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The management of elbow instability using an internal joint stabilizer: preliminary results.

Orbay JL, Mijares MR - Clin. Orthop. Relat. Res. (2014)

Bottom Line: Does it result in new complications?The absence of elbow instability was determined initially by radiographically observing concentric reduction of the ulnohumeral and radiocapitellar joints and later by radiography plus the absence of clinical signs and symptoms of elbow instability.See Guidelines for Authors for a complete description of levels of evidence.

View Article: PubMed Central - PubMed

Affiliation: The Miami Hand and Upper Extremity Institute, 8905 SW 87th Avenue, Suite 101, Miami, FL, 33176, USA, jlorbay@gmail.com.

ABSTRACT

Background: Nonsurgical and surgical treatments such as immobilization, transarticular pinning, and hinged or nonhinged external fixation have been used to treat unstable elbows. These methods all have drawbacks. We thought that a bent Steinmann pin introduced through the axis of ulnohumeral rotation and attached to the ulna could provide an improved method of treatment and that this could result in the development of a proper internal joint fixator that may have widespread application.

Questions/purposes: Does a fully internal hinged fixator crafted intraoperatively by the surgeon from a Steinmann pin for patients undergoing surgery for severe elbow instability result in restoration of range of motion and elbow stability? Does it result in new complications?

Methods: We reviewed the first 10 patients treated with the method for elbow instability. Diagnoses included fracture-dislocations of the elbow that remain unstable after fracture repair and unstable elbows that result from release of contracture or ulnohumeral synostosis. During that time, all patients meeting these criteria who underwent surgery by this surgeon (JLO) were treated with this approach. Charts, radiographs, and therapy notes were assessed at a minimum of 14 months (mean, 32 months; range, 14-59 months); no patients were lost to followup. Data recorded included age, sex, and elbow and forearm range of motion as well as any complications and reoperations that occurred. The absence of elbow instability was determined initially by radiographically observing concentric reduction of the ulnohumeral and radiocapitellar joints and later by radiography plus the absence of clinical signs and symptoms of elbow instability.

Results: Mean range of motion at latest followup was flexion 134°, extension -19°, pronation 75°, and supination 64°. All elbows were clinically and radiographically stable. Complications resulting in additional procedures occurred in four patients, including one recurrent deep infection in a patient with a remote history of sepsis, one wound hematoma that resolved after a drainage procedure performed in the office, one prominent implant treated by partial removal, and one patient with heterotopic ossification treated with excision of the heterotopic bone.

Conclusions: This technique restores elbow stability and permits motion without the use of transcutaneous pins. It seems promising for the treatment of patients with severe elbow instability but requires a second procedure for removal. Further investigation is needed to understand its place in the surgeon's toolbox and what drawbacks it may have.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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Related in: MedlinePlus

Extreme instability resulted after completion of surgical release and takedown of an ulnohumeral joint synostosis (S) on the anterior medial aspect of the trochlea. Reworking of both articular surfaces was necessary. Both collateral ligaments had to be released, but the triceps (T) and brachialis were kept intact. In this case, the collateral ligaments were ossified and were not present after bone resection.
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Fig5: Extreme instability resulted after completion of surgical release and takedown of an ulnohumeral joint synostosis (S) on the anterior medial aspect of the trochlea. Reworking of both articular surfaces was necessary. Both collateral ligaments had to be released, but the triceps (T) and brachialis were kept intact. In this case, the collateral ligaments were ossified and were not present after bone resection.

Mentions: Five patients had acute injuries: three were acute elbow dislocations with radial head and coronoid fractures that proved unstable when placed in flexion after repair or had redislocated after repair. One was an unstable posterolateral elbow dislocation in an elderly obese female that had dislocated multiple times after closed reduction. One presented with a medial elbow dislocation and an unstable fracture of the medial facet of the coronoid. Five patients had chronic problems: four had posttraumatic stiffness, heterotopic ossification, and/or ulnohumeral synostosis with a mean 10° arc of flexion/extension (Fig. 4A–C), and one had developed ulnohumeral synostosis in full extension associated with juvenile rheumatoid arthritis. These last five cases all resulted in unstable elbows after surgical release (Fig. 5). There were six males and four females with a mean age of 43 years (range, 9–67 years) at the time of surgery. Seven unstable elbows involved the left extremity and three involved the right.Fig. 4A–C


The management of elbow instability using an internal joint stabilizer: preliminary results.

