Surgical treatment of Monteggia variant fracture dislocations of the elbow in adults: surgical technique and clinical outcomes.

PURPOSE: Monteggia variant defined as Monteggia fracture dislocation with radial head or neck fracture, coronoid fracture, ulnohumeral joint dislocation or combination of these injuries. The aim of this study was to evaluate clinical outcomes of surgical treatment of Monteggia variant fracture dislocations with focus on the operative technique and management of associated radial head fractures. METHODS: Between January 2008 and January 2014, 22 patients (7 men, 15 women) with a mean age of 58.9 years (45-77 years) and unilateral Monteggia variant were included. The mean follow-up was 4.1 years (2.2-6.6 years). Patients underwent clinical and functional assessment using the Mayo Elbow Performance Index and the Oxford Elbow Score. RESULTS: Eighteen patients had radial head fractures; in five patients the fracture fragment involved less than one-third of the radial head and the fragment was excised, in four patients the radial head fracture was fixed with headless screws and in nine patients the radial head was replaced. At review the mean Mayo Elbow Performance Index was 76.6 (20-100) and the Oxford Elbow Score 35 (4-48). CONCLUSIONS: Our experience suggests that satisfactory outcomes can be obtained in the treatment of the complex Monteggia variant fracture dislocations by recognising the injury pattern and addressing all components of the injury in order to achieve elbow stability.

Arthroscopic "Remplissage" for shoulder instability: a systematic review.

PURPOSE: Large Hill-Sachs lesions engaging the glenoid rim predispose to recurrent anterior instability and failure of isolated labrum repairs. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement. This systematic review assessed the outcomes and complications of arthroscopic remplissage for anterior shoulder instability. METHODS: A search of the MEDLINE, EMBASE and evidence-based medicine Cochrane databases was conducted. Data were extracted by two reviewers in a standardised manner. Redislocation, instability and complication rates were calculated and expressed as percentages with 95 % confidence intervals. RESULTS: Of 4,284 studies identified, eight articles with a total of 207 patients were analysed. Mean redislocation rate was 4.2 ± 3.9 % (range 0-15 %), and mean recurrent instability rate 3.2 ± 3.8 % (0-15 %). Posterosuperior shoulder pain and stiffness were the only complications described. Overall, there was a mean reduction in external rotation in adduction of 5.6° (-40 to +30), reduction in external rotation in abduction of 11.3° (-50 to +7) and reduction in internal rotation of 0.9 (-4 to 0) vertebral levels. CONCLUSIONS: Arthroscopic remplissage alongside anterior labrum repair seems successful in treating recurrent shoulder instability in the presence of large or engaging Hill-Sachs lesion. However, the available literature consists mainly of heterogeneous case series. There is a need for a high-quality randomised trial to compare remplissage with other commonly used techniques for recurrent instability associated with substantial Hill-Sachs defects such as the Latarjet procedure. LEVEL OF EVIDENCE: Systematic review, Level IV.