The time point in surgical excision of heterotopic ossification of post-traumatic stiff elbow: recommendation for early excision followed by early exercise.

BACKGROUND: Post-traumatic heterotopic ossification (HO) around the elbow may severely impair joint function. Although surgical excision is effective at restoring range of motion (ROM), traditional surgical treatment is postponed for at least 1 year to prevent recurrence, which leads to secondary contracture of the elbow. Because the optimal timing of resection is controversial, our study was performed to compare recurrence and elbow function between early and late excision in our patients to determine whether the delay is necessary. METHODS: We retrospectively reviewed 164 patients during a 4-year period. In the control group (112 patients), HO was excised at an average of 23.0 months after initial injury (range, 9-204 months); in the early excision group (52 patients), resection was performed at an average of 6.1 months (range, 3-8 months). HO recurrence was assessed by the Hastings classification system. Final ROM and Mayo Elbow Performance Scores were also evaluated. RESULTS: Recurrent HO was observed in 30 of 112 patients (26.8%) in the control group and 15 of 52 (28.9%) in early excision group. No significant difference in HO recurrence was found between the 2 groups (P = .942). Moreover, there were no notable differences regarding ROM, Mayo Elbow Performance Scores, and complications postoperatively. CONCLUSIONS: Early excision associated with early exercise is effective for the treatment of HO aiming at a low recurrence rate and satisfactory function. The conventional surgical delay of more than 1 year may be shortened.

Limited Medial and Lateral Approaches to Treat Stiff Elbows.

Open arthrolysis is an effective way to treat elbow stiffness. However, previous approaches led to significant surgical trauma. The goal of the current study was to evaluate the outcome of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation to treat elbow stiffness. A total of 18 patients (18 elbows) with elbow stiffness were retrospectively reviewed. The same inclusion and exclusion criteria were used for all patients. Preoperatively, the mean flexion arc was 43°±28° and the mean Mayo Elbow Performance Score was 62 points. Limited medial and lateral approaches were used to provide safe and complete arthrolysis. The other protocols included ulnar nerve transposition, medial epicondyle osteotomy, radial head resection, ligament repair, and hinged external fixation. Patients were encouraged to begin early rehabilitation 24 hours after surgery. At a mean follow-up of 20 months, the flexion arc improved to 130°±11° and the mean Mayo Elbow Performance Score was 97 points (15 excellent, 3 good). One patient had elbow instability, but function met the requirements of his daily life. Transient ulnar nerve palsy without infection occurred in 4 patients. With limited medial and lateral approaches, elbow stiffness can be treated effectively with open arthrolysis. This method is trauma controlled. Furthermore, a hinged external fixator can provide sufficient and safe rehabilitation. The use of open arthrolysis with limited medial and lateral approaches combined with hinged external fixation is an effective and safe method to treat elbow stiffness.

Arthrolysis and delayed internal fixation combined with hinged external fixation for elbow stiffness associated with malunion or nonunion of capitellum fracture.

BACKGROUND: This study assessed outcomes after treatment of patients with capitellum fracture diagnosed >4 weeks after the trauma (delayed) who presented with stiff elbow. METHODS: We reviewed 7 patients with stiff elbows after delayed diagnosis of capitellum fractures between February 2007 and February 2012. They were treated with arthrolysis by twin incisions, late open reduction and internal fixation, and a hinged external fixator. According to the Bryan-Morrey-McKee classification, 3 patients had type I capitellum fractures and 4 patients had type IV. RESULTS: Mean follow-up was 28 months (range, 24-38 months). The mean delay from the initial trauma was 3.7 months. The flexion arc improved from a preoperative mean of 24° to a postoperative mean of 122°. The Mayo Elbow Performance Score increased from a mean of 56 points to 93 points. Anatomic fracture union occurred in all cases, and there was no secondary displacement. CONCLUSIONS: Arthrolysis, late internal fixation, and use of a hinged external fixator can solve problems associated with stiff elbow after delayed diagnosis of capitellum fracture. Combined use of these techniques may be a safe and effective treatment option.