Orbay JL, Mijares MR - Clin. Orthop. Relat. Res. (2014)

Extreme instability resulted after completion of surgical release and takedown of an ulnohumeral joint synostosis (S) on the anterior medial aspect of the trochlea. Reworking of both articular surfaces was necessary. Both collateral ligaments had to be released, but the triceps (T) and brachialis were kept intact. In this case, the collateral ligaments were ossified and were not present after bone resection.
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4048409&req=5

Fig5: Extreme instability resulted after completion of surgical release and takedown of an ulnohumeral joint synostosis (S) on the anterior medial aspect of the trochlea. Reworking of both articular surfaces was necessary. Both collateral ligaments had to be released, but the triceps (T) and brachialis were kept intact. In this case, the collateral ligaments were ossified and were not present after bone resection.
Mentions: Five patients had acute injuries: three were acute elbow dislocations with radial head and coronoid fractures that proved unstable when placed in flexion after repair or had redislocated after repair. One was an unstable posterolateral elbow dislocation in an elderly obese female that had dislocated multiple times after closed reduction. One presented with a medial elbow dislocation and an unstable fracture of the medial facet of the coronoid. Five patients had chronic problems: four had posttraumatic stiffness, heterotopic ossification, and/or ulnohumeral synostosis with a mean 10° arc of flexion/extension (Fig. 4A–C), and one had developed ulnohumeral synostosis in full extension associated with juvenile rheumatoid arthritis. These last five cases all resulted in unstable elbows after surgical release (Fig. 5). There were six males and four females with a mean age of 43 years (range, 9–67 years) at the time of surgery. Seven unstable elbows involved the left extremity and three involved the right.Fig. 4A–C

Bottom Line: Does it result in new complications?The absence of elbow instability was determined initially by radiographically observing concentric reduction of the ulnohumeral and radiocapitellar joints and later by radiography plus the absence of clinical signs and symptoms of elbow instability.See Guidelines for Authors for a complete description of levels of evidence.

View Article: PubMed Central - PubMed

Affiliation: The Miami Hand and Upper Extremity Institute, 8905 SW 87th Avenue, Suite 101, Miami, FL, 33176, USA, jlorbay@gmail.com.

ABSTRACT

Background: Nonsurgical and surgical treatments such as immobilization, transarticular pinning, and hinged or nonhinged external fixation have been used to treat unstable elbows. These methods all have drawbacks. We thought that a bent Steinmann pin introduced through the axis of ulnohumeral rotation and attached to the ulna could provide an improved method of treatment and that this could result in the development of a proper internal joint fixator that may have widespread application.

Questions/purposes: Does a fully internal hinged fixator crafted intraoperatively by the surgeon from a Steinmann pin for patients undergoing surgery for severe elbow instability result in restoration of range of motion and elbow stability? Does it result in new complications?

Methods: We reviewed the first 10 patients treated with the method for elbow instability. Diagnoses included fracture-dislocations of the elbow that remain unstable after fracture repair and unstable elbows that result from release of contracture or ulnohumeral synostosis. During that time, all patients meeting these criteria who underwent surgery by this surgeon (JLO) were treated with this approach. Charts, radiographs, and therapy notes were assessed at a minimum of 14 months (mean, 32 months; range, 14-59 months); no patients were lost to followup. Data recorded included age, sex, and elbow and forearm range of motion as well as any complications and reoperations that occurred. The absence of elbow instability was determined initially by radiographically observing concentric reduction of the ulnohumeral and radiocapitellar joints and later by radiography plus the absence of clinical signs and symptoms of elbow instability.

Results: Mean range of motion at latest followup was flexion 134°, extension -19°, pronation 75°, and supination 64°. All elbows were clinically and radiographically stable. Complications resulting in additional procedures occurred in four patients, including one recurrent deep infection in a patient with a remote history of sepsis, one wound hematoma that resolved after a drainage procedure performed in the office, one prominent implant treated by partial removal, and one patient with heterotopic ossification treated with excision of the heterotopic bone.

Conclusions: This technique restores elbow stability and permits motion without the use of transcutaneous pins. It seems promising for the treatment of patients with severe elbow instability but requires a second procedure for removal. Further investigation is needed to understand its place in the surgeon's toolbox and what drawbacks it may have.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Show MeSH
Related in: MedlinePlus