Treatment of persistent instability after posterior fracture-dislocation of the elbow: restoring stability and mobility by internal fixation and hinged external fixation.

BACKGROUND: Long-term results after the treatment of fracture-dislocations of the elbow have often been disappointing, because of post-traumatic instability, stiffness, and early arthritis. We present the results after surgical restoration of stability in complex fracture-dislocations of the elbow using early postoperative mobilization with a hinged external fixator after internal reconstruction of the static stabilizers. METHODS: Twenty patients with persistent instability after fracture-dislocation of the elbow were treated at a mean of 11 weeks after injury. We evaluated 17 elbows in 16 patients (mean age, 44 years) at a mean of 44 months after the definitive surgical procedure. RESULTS: Overall, 10 of 17 elbows had a good or excellent result. The mean range of motion was 96° (SD, 23°). The mean Mayo Elbow Performance Score (MEPS) was 74 (SD, 18), and the mean Functional Elbow Score was 68 (SD, 21). Patients treated within 6 weeks after the trauma had significantly better scores, with a mean MEPS of 81 (SD, 18), than patients treated after a delay, with a mean MEPS of 62 (SD, 13). No patients had recurrent dislocation. Secondary arthritis was mainly found in the delayed-treatment group. Of 17 elbows, 7 (41%) had complications. CONCLUSION: Surgical restoration of the static stabilizers in combination with hinged external fixation leads to satisfactory results when performed within the first 6 weeks after injury. When definite surgical stabilization is delayed more than 6 weeks, the procedure can still restore stability but the functional results are often disappointing.

Long-term outcome after ulnar osteotomy for missed Monteggia fracture dislocation in children.

PURPOSE: Missed Monteggia fracture dislocation in children is a serious condition. The treatment of this rare condition is controversial and reports on the long-term outcome are sparse. We present a series of patients treated with open reduction and ulnar osteotomy with a mean long-term follow-up of 8 years (range 3-17). METHODS: All 16 patients had Bado type 1 (anterior radial head) dislocation. The mean delay from injury to surgery was 17 months (range 1-83). Bilateral radiographs, Oxford Elbow Score, strength measurements, and range of motion were obtained in all patients. RESULTS: There were no major complications to surgery. The radiographic results showed ten patients with reduction of the radial head and with no arthrosis, four patients with arthrosis or subluxation, and two patients with a dislocated radial head. We found a significant correlation between radiographic outcome and delay to ulnar osteotomy (P = 0.03). Typical clinical findings were a small but significant extension deficit and mean loss of supination of 10° (range 0-90, P < 0.01). Ligament reconstruction or transfixation of the radial head did not influence the radiographic or clinical outcome. CONCLUSIONS: Case reports of similar patients treated conservatively demonstrate high morbidity, and, therefore, open reduction and ulnar osteotomy seemed justified. However, this study underlines the importance of minimizing the delay between injury and ulnar osteotomy. If surgery is performed within 40 months after injury, good to fair long-term radiographic results can be obtained. Open reduction and ulnar osteotomy were performed because patients treated conservatively demonstrate high morbidity.

Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up.