Comparative study of radial head resection and prosthetic replacement in surgical release of stiff elbows.

PURPOSE: Elbow trauma can compromise the arc of elbow flexion and forearm rotation. This study aimed at comparing the outcomes of radial head resection and prosthetic replacement in the surgical release of post traumatic elbow stiffness and associated restriction in forearm rotation. METHODS: We retrospectively reviewed the data of patients who underwent open arthrolysis with radial head resection (n = 15; resection group) or radial head replacement (n = 19; replacement group). The pre- and postoperative measurements of the elbow range of motion (ROM) were recorded. Elbow function was evaluated by the Broberg and Morrey Evaluation System; the Mayo Elbow Performance Index (MEPI); and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: Over a mean follow-up duration of 22 months, the improvement in the arc of flexion and extension was 79° (range, 45-125°) and 82° (range, 10-110°), while that in the ROM for forearm rotation was 96° (range, 40-150°) and 102° (range, 15-150°) in the resection and replacement groups, respectively. There were no significant intergroup differences in the elbow ROM measured at the last follow up. The Broberg and Morrey, MEPI, and Dash scores in the two groups were comparable. CONCLUSIONS: Both resection and prosthetic replacement of the radial head with open arthrolysis of post traumatic elbow stiffness were feasible in treating the associated restriction of forearm rotation. We recommend that if the elbow is stable after complete release, radial head resection is preferable to prosthetic replacement because it is technically less demanding.

Stability of severely stiff elbows after complete open release: treatment by ligament repair with suture anchors and hinged external fixator.

BACKGROUND: Instability is a crucial issue in severe post-traumatic elbow stiffness during complete-release surgery. This study aimed to evaluate the efficacy of ligament repair using a suture anchor in the operative treatment of severely stiff elbows for which a hinged external fixator was indicated. METHODS: We retrospectively reviewed 46 cases of severely stiff elbows (flexion arc <60°) undergoing open release. During the operation, all 46 elbows were noted to have instability. Suture anchors were applied to restore the ligament if it was impossible to repair the ligament directly, and a hinged external fixator was simultaneously applied to protect the vulnerable ligament and facilitate rehabilitation. No allograft or autograft was used in any of our cases. The stability, arc of motion, Mayo Elbow Performance Score, ulnar nerve symptoms, and radiographs were evaluated. RESULTS: At a mean follow-up of 24.3 months, the postoperative Mayo Elbow Performance Score was 91 points, as compared with 63 points preoperatively. The mean flexion arc improved from 25° to 126°. Three patients presented with moderate elbow instability when the hinged external fixator was removed; however, all of them regained stability by the last follow-up. Furthermore, 7 cases of new-onset nerve palsy were noted; however, all of them resolved with conservative management. None of the patients required secondary surgery for any reason. CONCLUSIONS: Repair of an avulsed collateral ligament with suture anchors and hinged external fixation was effective in restoring functional mobility in patients with severe post-traumatic elbow stiffness after complete release. This could be an option for treating ankylosed, severely or very severely stiff elbows.

Arthrolysis combined with reconstruction for treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention.

INTRODUCTION: The treatment of terrible triad injury with a poor outcome after intervention has not been successful thus far. The purpose of this study was to evaluate the efficacy of arthrolysis and reconstruction in the treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention. MATERIALS AND METHODS: Twelve patients (12 elbows) with the diagnosis of terrible triad injury were respectively reviewed. All the 12 patients had elbow dysfunction after conservative and surgical treatment of the terrible triad injury. Preoperatively, the flexion arc and forearm rotation were 36.7° ± 28.5° and 51.3° ± 43.4°, respectively, and the Mayo Elbow Performance Score was 56.3 points. The mean interval between the primary injury and our surgical treatment was 6.6 months. Our surgical intervention included elbow arthrolysis, ulnar nerve transposition, radial head replacement, coronoid process and ligament repair, and hinged external fixation. Patients were encouraged to participate in rehabilitation training 24 h after surgery. RESULTS: The mean follow-up duration was 20.1 months; the flexion arc and forearm rotation were 122° ± 18° and 140° ± 20°, respectively, and the mean Mayo Elbow Performance Score was 94.6 points (9 excellent, 3 good). Concentric stability was restored in all elbows. Complications included superficial pin tract infection (1), heterotopic ossification (3), and ulnar nerve palsy (1); the ulnar nerve symptoms had improved at the last follow-up. CONCLUSIONS: The combination of open arthrolysis and reconstruction performed at a mean interval of 6-month posttrauma can restore functional mobility in cases of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Thus, it may be an effective alternative for the treatment of the poor outcome terrible triad injury. We recommend early functional rehabilitation with adherence to the guidelines for hinged external fixation.

