage of the precontoured locking plate can be recommended as the optimal surgical approach for the treatment of comminuted distal humerus fracture.

Applied anatomical study of the modified anconeus flap approach.

Conventional surgical therapy for an intercondylar humerus fracture might result in multiple potential complications. Our study was conducted to evaluate the modified anconeus flap approach by adequately exposing the distal humeral articular surface, avoiding osteotomy of the olecranon and transection of the main part of the triceps brachial tendon from the olecranon. Preparations of 20 upper limb specimens from adult cadavers were used in this study. We investigated the anatomical features of the distal tendon of the triceps brachii. Then, we designed a modified anconeus flap approach in cadaver specimens combined with the medial paratricipital approach, and we compared the extent of exposure of the distal humeral articular surface between the triceps-reflecting anconeus pedicle approach and this modified approach. The downward neurovascular bundles supplying the anconeus were located far from the intramuscular tendon of the triceps brachii. In addition, the medial head of the triceps was continuous with the anconeus near the lateral epicondyle of the humerus. These anatomical properties could assist in reducing adverse events in surgery. The percentage of the exposed humerus distal articular surface was 42.7% by applying the modified anconeus flap approach combined with the medial paratricipital approach. The modified anconeus flap approach can overcome the shortcomings of osteotomy or triceps transverse and fulfill reduction and internal fixation of most distal humerus intercondylar fractures. The present study has demonstrated a new approach for adequately exposing the distal humeral articular surface during surgery for an intercondylar humerus fracture. With this modified approach, osteotomy of the olecranon and the separation or transection of the main part of the triceps brachial tendon from the olecranon are not necessarily required. Therefore, we suggest that this novel approach could be applied as the primary surgical approach in intercondylar humerus fracture surgeries if the surgeons are familiar with the regional features of distal tendon of the triceps brachii and anconeus.

Critical analysis of triceps-reflecting anconeus pedicle (TRAP) approach for operative management of intra-articular distal humerus fractures

Abstract In the operative management of intra-articular distal humerus fractures, optimal approach that not only allows good visualization and stable fixation of the entire fracture geometry but also affords aggressive postoperative elbow rehabilitation with minimal complications is critical to achieve a consistently good results in these challenging fractures. Though numerous approaches have been described in the literature, namely Bryan Morrey triceps reflecting, Triceps splitting, paratricipital, triceps reflecting anconeus pedicle (TRAP) and olecranon osteotomy; there is no agreement on ideal approach for these fractures with minimal complications. Hence we envisaged to conduct a study on the critical analysis of TRAP approach for the management of intra-articular AO type C distal humerus fractures with the purpose of studying the feasibility of the approach in affording adequate exposure and fixation of the entire fracture geometry and allowing aggressive postoperative elbow rehabilitation. We also report our short term clinical, functional and radiological outcome using this approach in AO type C distal humerus fractures. Fifteen cases (age group 16-57 years; mean 31.8 years) with AO type C fractures, All fractures united without loss of fixation, fracture displacement, hardware failure or bone grafting. One postoperative ulnar nerve palsies that was surgically explored recovered partially subsequently. Two superficial infections responded to surgical debridement and had final excellent outcome. Wound complications not requiring secondary surgical procedures like postoperative hematoma, superficial skin dehiscence and necrosis over tip of olecranon was seen in 4 cases that eventually healed uneventfully. Heterotopic ossification was seen in 2 cases (1 each of Brooker grade 3 and 1). Three cases had clinically evident (MRC grade 3 or less) triceps weakness. One case needed retightening of 1 distal screw following backout (MEPS 90). The mean MEPS was 85 points. Six cases have excellent, 4 cases had good and 5 cases have fair outcome. TRAP approach allows adequate fracture visualization and stable fracture fixation even in comminuted AO type C3 fracture of the distal humerus, with the advantage of intact olecranon that does serve as a template around which critical intra-articular fracture reduction is afforded. The approach permits aggressive postoperative elbow rehabilitation without elbow instability. However, wound related complications and residual triceps weakness may be of concern in some cases. Accurate and strong reattachment of the reflected extensor mechanism is absolutely critical for postoperative elbow rehabilitation and good functional outcome.