PURPOSE: The purpose of this study was to compare long-term results after surgical and conservative primary treatment of first-time traumatic anterior shoulder dislocation. METHODS: Arthroscopic diagnosis after first-time traumatic anterior shoulder dislocation was performed, and in cases of a Baker type 1, 2, or 3 lesion, patients were randomized either to conservative treatment with a fixed sling for 1 week followed by a rehabilitation program or to open repair with a similar rehabilitation program. RESULTS: In this study 76 patients (14 female and 62 male patients), aged 15 to 39 years, were randomized to surgical repair (n = 37) or conservative treatment (n = 39). Of the patients, 6.6% had Baker type 1 lesions, 13.2% had type 2 lesions, and 80.3% had type 3 lesions. After a minimum of 2 years' follow-up, 56% had recurrence after conservative treatment and 3% after open repair (P < .005). Among nondislocators, 39% in the conservative group and 7% in the repair group had a positive apprehension test. When evaluated after 10 years by use of the Oxford self-assessment score, 72% of patients in the surgical group had good or excellent results. Of the conservatively treated patients, 75% had unsatisfactory results because of recurrence, instability, and pain or stiffness. CONCLUSIONS: Arthroscopic evaluation after first-time anterior shoulder dislocation revealed a Baker type 2 or 3 lesion in 93.5% of patients. At 2 years' follow-up, 21 (54%) of the conservatively treated patients had recurrence, as compared with 1 patient with recurrence (3%) after open surgical repair. After 8 years, a further 3 patients in the conservatively treated group had redislocations, 1 had subjective instability, and 4 had pain or stiffness, resulting in 74% having unsatisfactory results according to the Oxford score. Of the patients who had surgical repair, 72% had good or excellent results after 10 years. Because open repair produces superior results compared with conservative treatment, we recommend that the surgeon consider performing primary repair in active patients to reduce the risk of recurrence. LEVEL OF EVIDENCE: Level I, high-quality prospective, randomized controlled trial.

Kinematics of the ligamentous unstable elbow joint after application of a hinged external fixation device: a cadaveric study.

We studied the kinematics of 8 ligamentous unstable elbow joint preparations after application of the Orthofix elbow external fixation device. Valgus, varus, external rotatory, and internal rotatory load tests were performed in lateral collateral ligament (LCL)-deficient and LCL/medial collateral ligament (MCL)-deficient joints. After placement of the fixator, the mean extension decreased significantly to 19.5 degrees +/- 7.2 degrees in the LCL-deficient joint and to 19.1 degrees +/- 6.6 degrees in the LCL/MCL-deficient joint compared with the mean extension of the intact joint, which was 10.5 degrees +/- 4.2 degrees. After application of the fixator, valgus displacement was significantly decreased by 4.0 degrees +/- 3.4 degrees in the LCL-deficient joint and by 3.6 degrees +/- 3.3 degrees in the LCL/MCL-deficient joint compared with the intact joint. External rotatory displacement was significantly decreased in the LCL-deficient joint by 4.9 degrees +/- 3.7 degrees and in the LCL/MCL-deficient joint by 5.0 degrees +/- 4.7 degrees. Internal rotatory displacement was significantly decreased by 3.3 degrees +/- 2.7 degrees in the LCL-deficient joint, but it was not significantly changed in the LCL/MCL-deficient joint. The Orthofix elbow external fixator guided elbow motion to a more varus position compared with the intact elbow and decreased the range of motion of the joint, constraining mainly extension. We conclude that the fixator stabilized the ligamentous unstable elbow joint efficiently but at the expense of changes in the normal motion pattern.

Long-term results with the Kudo type 3 total elbow arthroplasty.

From 1992 to 1993, 17 elbows were replaced with the unlinked Kudo type 3 total elbow arthroplasty in 16 patients with arthritic joint destruction. Of these elbows, 8 were available for clinical examination after a mean of 9.5 years. Of the 17 elbow implants, 5 were revised: 2 because of loosening of the ulnar component, 1 because of dislocation, 1 because of a periprosthetic fracture, and 1 because of a late deep infection. At 9.5 years' follow-up, 67.9% of the prostheses had survived, and the mean survival of the implant was 8.7 years (95% confidence interval, 7.5-10 years). In this study, we observed high rates of progressive valgus tilting of the ulnar component. This valgus tilting is of major concern because it provides more stress to a smaller area on the polyethylene. It may, therefore, cause an increased degree of polyethylene wear and, thereby, reduce the final implant survival rate.

Capitellocondylar total elbow replacement in late-stage rheumatoid arthritis.