Open arthrolysis and prosthetic replacement of the radial head for elbow stiffness associated with rotation limitation.

BACKGROUND: Limited forearm rotation is a frequent combined disorder in elbow stiffness. If the radial head cannot be saved during open arthrolysis, prosthetic replacement might be considered because it enhances stability and allows early motion. METHODS: In this study we retrospectively analyzed the outcome of 8 patients (7 men, 1 woman) who underwent open arthrolysis and simultaneous prosthetic replacement after resection of the radial head to restore elbow range of motion and forearm rotation. Patients were a mean age of 31.7 years (range, 22-40 years). RESULTS: Postoperatively, the mean (range) active range of motion improved from 29.4° (0°-70°) to 113.1° (80°-135°), mean (range) supination increased from 38.8° (0°-80°) to 77.5° (50°-90°), and mean (range) pronation improved from 18.8° (0°-80°) to 68.8° (50°-80°). The Mayo Elbow Performance Score improved from a mean (range) of 57.5 (50-70) to 92.5 (85-100) points. No elbow valgus instability was detected over a mean duration of 26 months of follow-up. The implant was considered stable in all patients. CONCLUSIONS: Open arthrolysis and prosthetic replacement of the radial head are effective in treating elbow stiffness with associated rotation limitation after resection of the radial head.

Open arthrolysis and hinged external fixation for posttraumatic ankylosed elbows.

BACKGROUND: An ankylosed elbow is defined as an elbow having a range of motion of 0°. Movement is extremely limited. This study retrospectively analyzes the results of arthrolysis and hinged external fixation performed on 15 patients suffering from ankylosed elbows. METHODS: Fifteen completely ankylosed elbows were treated by arthrolysis and hinged external fixation. Patients comprised nine men and six women, with a mean age of 37.93 years (37.93 ± 9.68) when arthrolysis was performed. Before surgery, the elbows were ankylosed at various angles ranging from 30° to 85°. Eleven patients underwent arthrolysis by medial and lateral approaches, three patients by the posterior approach, and one patient by posterior and lateral approaches. Hinged external fixators were applied to all patients. Subcutaneous anterior transposition of the ulnar nerve was performed in all patients. RESULT: All patients received satisfactory follow-up. The range of motion of the elbow improved from 0° preoperatively to a postoperative mean of 115.67° (115.67 ± 23.29). The Mayo Elbow Performance Score improved from a mean of 67.67 ± 11.00 to 86.67 ± 8.38 points, with excellent results in nine patients, good in five, and fair in one. This difference is statistically significant (t = -6.862; p < 0.001). CONCLUSION: Open arthrolysis and monolateral hinged external fixation are effective in treating posttraumatic ankylosed elbow. Arthrolysis should be performed by a combination of lateral and medial approaches. In addition, routine hinged external fixation and anterior transposition of the ulnar nerve may improve the postoperative recovery of elbow stiffness.

Combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow.