Comments on Li et al.: Bilateral plate fixation for type C distal humerus fractures: experience at a single institution

Dear Sir, We read with interest the article entitled “Bilateral plate fixation for type C distal humerus fractures: experience at a single institution” by Shao-hua Li et al. and congratulate the authors for their work [1]. In the surgical technique, the authors converted type C fractures into type A fractures after passing intercondylar K-wire, but the authors did not mention how the compression between the fragments was achieved. We could determine from the X-ray that compression screws were passed through the plate holes but are curious as to whether the same technique was followed in all the patients [2]. The authors used 90-90 plating for fixation of type C distal humeral fractures. However, principle-based parallel plating for intercondylar fractures enhances fixation in the distal fragments with structural stability at the supracondylar level [2, 3]. The 90-90 plate fixation is not a good option for type C fractures, especially in the presence of comminution, osteoporosis and bone loss [2–4]. If the authors had compared the two techniques it would be a significant addition to the literature. Also, the authors did not mention the management of concomitant fractures of the distal end radius (three cases in their study). We would like to know if they were fixed or treated conservatively. The authors did not discuss the postoperative mobilisation protocol they followed. These complex fractures require early joint mobilisation. At one point the authors did mention a long period of immobilisation with the TRAP (triceps reflecting anconeus pedicle) approach. We would like to disagree because, on the contrary, it has been repeatedly published that the TRAP approach allows early mobilisation [3, 4]. There was a 13% incidence of heterotopic ossification in this study. How were these patients treated and what were the long term outcomes? The authors used tension band wiring with K-wires to fix olecronon osteotomy, but have attributed the delayed healing of the olecranon osteotomy site to early mobilisation. This is contrary to the principle of tension band wiring and articular reconstructions [5].

Surgical management of intercondylar fractures of the humerus using triceps reflecting anconeus pedicle (TRAP) approach

Background:Operative fixation of intra-articular fractures of the distal humerus requires adequate exposure. The transolecranon approach is a commonly used approach. The olecranon osteotomy has potential complications related to prominence/migration of hardware, displacement/nonunion of osteotomy and triceps weakness. Triceps-reflecting anconeus pedicle (TRAP) approach avoids the olecranon osteotomy without compromising the operative exposure. We present outcome of fixation of displaced intra-articular distal humeral fractures with the use of TRAP approach.Materials and Methods:We reviewed the functional and radiological results of 40 consecutive patients with intercondylar fractures of the humerus treated by internal fixation through TRAP approach. There were 28 males and 12 females and the average age was 32 ± 4.5 years. The right elbow was involved in 27 patients and the left elbow in 13 patients. The mechanism of injury was a fall in 20 patients, a motor-vehicle accident in 16 patients and direct trauma in four patients.Results:At a minimum follow-up of 12 months (average 18 ± 4 months) 35 (87.5%) patients had good triceps strength. The average range of motion was 118.4 ± 7 degrees (range 80°-130°). The average time to union was 3.2 ± 1.6 months (range two to six months). No patient had triceps rupture, implant failure, neurovascular deficit or nonunion. Two patients needed removal of the implant because of subcutaneous prominence.Conclusions:The TRAP approach provides good visualization for fixation of intercondylar fractures of the humerus, without any noticeable untoward effect on triceps strength and postoperative rehabilitation; and one can avoid iatrogenic fracture of the olecranon and its associated complications.

Intercondylar fractures of the distal humerus treated with the triceps-reflecting anconeus pedicle approach

Treatment choice for displaced, intercondylar fractures of the distal humerus is open reduction and internal fixation (ORIF) through a posterior approach. The triceps-reflecting anconeus pedicle (TRAP) approach, combination of modified Kocher and Bryan-Morrey has been described as a conservative surgical exposure for fixation of the complex intercondylar fractures. Eleven patients with intercondylar fractures of the humerus operated with this approach were reviewed. The mean follow-up was 26 (14-40) months. The aetiology of injuries was mostly fall on the elbow. There were five females and six males and the average age of the patients was 58.3 years (range 16-70 years). According to Müller et al.'s classification; five were Type C1, four were Type C2 and, two were Type C3. At the final follow-up; Type C1 and C2 fractures had a ROM of 116 degrees (range 95 degrees-140 degrees) and, Type C3 fractures had a ROM of 85 degrees which showed limitation of elbow motion. Average humerotrochlear angle is 93.4 degrees (range 90 degrees-98 degrees). Two patients had transient n. ulnaris paraesthesia and one had heterotopic ossification. Our results demonstrate that TRAP approach is extensile enough in treating these complex fractures however both articular reconstruction and fixation can be easily managed without creating an olecranon fracture. No significant triceps weakness and dysfunction was observed after TRAP approach in the treatment of the intercondylar fractures of the humerus.

THE TRICEPS-REFLECTING ANCONEUS PEDICLE (TRAP) APPROACH FOR DISTAL HUMERAL FRACTURES AND NONUNIONS

Adequate exposure is a prerequisite for treatment of distal humeral fractures, as with most surgical procedures. Challenging as they may be to reduce and fix, these fractures can be made more or less difficult to treat based on exposure; complications of successful treatment may arise as a result of the exposure. In this article the authors describe the triceps-reflecting anconeus pedicle (TRAP) approach to the distal humerus, which provides an extensile and versatile approach for treatment of fractures and nonunions. The TRAP approach provides almost the same exposure as an olecranon osteotomy, without the complications of the osteotomy, and has the added advantage of retaining the whole olecranon to use as a template against which to assemble the articular fragments of the trochlea.