Olecranon osteotomy vs. triceps-sparing for open reduction and internal fixation in treatment of distal humerus intercondylar fracture: a systematic review and meta-analysis / 中华医学杂志(英文版)

BACKGROUND@#The open reduction and internal fixation (ORIF) was a standard treatment approach for fracture at distal humerus intercondylar, whereas the optimal way before ORIF remains inconclusive. We, therefore, performed a systematic review and meta-analysis to assess the efficacy and safety of olecranon osteotomy vs. triceps-sparing approach for patients with distal humerus intercondylar fracture.@*METHODS@#The electronic searches were systematically performed in PubMed, EmBase, Cochrane library, and Chinese National Knowledge Infrastructure from initial inception till December 2019. The primary endpoint was the incidence of excellent/good elbow function, and the secondary endpoints included Mayo elbow performance score, duration of operation, blood loss, and complications.@*RESULTS@#Nine studies involving a total of 637 patients were selected for meta-analysis. There were no significant differences between olecranon osteotomy and triceps-sparing approach for the incidence of excellent/good elbow function (odds ratio [OR]: 1.37; 95% confidence interval [CI]: 0.69-2.75; P = 0.371), Mayo elbow performance score (weight mean difference [WMD]: 0.17; 95% CI: -2.56 to 2.89; P = 0.904), duration of operation (WMD: 4.04; 95% CI: -28.60 to 36.69; P = 0.808), blood loss (WMD: 33.61; 95% CI: -18.35 to 85.58; P = 0.205), and complications (OR: 1.93; 95% CI: 0.49-7.60; P = 0.349). Sensitivity analyses found olecranon osteotomy might be associated with higher incidence of excellent/good elbow function, longer duration of operation, greater blood loss, and higher incidence of complications as compared with triceps-sparing approach.@*CONCLUSIONS@#This study found olecranon osteotomy did not yield additional benefit on the incidence of excellent/good elbow function, while the duration of operation, blood loss, and complications in patients treated with olecranon osteotomy might be inferior than triceps-sparing approach.

Case-control study on single locking plate and locking plate with suture anchors for the treatment of unstable distal clavicle fractures / 中国骨伤

OBJECTIVE@#To compare therapeutic effects of single locking plates and locking plates with suture anchors in treating type Neer IIb distal clavicle fractures.@*METHODS@#From January 2013 to January 2015, 40 distal clavicle fractures patients with Neer IIb were treated by retrospectively analyzed and divided into single locking plates (control group) and locking plates with suture anchors(observation group) according to methods of operation. There were 20 patients in control group treated by single locking plates, including 16 males and 4 females aged from 26 to 64 years old with an average of(40.60±12.64) years old; while there were 20 patients in observation group treated by locking plates with suture anchors, including 15 males and 5 females aged from 20 to 57 years old with an average of(37.30±10.56) years old. Length of incisions, operation time, blood loss, hospital stays, fracture healing observed by X-ray, position of internal fixation, and changes of coracoclavicular distance were compared, Constant-Murley score was used to evaluate shoulder joint function.@*RESULTS@#All patients were followed up from 22 to 42 months with an average of (30.08±6.72) months. There was no statistical significance in length of incisions, operation time, blood loss, hospital stays and fracture healing time (>0.05). Constant-Murley score in control group was 83.10±5.81, and lower than that of observation group (92.30±6.05)(<0.05) at final following-up. Coracoclavicular distance in control group (11.22±3.85) mm, was longer than that of observation group (8.71±2.14) mm(<0.05).@*CONCLUSIONS@#Compared with locking plates, locking plates with suture anchors for type Neer IIb distal clavicle fractures has better shoulder joint, shorter coracoclavicular distance. It showed coracoclavicular ligament is an effectiveness method for treating Neer IIb distal clavicle fractures.

