Fig. 28.1
Deformity in the varus of the elbow with loss of range of motion following supracondylar fracture. The angulation and the level of the osteotomy are determined in the preoperative X-ray and CT scan evaluations
It is well described that varus deformity causes the medialization of the olecranon and triceps insertion. This results in the triceps muscles being forced to become medial with respect to the mechanical axis of the elbow. This situation increases stress on the lateral collateral ligament complex which may lead in time to posterolateral rotatory instability. The clinical signs of this situation will be increased pain and clicking during the flexion and extension movements. The surgical indication is related not only to the deformity with snapping of the medial triceps with or without ulnar nerve symptoms but also to the posterolateral instability when the forearm is in full supination. The more common surgical treatment is osteotomy with internal fixation and ligament reconstruction or retention in cases of lateral ligament deficiency.
This surgical procedure can be performed in supine or lateral position (we prefer the lateral decubitus). A posterior skin incision is performed, and the ulnar nerve is identified and decompressed to the medial epicondyle through the two heads of the flexor carpi ulnaris. The medial intermuscular septum is excised, and the ulnar nerve is moved to a position anterior to the epicondyle in order for it to be in a safe position during the procedure. The triceps tendon is lifted from the posterior surface of the humerus, and the anterior muscles are also detached from the humerus to expose the osteotomy site all around the humeral bone. The lateral side of the triceps is reflected together with the anconeus muscle, and the lateral ligament complex is exposed. The osteotomy can be performed with or without triceps splitting. The angulation and the level of the osteotomy (three-cut osteotomy) are determined in the preoperative X-ray evaluations. A goniometer is useful to determine the correct angulation and level of the lateral closing wedge osteotomy. Distal cutting is performed as distally as possible above the olecranon fossa. The depth of the osteotomy is marked with electrocautery, and an oscillating saw is used to perform the three levels of bone cuts, while the anterior tissue and muscles are moved out of the way. A cut is made, and the triangular bone block shape is removed leaving a lateral edge to the cortex, to improve the stability of the reduction. The distal and proximal cutting levels are reduced to recover the anatomic axis in the frontal and sagittal planes. The proximal aspect of the lateral humeral cortex is modeled to adjust it to the lateral spike of the distal fragment. The fixation can be performed with 3.5-mm screws placed from lateral to medial, or a precontoured plate can be used on the medial side or on both sides; this will improve stability in particular in adults. A cortical bone graft can be also carried out in conjunction, to improve healing in adults. Usually, at this point the tension of the lateral ligament complex can be found to be inadequate, and reconstruction or augmentation is then advised, depending on tissue quality. A postoperative program has to then be carried out to optimize bone healing and ligament reconstruction. The arm is held in a hinge elbow brace with the forearm pronated for 6–8 weeks (depending on the kind of ligament reconstruction) with limited range of motion. Finally, the brace is removed, and the full range of motion is allowed. The full range of activities with strengthening will be allowed after 4–6 months depending on the healing progress.
28.1.1.2 Extension Malunion
The extension malunion is the posterior angulation of the distal humerus on the sagittal plane. The loss of humerus antiversion, also known as “gunshot deformity,” is clinically defined and is related to hyperextension and loss of flexion (Fig. 28.2). Two major groups of surgical procedures can be performed in adults: osteotomy to correct the posterior angulation and recontouring arthroplasty. Osteotomy can be considered in cases of high-degree retroversion of the distal humerus with clinical deformity, as previously described.
Fig. 28.2
The loss of humerus antiversion, also known as “gunshot deformity,” is clinically defined, and it is related to hyperextension and loss of flexion
A radical debridement of the posterior and anterior compartments can be achieved by an open Outerbridge-Kashiwagi operation as a “house-keeping procedure” [2] which includes olecranon tip resection, transhumeral fenestration, and coronoid tip resection.
Recontouring arthroplasty can be performed with either open or arthroscopic techniques. Preoperative evaluations should include a physical examination to assess the range of motion loss and an examination of the extra-articular deformity and the intra-articular status of the distal humerus by means of imaging studies. Imaging studies (X-rays and CT scan) allow an evaluation of the nature and degree of malunion and to identify any associated loose bodies or heterotopic ossifications. The aim of open and arthroscopic procedures is to increase the range of motion and not to alter the retroversion of the distal humerus with no change in the clinical aspect. The remodeling procedure has to be performed on both sides of the ulno-humeral articulation, following the anterior capsulectomy and the remodeling of the coronoid and radial head fossa, and also on the ulnar side to reduce the coronoid apex. Following these surgical steps, an increase in range of motion can be obtained. Posterior capsulectomy with incision of the posterior band of the medial collateral ligament associated with ulnar nerve neurolysis is an advanced technique to improve range of motion in terms of flexion and to reduce the risk of secondary neuropathy.