BACKGROUND: Various methods are available to treat the stiff elbow. However, there is no consensus on which one is most useful. This study involves the effects of combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow. PATIENTS: We treated 12 patients with stiff elbows using a combination of arthrolysis by lateral and medial approaches and hinged external fixation. The arthrolysis was applied to the elbow for complete soft-tissue release, and the hinged external fixation mainly for rehabilitation and stability of the elbow after arthrolysis. With the help of the hinged external fixation, nonsurgical treatment including exercises was effectively performed to maintain the stability and the results of arthrolysis. Before surgery, the mean extension was -35 degrees and the mean flexion 70 degrees. One patient had a loss of 70 degrees in pronation. RESULTS: Satisfactory follow-up was given to 11 patients with the mean length of 15 month. The mean postoperative extension was -8 degrees whereas flexion 122 degrees. Two of 11 patients had a transient ulnar paresthesia and returned to normal after 8-month follow-up. The loss of pronation in one patient reduced to 30 degrees afterward. There were no complicating infections. All patients reported satisfactory effect. CONCLUSION: The combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow is safe and effective.

The free peroneal perforator-based sural neurofasciocutaneous flap: a novel tool for reconstruction of large soft-tissue defects in the upper limb.

BACKGROUND: The sural neurofasciocutaneous flap has been widely used for reconstruction of soft-tissue defects in the lower leg, ankle, and foot. It can provide a large amount of tissue without compromising the function of the leg. The authors report the applications of the free peroneal perforator-based sural neurofasciocutaneous flap. METHODS: The free sural neurofasciocutaneous flap based on a single peroneal perforator is described. The peroneal perforator, which emerges from the posterior crural septum at the junction of middle and lower thirds of the fibula, was chosen as the pedicle of the flap. Six perforator-based sural neurofasciocutaneous flaps were transferred to resurface large soft-tissue defects in the upper limb. The size of the defects ranged from 15 × 6 cm to 45 × 10 cm. RESULTS: All six flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 10 cm. The average diameter of the peroneal perforator ranged from 1.0 to 1.5 mm, and the length of the perforator pedicles ranged from 4 to 6 cm. One patient developed arterial thrombosis after surgery, which was treated by removal of the thrombus and reanastomosis. No severe venous congestion was observed. All the patients were satisfied with the aesthetic outcome postoperatively at 3 to 12 months' follow-up. There were no serious donor-site complications. CONCLUSION: The free perforator-based sural neurofasciocutaneous flap is a good alternative for reconstruction of extensive soft-tissue defects in the upper limb.

Peripheral nerve regeneration using composite poly(lactic acid-caprolactone)/nerve growth factor conduits prepared by coaxial electrospinning.

Many neurotrophic factors have been shown to promote neurite outgrowth by improving the microenvironment that is required for nerve regeneration. However, the delivery of these bioactive agents to the nerve injury site, as well as effective and local release, remains a challenging problem. We have developed a novel composite nerve conduit comprised of poly(lactic acid-caprolactone) (P(LLA-CL)) and nerve growth factor (NGF). This was developed from core-shell structured biodegradable nanofibers, which were fabricated by coaxial electrospinning of P(LLA-CL) for the shell and bovine serum albumin (BSA) or BSA/NGF for the core. In rats, gaps of 10-mm long sciatic nerves were bridged using an autograft, an empty P(LLA-CL) conduit, a NGF injection P(LLA-CL) conduit, a P(LLA-CL)/NGF composite conduit, respectively. Regenerated nerve fibers were harvested and morphological and functional evaluation of nerve regeneration was performed at 12 weeks postsurgery. Although partial biodegradation and small cracks in the conduits were observed, the conduit outlines remained intact for 12 weeks after surgery. Based on functional and histological observations, the number and arrangement of regenerated nerve fibers, myelination, and nerve function reconstruction was similar in the P(LLA-CL)/NGF conduit group to that of the nerve autograft group (p > 0.05), but was significantly greater to the empty P(LLA-CL) and injection NGF P(LLA-CL) conduit groups (both p < 0.05). Therefore, the composite P(LLA-CL)/NGF conduit, which exhibited favorable mechanical properties and biocompatibility, could effectively promote sciatic nerve regeneration in rats.

The extended peroneal artery perforator flap for lower extremity reconstruction.