Is anterior transposition of ulnar nerve beneficial during open reduction and internal fixation for intercondylar humerus fractures / 中国骨伤

OBJECTIVE@#To compare activity, function and postoperative ulnar nerve function of elbow joint by anterior transposition of ulnar nerve or not during open reduction and internal fixation for intercondylar humerus fractures.@*METHODS@#From January 2013 to May 2017, 168 patients with intercondylar humerus fractures were treated surgically with open reduction and internal fixation (ORIF). The patients were divided into anterior subcutaneous transposition group and simple decompression group according to handling method of ulnar nerve. There were 48 patients in transposition group, including 23 males and 25 females with an average age of (42.5±15.7) years old ranging from 14 to 77 years old, and ulnar nerve treated enough free and anterior subcutaneous transpostion after reduction of intercondylar humerus fractures; while there were 120 patients in simple decompression group, including 62 males and 58 females with an average age of (43.4±17.3) years old ranging from 14 to 81 years old, ulnar nerve returned to sulci nervi ulnaris. Activity of flexion and extension of elbow joint, range of rotation of forearm were recorded at the latest following-up, Mayo score of elbow joint was used to evaluate clinical effect, McGowan grading was used to assess dysfunction of unlnar nerve.@*RESULTS@#There was 1 patient delayed union, and 2 patients occurred joint stiffness in transposition group; while 1 patient suffered from incision infection, 1 fracture nonunion, and 4 joint stiffness in simple decompression group; and there was no statistical difference between two groups(>0.05). Forty-eight patients in transposition group were followed-up from 12 to 59 months with an average of (32.2±14.2) months, activity of flexion and extension of elbow joint was (116±28)°, range of rotation of forearm was (152±12)°, MEPS score was 88.6±11.6; and 28 patients got excellent results, 16 good, 3 moderate and 1 poor. There were 17 patients occurred injury of ulnar nerve, and 7 patients still occurred dysfunction of ulnar nerve, and 6 patients were grade I, 1 patient was grade II according to McGowan grading. In simple decompression group, there were 120 patients were followed-up from 13 to 61 months with an average of (32.0±14.9) months, activity of flexion and extension of elbow joint was (119±27)°, range of rotation of forearm was (154±16)°, MEPS score was 88.9±12.5; and 67 patients got excellent results, 44 good, 7 moderate and 2 poor. There were 42 patients occurred injury of ulnar nerve, and 22 patients still occurred dysfunction of ulnar nerve, and 18 patients were grade I, 4 patients were grade II according to McGowan grading. There were no statistical differences in following time, activity of flexion and extension of elbow joint, range of rotation of forearm, MEPS score and dysfunction of ulnar nerve.@*CONCLUSIONS@#Whether anterior transposition of ulnar nerve or not has no clarified effects for open reduction and internal fixation for intercondylar humerus fractures.

Clinical observation of olecranon sled for the treatment for olecranal fracture / 中国骨伤

OBJECTIVE@#To explore clinical effect of olecranon sled in treating olecranal fracture.@*METHODS@#Four patients with olecranal fracture treated by olecranon sled in March 2017, including 2 males and 2 females, age of 40, 46, 47, 72 years old, 3 patients on the left side and 1 patient on the right side. All patients were caused by falling down. Fracture were transverse, oblique and slightly compressive articular surface fracture. The time from injury to operation ranged from 1 to 3 days. Operative time, blood loss, complications and flexion and extension of elbow joint, and function of forearm were observed, VAS score was used to evaluate relieve degree of pain, and Mayo score was applied to assess recovery of elbow function.@*RESULTS@#Four patients were followed up until September 2018. Operative time ranged from 40 to 60 min, blood loss was for 20 to 40 ml, and no complications occurred. All fracture were healed at 4 months after operation. Elbow flexion was for 140° to 150°, extension of elbow was from 0° and extend to 10°, activity of flexion and extension ranged from 140 ° to 160°, MEPS score was 100. No pain occurred during doing activity, and VAS score was 0.@*CONCLUSIONS@#Low-profile design and integrated design of olecranon sled could avoid irritation of tension band and plate, and it is a simple and ideal internal fixation method for simple and mildly comminuted olecranon fracture, which is not suitable for severely comminuted olecranon fracture.