28.1.2 Intra-articular Malunion
Intra-articular malunions involve the articular surface (shape, orientation, dimension, and axis of rotation) of the trochlea and capitellum humeri. The most common intra-articular deformity is secondary to the loss of orientation and dimension of the trochlea shape with or without change in angulation of the rotational axis. Clinically, patients lose flexion-extension range of motion due to the incongruency between the olecranon and the trochlea. If the intra-articular malunion is associated with an extra-articular deformity, the elbow becomes stiff due to the malunion of the three axes within the elbow (diaphyseal, intercondylar, and rotational axes). Imaging studies are useful to assess the status of the articular surface and its deformity. Computer tomography with three-dimensional reconstructions reproduces the elbow joint and allows the investigator to understand the nature of the articular deformity and the alignment between the olecranon and trochlea and the radial head and the capitellum humeri. Different surgical options (ulno-humeral arthroplasty, interposition arthroplasty, or elbow prosthesis) are available for this group of patients with distal humerus deformities depending on the nature and extent of the articular changes and on patient age.
28.1.2.1 Surgical Techniques for Preserved Joint Congruency with Limited Articular Damage (Less Than 50 %) (Fig. 28.3)
Fig. 28.3
Preserved joint congruency with limited articular damage (less than 50 %). The articular deformity is not further compromised by severe joint destruction, avascular necrosis, or secondary degenerative changes
Ulno-humeral arthroplasty can be performed following open or arthroscopic techniques. This surgical procedure is indicated if the articular deformity is not further compromised by severe joint destruction, avascular necrosis, or secondary degenerative changes.
The open technique can be performed using a posterior midline skin incision; the ulnar nerve is isolated, and triceps splitting is performed. The posterior compartment is exposed, and the articular bone surface of the distal humerus and olecranon is reshaped. The anterior compartment can be exposed using medial and lateral column procedures, and the anterior bone remodeling is then adjusted. The arthroscopic procedure follows the same open surgical steps. The standard setups and portals are made. We usually isolate the ulnar nerve through a medial skin incision just above the ulnar nerve groove. Posterior debridement is performed with standard approaches, the capsula is lifted from the bone to create a space, and bone remodeling is performed with a 5-mm round burr, on both sides of the joint to reduce impingement and maltracking of the ulno-humeral joint.
Remodeling of the anterior is routinely performed using blunt retractors to help with visualization and to protect the nearby neurovascular structures.
Once the bony debridement and remodeling are completed, the anterior and posterior capsulae are excised. The medial capsula can be excised through a medial skin incision performed to isolate the ulnar nerve.
The aim of both surgical techniques is to improve the range of motion without altering the articular surface.
28.1.2.2 Surgical Techniques for Lost Joint Congruency with Extensive Articular Damage (More Than 50 %) (Fig. 28.4)
Fig. 28.4
Lost joint congruency with extensive articular damage (more than 50 %). Severe joint destruction of the articular surface that involves more than half of the joint surface and with significant incongruity between the trochlea and olecranon
Interposition arthroplasty is indicated for severe joint destruction or avascular necrosis of the articular surface that involves more than half of the joint surface or with significant incongruity between the trochlea and olecranon or between the radial head and the capitellum humeri.
Usually, the trochlea is altered in conformity and size due to the reduction with high-compression screws. In these cases, the trochlea needs to be treated with a broad remodeling technique to recover an adequate size and congruency with the olecranon. Following this broad remodeling, the use of interposition tissue can be useful to interpose within the articular joint. Tissues commonly used are the Achilles tendon (for allografts) or the fascia (for autografts or allografts). The medial and lateral collateral ligaments can be reconstructed using a portion of the tissue grafts. External joint distraction is also performed in conjunction to protect the reconstruction for 5–6 weeks and to allow early mobility.
In cases of severe joint destruction that cannot be recovered with conservative procedures, elbow replacement can be considered.
Elbow replacement (total or hemi) may be the principal indication for older patients with lower mobility requirements. In selected cases, this course of action offers reliable improvements in pain relief and mobility even if it does introduce the potential for complications related to the mechanical failure of the implant or of the soft tissues.
Recently, hemi-humeral arthroplasty has been introduced with anatomic designs that reproduce the trochlea surface. From our experience, this is correctly indicated in cases of preserved olecranon articular surface and ligaments, but little information is available from the literature, on medium- and long-term follow-up.
The surgical technique to implant the hemi- or total elbow prosthesis (arthroplasty) can be performed using a posterior midline approach. The ulnar nerve should be isolated, and the extensor mechanism is prepared using a splitting or preserving approach to expose the articular bone surface.
