[Incidence and risk factors of ulnar nerve dysfunction after open reduction and internal fixation of humeral intercondylar fractures].

Objective: To investigate the incidence and related risk factors of ulnar nerve dysfunction after open reduction and internal fixation of humeral intercondylar fractures. Methods: A total of 168 patients who underwent open reduction and plate and screw fixation of a humeral intercondylar fracture between January 2013 and May 2017 were retrospectively analyzed. There were 85 males and 83 females, aged from 14 to 77 years with a mean age of (43±17) years. Diagnosis of ulnar neuropathy was defined as documentation of sensory and motor dysfunction of the ulnar nerve in the medical record. The explanatory (independent) variables included age, gender, injury type, AO typing, time from injury to surgery, surgery approach, plates fixation methods and whether the nerve was transposed. Univariate and multivariate analyses were performed to determine risk factors associated with postoperative ulnar nerve dysfunction. Results: Acute injury-related ulnar nerve neuropathy was diagnosed in 12(7.1%) of 168 patients. Among the other 156 patients without preoperative ulnar nerve neuropathy,the total postoperative ulnar neuropathy was found in 52 patients (33.3%), and in 26(16.7%) at the final follow-up, according to the McGowan grades system; 23(88.5%) of 26 patients were clinically graded as grade 1, and 3(11.5%) were graded as grade 2. Multivariate logistic analysis showed that triceps sparing approach (OR=2.639, P=0.039) and parallel double plate fixation (OR=3.089, P=0.046) were associated with a risk of postoperative ulnar nerve dysfunction. Conclusion: There is a substantial incidence of postoperative ulnar nerve dysfunction after open reduction and plate and screw fixation of humeral intercondylar fracture, postoperative ulnar neuropathy may occur from the time of injury through the long-term follow-up period, triceps sparing approach and parallel double plate fixation are the risk factors for ulnar neuropathy.

[Treatment of the old terrible triad of the elbow without operative history].

OBJECTIVE: To introduce the surgical techniques and treating results of the old "terrible triad" of the elbow. METHODS: A retrospective analysis of 11 cases of old "terrible triad" of the elbow treated by the author from March 2009 to February 2014 were performed, with 9 males and 2 females; mean age was (31.82±8.66) years (17-45 years). The average time after injury was (6.36±2.50) weeks (4-12 weeks), with 7 cases on the left and 4 right. The combined injury included 2 cases with distal radius fractures, 1 with ankle fractures, fractures of the distal radius and the head injury (minor epidural hematoma, no surgery), and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation, and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures: 2 cases were type I, 5 were type II, 4 were type III. Classification of the coronoid process: Regan & Morrey: 1 was type I, 10 were type II; according to O'Driscoll classification, all the fractures were tip fracture, one was the first subtype, 10 were the second subtype. The elbow were released, the coronoid process were fixed by lasso suture combined with Kirschner wires. Radial head fractures were resected in 1 case, and replaced in 1 case, 3 cases with no treatment, 6 cases with osteotomy and 3.0 mm headless compression screw (HCS) fixation. The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicondyles, No.2 Ethibon was used in 2 cases through bone holes, and suture anchorsin the other 9 cases. All the patients were fixed by Stryker DJD II hinged external fixator to protect the bone and soft tissue. RESULTS: The average follow-up time was (38.36±21.92) months (19-77 months). All the patients had no obvious pain, instability and ulnar nerve symptoms in the last follow-up. The average elbow flexion was 134.09°±12.41° (100°-140°), average extension was -15.91°±14.46 ° (-40°-0°), range of flexion and extension was 118.18°±23.80° (70°-140°). Average pronation was 70.91°±26.63° (20°-90°), supination was 70.91°±26.63° (20°-100 °). The range of motion (ROM) of forearm rotation was 150.91°±43.00° (40°-180°). Average Mayo elbow performance score (MEPS) was 96.36±5.04 (85- 100).X-ray showed that no degenerative changes. Five patients had heterotopic ossifications, according to Hastings and Graham grading: 1 case was grade I, 3 cases were grade IIA, 1 case was IIB. CONCLUSION: The old "terrible triad" of elbow with no operative history is difficult to treat. The elbow's functions and stabilization can be recovered by thorough elbow release, repair of coronoid process and anterior capsule, radial head fractures, lateral collateral ligament and the common extensor tendon insertion, combined with hinged external fixator. Joint stiffness and heterotopic ossification are common complications.

[Effect of radiotherapy and indomethacin together in the prevention of recurrence of ectopic ossification around the elbow after resection].

OBJECTIVE: To discuss the effect of single low dose local radiotherapy and indomethacin together in the prevention of recurrence of ectopic ossification around the elbow after resection. METHODS: From Jun. 2009 to Dec. 2011, we performed excision of ectopic ossification around the elbow in 78 stiff elbows. For each case, we used both medial and lateral approaches, and we performed both anterior and posterior capsulectomies and removal of ectopic ossification. In the lateral approach, we started proximally, the lateral supracondylar ridge of the humerus was exposed from the interval between extensor carpi radialis longus (ECRL) and triceps, and then distally passed the interval between ECRL and extensor carpi radialis brevis (ECRB). With the medial approach, after releasing the ulnar nerve, the pronator teres muscle origin was reflected from the medial epicondyle, and then the common flexor-pronator tendon was split longitudinally distally and the brachalis and the anterior portion of the flexor-pronator group were dissected off the anterior humerus. If there was forearm rotation dysfunction, we used extensive lateral approach, the anconeus muscle was reflected from the ulna and the scar tissue and ectopic ossification around the proximal radioulnar joint were resected. The important structures, such as the lateral ulnar collateral ligament (LUCL) and the anterior part of the medial collateral ligament (AMCL), should be carefully protected, because they were important for the elbow stability. Anterior transposition of the ulnar nerve depended on the patients' condition. We performed low dose radiotherapy 4 hours before operation, and we used indomethacin for 6 weeks after operation. In these patients, there were 46 males and 32 females, whose age averaged (35.8±7.9) years (16-65 years). According to Hastings-Graham classification, there were 56 IIA, 5 IIB, 6 IIC and 11 III before operation. RESULTS: We followed up these patients for 26 months with an average of 24-36 months, all the patients improved their elbow function, and no recurrence of ectopic ossification appeared except for 1 patient. For this patient, his elbow function was excellent, and according to Hastings-Graham classification, his ectopic ossification was of type I. CONCLUSION: Single low dose local radiotherapy and indomethacin together are effective in the prevention of recurrence of ectopic ossification around the elbow after excision.