Clinical outcomes of open reduction and internal fixation in treating Gustilo typeI and II patients with open distal humeral fractures / 中国骨伤

OBJECTIVE@#To analysis clinical effects of open reduction and internal fixation in treating Gustilo type I and II patients with open distal humeral fracture.@*METHODS@#From 2013 May to 2017 June, 24 patient with Gustilo grade I and II open distal humeral fractures were treated with open reduction and internal fixation, including 20 males and 4 females, aged from 14 to 65 years old with an average of (41.3±13.1) years old. According to Gustilo classification, 16 patients were type I, 8 patients were typeII. Range of motion, complications and secondary surgery were recorded; elbow function were evaluated with VAS (visual analogue scale), MEPS (Mayo elbow performance score) and QuickDASH (quick disabilities of the arm, shoulder, and hand) at 12 months after operation.@*RESULTS@#All patients were followed up from 15 to 60 years with an average of (34.1±11.9) months. VAS score was 0(0, 2); flexion and extension ranged from 50 °to 145° with an average of (115.2±26.1)°; the range of rotation ranged from 100° to 160° with an average of (147.7±17.0)°. MEPS score was for 75 to 90 (90.0±9.1), and 14 patients got excellent result, 10 patients moderate. Quick DASH score was 4.6(0, 14.8). There were 22 patients occurred complications, such as ulnar nerve symptom and internal fixation irritation, and 10 patients accepted the second operation.@*CONCLUSIONS@#Open reduction and internal fixation is a safe and efficient method in treating Gustilo type I and II patients with open distal humeral fractures, which has an advantages of good range of movement and function score.

Progress on diagnosis and treatment of low transcondylar fractures of distal humerus / 中国骨伤

Low transcondylar fractures of the distal humerus in adults is rarely seen and reported in literatures. It has a bimodal distribution in terms of age, affecting the elderly and younger patients. The fracture is characterized by a very low transverse intra-capsular and extra-articular fracture lines extending from the level of lateral epicondyle to medial epicondyle. Standard elbow plain films and CT scans are crucial and indispensable for diagnosis. Conservative treatment is suitable for undisplaced fractures, patients who are intolerant of anesthesia, or people with advanced dementia. Open reduction and internal fixation (ORIF) is preferred. Parallel and orthogonal plate fixation are widely adopted while some researchers preferred crisscross-type screw fixation or bicolumnar 90-90 plating. In addition, some customized posterolateral plates are specially designed to be able to insert a transverse screw, functioning as lateral support. However, most of the recent researches conducted on low transcondylar fractures of the distal humerus are retrospective studies with relatively lower level of evidence compared to prospective and randomized controlled ones which remain a vacancy in this field. Therefore, further studies comparing the biomechanical properties and clinical prognosis of different configurations of internal fixation or total elbow arthroplasty for the treatment of low transcondylar fractures are needed in the future.