The peroneal artery perforator flap and its modifications have been widely used for coverage of soft tissue defects of ankle and foot in the past decade. In this article, we report on a series of upper knee, ankle, and foot reconstructions with a proximally or distally based extended peroneal artery perforator (EPAP) flap supplied by distinct perforating branches off the proximal or distal peroneal artery. Total pedicle length obtained ranged from 6 to 12 cm. Twelve patients with soft tissue defects of the lower extremity underwent reconstruction using the EPAP flap. The flaps were designed with the sizes from 10 x 6 cm to 25 x 15 cm. All 12 flaps survived completely without complications. Our experience demonstrates that the EPAP flap is reliable and versatile and can provide a large amount of soft tissue for coverage of defects in the leg anywhere from knee to forefoot obviating the need for free tissue transplantation.

Free peroneal perforator-based sural neurofasciocutaneous flaps for reconstruction of hand and forearm.

BACKGROUND: Sural neurofasciocutaneous flap has been popularly used as an excellent option for the coverage of soft tissue defects in the lower third of leg, ankle and foot, but its free transplantation has been rarely reported. The objective of our work was to investigate the operative technique and clinical results of repairing the soft tissue defects of hand and forearm with free peroneal perforator-based sural neurofasciocutaneous flap. METHODS: Between May 2006 and March 2007, 10 patients including 7 men and 3 women were treated. Their ages ranged from 22 to 51 years. They presented to emergency with large soft tissue defects of 16 cm x 7 cm to 24 cm x 10 cm in size in hand and forearm after injured by motor vehicle accidents (2 cases) or crushed by machine (8 cases). Thorough debridements and primary treatments to associated tendon ruptures or bone fractures were performed on emergency. And free peroneal perforator-based sural neurofasciocutaneous flaps were transplanted when the wound areas were stable at 5 to 7 days after emergency treatment. The flaps were designed along the axis of the sural nerve according to the shape and size of the soft tissue defects, with the peroneal perforator above the lateral malleolus as the pedicle and along with a part of the peroneal artery for vascular anastomosis. Then the flaps were harvested to repair the recipient sites with the peroneal artery anastomosed to the radial (or ulnar) artery and the peroneal veins to one of the radial (or ulnar) veins and the cephalic vein respectively. The flap sizes ranged from 18 cm x 8 cm to 25 cm x 12 cm. The donor areas were closed by skin grafts. RESULTS: All of the 10 flaps survived after surgeries. Marginal necrosis occurred in only 2 cases. The skin grafts survived entirely in the donor sites, and no obvious influence on the donor legs was observed. All of the transplanted flaps presented favourable contours and good functions at 9 to 12 months' follow-up. CONCLUSIONS: Peroneal perforator-based sural neurofasciocutaneous flap has favourable appearance, constant vascular pedicle, reliable blood supply, large size of elevation, and minimal influence on the donor site. The free transplantation of this flap offers a satisfactory alternative for repairing the large soft tissue defects of forearm and hand.

Double-column fixation for type C fractures of the distal humerus in the elderly.

BACKGROUND: Although several studies reported good results of open reduction and internal fixation of displaced fracture of the adult distal humerus, few studies have specifically addressed the results of such surgical fixation in osteoporotic bone in the elderly. METHODS: This study focused on AO type C fractures in the elderly by using 2 plates for fixation of the lateral and medial columns to reconstruct a stable triangular frame of the distal humerus. The study comprised 35 patients, and 32 were available for final evaluation at a mean follow-up of 24.5 months (range, 14-60 months). RESULTS: Mayo Elbow Function Score showed 25 patients (78%) achieved an excellent functional result, and 7 (22%) had a good result. No patients were considered to have a fair or poor result. At the final follow-up, the mean range of flexion to extension of the elbow was 22 degrees (range, 10 degrees -40 degrees) to 125 degrees (range, 100 degrees -140 degrees). All fractures united at average of 3.5 months (range, 2.5-5.3 months). CONCLUSION: Open reduction and internal fixation using double-columned plating is a useful and effective technique in the management of displaced, comminuted, intra-articular fractures of the distal humerus in elderly patients. LEVEL OF EVIDENCE: Level 4; Case series, treatment study.