Between 1994 and 2000, 51 capitellocondylar elbow replacements were inserted in 41 patients. All patients had late-stage rheumatoid arthritis. The mean age at operation was 56 years (range, 25-78 years). There were 12 men and 29 women. At follow-up, 6 patients had died of unrelated causes with the implant in situ and without radiographic loosening, and 1 patient was lost to follow-up. The remaining 43 elbows in 34 patients were followed up clinically and radiographically at a mean of 6.9 years (range, 26-119 months). Relief of pain was complete in 91% of the surviving elbows, and in 9%, there was only mild pain. Pain-free range of motion at follow-up was significantly improved. Flexion increased a mean of 43 degrees ; extension, 16 degrees ; supination, 24 degrees and pronation, 26 degrees . Of the elbows, 7 underwent revision, 3 because of deep infection, 1 for aseptic loosening, and 3 because of instability. Other complications included 2 maltracking elbows, 2 triceps tendon ruptures, 2 cases of operative olecranon bursitis, and 2 ulnar nerve palsies. One elbow showed radiolucent lines of more than 1 mm in the circumference of the ulnar component; none of the other elbows showed any signs of progressive radiographic loosening. At a mean follow-up of 6.9 years, a functional prosthesis was retained in 82.7% of the elbows, and the mean survival of the implant was 8.6 years (95% CI, 7.8-9.5 years).

Elbow joint laxity after experimental radial head excision and lateral collateral ligament rupture: efficacy of prosthetic replacement and ligament repair.

The objectives of this experimental study were to investigate the effect of radial head excision and lateral collateral ligament (LCL) division on elbow joint laxity and to determine the efficacy of radial head prosthetic replacement and LCL repair. Valgus, varus, internal rotation, and external rotation of the ulna were measured during passive flexion-extension and application of a 0.75-Nm torque in 6 intact cadaveric elbows and after (1) either excision of the radial head or division of the LCL, (2) removal of both constraints, (3) isolated radial head prosthetic replacement, (4) isolated LCL repair, and (5) radial head replacement combined with LCL repair. Isolated radial head excision increased varus (mean, 4.8 degrees) and external rotatory laxity (mean, 7.1 degrees), as did isolated LCL division (mean, 14.1 degrees for varus; mean, 14.7 degrees for external rotation). After removal of both constraints, varus and external rotatory laxities were increased by 19.0 degrees and 20.1 degrees, respectively, compared with the intact specimens. Isolated radial head replacement reduced mean varus laxity to 14.6 degrees and mean external rotatory laxity to 14.8 degrees. Isolated LCL repair normalized varus laxity but resulted in a 2.9 degrees increase in external rotatory laxity. The combined procedures restored laxity completely. The radial head is a constraint to varus and external rotation in the elbow joint, functioning by maintaining tension in the LCL. Still, removal of both constraints induces severe laxity, and in this case, prosthetic replacement may substitute for the constraining capacity of the native radial head. The combination of LCL repair and radial head replacement restores laxity completely, but an isolated LCL repair performs almost as well, probably by compensating for the ligamentous tension lost from radial head excision.

Functional anatomy of the lateral collateral ligament complex of the elbow: configuration of Y and its role.

A previous anatomic study has revealed that the lateral collateral ligament (LCL) complex of the elbow has a Y-shaped configuration, which consists of a superior, an anterior, and a posterior band. The LCL complex, including the annular ligament, functions as a 3-dimensional (3D) Y-shaped structure. On the basis of this concept, joint laxity after transection of the anterior band was studied in 5 normal, fresh-frozen cadaver elbows with a 3D kinematic testing apparatus. Cutting the anterior band produced significant laxity to varus torque with a mean 5.9 degree at 10 degree of elbow flexion and caused significant laxity to torque in external rotation with a mean 8.5 degree at 40 degree of flexion. No significant laxity was observed during application of valgus or internal rotational torque. Further transection of the posterior band resulted in gross instability with dislocation of the ulnohumeral joint. The laxity occurring after severance of the anterior band suggests that these fibers play a role in preservation of elbow stability against varus and external rotational torque. These results indicate that the LCL functions as a complex with a Y structure and not as an isolated linear ligament. A concept of conjoint point is hypothesized for the function of the LCL complex to restrain posterolateral rotatory instability.