Anterior Subcutaneous Transposition of the Ulnar Nerve Affects Elbow Range of Motion: A Mean 13.5 Years of Follow-up / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Surgical decompression of the ulnar nerve is effective for cubital tunnel syndrome. However, deep approaches may result in iatrogenic elbow stiffness. This long-term study was to evaluate the range of motion (ROM) of the elbow and functional outcomes after anterior subcutaneous transposition.</p><p><b>METHODS</b>A total of 115 patients (78 male and 37 female; mean age: 46.6 years) who underwent anterior subcutaneous transposition of the ulnar nerve between 2001 and 2005 were evaluated retrospectively; mean follow-up was 13.5 years. Elbow ROM was measured as flexion arc, flexion, and extension preoperatively and at the final follow-up, and compared via a mixed analysis of variance adjusting for age. Neuropathy was assessed preoperatively using a modified McGowan neuropathy grade and postoperatively using modified Wilson-Krout criteria. An ordinal logistic regression analysis used postoperative modified Wilson-Krout criteria as the outcome and preoperative factors as predictors.</p><p><b>RESULTS</b>Preoperative McGowan grades were Grade 1 in 14 patients (12.2%), Grade 2A in 28 (24.3%), Grade 2B in 53 (46.1%), and Grade 3 in 20 (17.4%) patients. Postoperatively, 66 patients (57.4%) had excellent results, 26 (22.6%) had good results, 16 (13.9%) had fair results, and 7 (6.1%) had poor results at the final follow-up, as per the Wilson-Krout criteria. There were no complications. Pre- and postoperative elbow ROM was significantly decreased in patients with previous trauma or surgery of the elbow compared with those without (P < 0.05). Anterior subcutaneous transposition of the ulnar nerve did not significantly affect elbow ROM regardless of previous trauma or surgical history nor preoperative ROM (P > 0.05), after adjusting for age. Patients with prolonged symptoms prior to surgery and worse neuropathy tended to have less satisfactory functional outcomes (P < 0.05), after adjusting for covariates.</p><p><b>CONCLUSIONS</b>Anterior subcutaneous transposition of the ulnar nerve is an effective and reliable treatment of cubital tunnel syndrome with satisfactory outcomes and minimal effect on elbow ROM.</p>

Inserting the Ulnar Prosthesis into Radius as a Novel Salvage Surgery for Revision Total Elbow Arthroplasty with Massive Bone Defect / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Infection and aseptic loosening are common complications of total elbow arthroplasty (TEA) and often require revision surgery. However, bone defects, along with other complications, bring an extra difficulty to the second surgery, especially for patients with a massive bone defect in the proximal ulna. Several methods including allograft or autograft have been introduced into practice, but none sufficiently solves these problems.</p><p><b>METHODS</b>We conducted a new surgical method for patients with a massive ulnar bone defect needing revision TEA. During revision arthroplasty, the ulnar prosthesis was inserted into the radius as a salvage procedure. Four consecutive patients received revision arthroplasty with this method between 2013 and 2016. Patients' data were collected to evaluate the clinical outcome.</p><p><b>RESULTS</b>All patients had a Grade III ulnar bone defect. At the last follow-up session, all patients reported a painless, functional elbow joint. Three patients suffered from a periprosthetic infection that was completely cured using the two-stage method. No major complications, including infection, aseptic loosening, or wound problems were found. One patient had a transient ulnar neuritis, and another had a transient radial neuritis. Both patients had full recovery at the last follow-up session.</p><p><b>CONCLUSIONS</b>Inserting an ulnar prosthesis into the radius is a novel procedure for patients with a massive bone defect due to infection or aseptic loosening. It is a safe, quick, and effective treatment with a promising short-term outcome. This method should be provided as a salvage procedure for patients with a nonreconstructable ulnar bone defect.</p>

Review and selection of the approach of total elbow arthroplasty / 中国骨伤

Total elbow arthroplasty was initially used to manage the rheumatoid arthritis of elbow. With the developement of technology in recent decades, the indication of total elbow arthroplasty include the trauma associated unstable joint, traumatic arthritis and distal humerus fractures in elderly. But the high risk of complications, which includes infection, ulnar nerve deficit and tricep insufficiency, is still an unsolved issue. The most widely used approach nowadays is the Bryan-Morrey approach, while some authors also report triceps on approach recently. This article is an overview in approaches and biomechanical researches of total elbow arthroplasy by reviewing the domestic and overseas involved literatures.

Choices to treat fracture of distal humerus in the elderly patients / 中国骨伤

Fractures of distal humerus in elderly patients are difficult to treat, as diminished bone mineral quality and increased trauma-associated articular surfaces destruction may make stable joint reconstruction even more difficult. In active patients, internal fixation is still a primary choice because of use age of total elbow replacement, but disagreements have still existed on how to treat these fractures in elderly patients. In the past years, treatment of fractures of distal humerus make much progress, including the introduction of dual plates fixation, widespread application of three-dimensional CT reconstruction, recognition of complicated fractures, understanding of the parallel plate technique, application of periarticular plates, and the selective use of total elbow arthroplasty. This article is an overview in treating options of fracture of distal humerus in the elderly patients by review the civil and overseas involved literatures.

Semi-constrained total elbow arthroplasty for the treatment of the elbow disorders / 中华外科杂志

<p><b>OBJECTIVE</b>To retrospectively review the results of Coonrad-Morrey semi-constrained total elbow arthroplasty (TEA) for the treatment of different elbow disorders.</p><p><b>METHODS</b>Between December 2003 and April 2008, 30 patients with different kinds of elbow disorders including elbow fracture, non-healing elbow fracture, rheumatoid arthritis and osteoarthritis were treated with TEA using the semi-constrained Coonrad-Morrey elbow replacement prostheses. One patient had bilateral total elbow replacements. There were 22 females and 8 males, with a mean age of 66 years (47 to 78).</p><p><b>RESULTS</b>Twenty patients (21 elbows) were available for review. The average length of follow-up was 35 months (from 12 to 52 months). The mean Mayo elbow performance score was 84 points. Excellent results were achieved in 6 elbows (28%), 11 elbows had good outcome (52%), 2 elbows had improvement (10%), while the other 2 elbows had no improvement (10%). The 2 elbows with distal humeral fractures, had no pain after treatment but developed heterotopic ossification, which caused stiffness and lower the Mayo elbow performance score. One delayed healing of the wound, one patient experienced temporary radial nerve hypesthesia and one elbow showed transparent region around the implant without radiological sign of loosening in the implanted prostheses.</p><p><b>CONCLUSIONS</b>This study reveals good to excellent outcome with the use of semi-constrained TEA for the treatment of rheumatoid arthritis, elbow fracture, osteoarthritis and non-healing elbow fractures in elder patients. The non-healing elbow fractures in elder patients would accompany with severe osteoporosis and comminuted fracture, which would affect the result of open reduction internal fixation. So TEA may be one optimal treatment for these patients.</p>

Posterior monteggia fracture-dislocations of proximal ulna / 中华外科杂志

<p><b>OBJECTIVES</b>To discuss the diagnosis and differential diagnosis, and to establish an effective protocol to treat the posterior Monteggia fracture-dislocations of proximal ulna in adult according to our experience.</p><p><b>METHODS</b>Between April 2004 and December 2007, 16 patients with posterior Monteggia fracture-dislocations were treated surgically, 13 were followed up at a mean of 28 months (range, 12 - 58 months). All the operations were through the posterior midline approach. The fractures of radial head and coronoid process were reduced and fixed, if possible. The proximal ulna fractures were fixed with a single plate in 7 cases, plate combined with K-wires in 2, plate combined with K-wires tension band in 3, and K-wires tension band combined with screws in 1.</p><p><b>RESULTS</b>No elbow was painful or unstable at the last follow up examination. They had an average of 100 degrees (range, 0 degrees to 145 degrees ) of flexion-extension of elbow. The average motion of forearm rotation was 119 degrees (range, 0 degrees to 170 degrees ). The mean Mayo Elbow Performance Score (MEPS) was 93.1 points (67 - 100 points), excellent and good results were achieved in 92.3%. The mean system of Broberg and Morrey score was 88.8 points (53 - 100 points), excellent and good results were achieved in 76.9%.</p><p><b>CONCLUSIONS</b>Attention should be paid to the diagnosis and differential diagnosis of the posterior Monteggia fracture-dislocation of proximal ulna. Anatomically reduction and stable fixation of proximal ulna is the keystone for the surgical treatment.</p>