28.1.3 Outcomes of Malunion
There is limited information about the outcomes of surgical correction of distal humerus malunions, but most of these procedures have been performed in the young or adult populations with high degrees of varus and retroversion deformity. Elbow stiffness and instability are the most common clinical, surgical sequelae following a malunion of the distal humerus [3]. The treatment, which is technically demanding, since it requires great surgical experience, includes correct osteotomy or debridement with recontouring arthroplasty. The primary goal is to restore the original anatomic morphology and stability of the elbow, to allow motion without pain. In the preoperative planning stages, a CT scan should be performed to assess the joint congruency and intra-articular bone deformity. Moreover, the choice of surgical treatment must take into account patient age and extent of disabilities.
McKee et al. [4] reported 13 patients treated with osteotomy and bone graft associated with capsular release. The mean age of patients was 40 years, and the mean follow-up time was 25 months (ranging from 12 to 60 months). According to the Mayo Elbow Performance Score (MEPS), 2 were excellent, 3 good, and 8 fair. All the osteotomies healed with an average range of mobility between 25° and 122°. Other experiences have been reported in the literature with good results in osteotomy healing and useful outcomes in elbow motion and pain relief [5–8].
A variety of procedures have been described for operative humerus osteotomy; Lim et al. [9] analyzed the results of three-dimensional corrective osteotomy in the middle-aged population. Twenty consecutive patients underwent corrective osteotomy at an average age of 47.9 years (range, 41–55 years). The osteotomy was fixed with single plating in eight patients and with double plating in 12. The average follow-up was 23 months (range, 18–109 months). Osseous union was radiographically demonstrated in all patients at an average of 17.5 weeks. Delayed union of further than 12 weeks was observed in 15 patients (75 %). The average time to union in the single-plating group was 21.0 weeks compared with 15.1 weeks in the double-plating group. Failure of fixation occurred in two patients who had single plating. The average final MEPS was 90.3 points (range, 70–100 points).
Hahn et al. [10] reported their experience using a corrective dome osteotomy performed in 19 adult patients. The mean age was 31.1 years, and the mean follow-up was 41 months. None of the patients had recurrence of deformity. An excellent result was achieved in 13 patients and good in 6. They therefore concluded that corrective dome osteotomy with stable fixation is a valid option in cases of distal humerus deformity also among adults.
Gong et al. [11] reported their experience with 12 consecutive patients treated with lateral oblique closing wedge osteotomy with a larger contact area and stable fixation. The mean age at the time of the surgery was 39 years (range, 31–48 years). The minimum follow-up was 15 months. All patients achieved healing of the osteotomy and regained preoperative arcs of elbow motion at a mean of 7 weeks. The final MEPS and Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) averaged 95.4 points and 5.5 points, respectively. The conclusion of their report was that humerus osteotomy and fixation with lateral plating is a sound technique for humerus deformities in adults, with early recovery of elbow motion and satisfactory deformity correction.
The outcomes of recontouring arthroplasty were reported in patients with a lesser amount of extra-articular or intra-articular deformities.
Husband and Hastings [12] used this technique on seven patients with a mean age of 32 years at 38-month follow-up. They were able to recover functional arc of motion in six patients with a mean range of 117°.
Mansat and Morrey [13] reported 37 patients treated with the column procedure. At 43 months of mean follow-up, they reported a satisfactory result in 82 % of cases, while 89 % improved the range of motion with a mean arc of 94°. More recently, Stans et al. [14] reported 37 patients treated with capsular release and bony debridement at 15 months of mean follow-up. They described an improvement in elbow motion in 75 % of cases with an average arc of 94°.
Capsular release and bone recontouring can be also performed using either open or arthroscopic procedures. Most of these cases are analyzed as part of a posttraumatic series, and it is difficult to agree whether the stiffness in the elbow is the consequence of distal humerus malunion from the simple contracture with heterotopic ossifications.
In 2000, Cohn et al. [15] reported their experience with the treatment of osteoarthritis (primary and posttraumatic) in the elbow, comparing open and arthroscopic debridement. The outcomes of 18 patients treated by the Outerbridge-Kashiwagi (O-K) open procedure and 26 patients treated by arthroscopic debridement and fenestration of the olecranon fossa were compared at mean follow-up of 35 months. At the end of their study, they found that both procedures were effective, with no major complications. Patients treated by arthroscopic debridement and fenestration achieved better relief of pain, whereas those patients undergoing the O-K open procedure achieved significantly greater improvement in range of motion. In the same years, Kim and Shin [16] reported their series of 63 patients focused on arthroscopy for limited elbow range of motion. The mean range of motion was 79° before surgery. Patients with posttraumatic stiffness had a more marked reduction in extent and total range of motion (73°) compared to those with degenerative stiffness (86°) before surgery. However, no significant differences were found in the postoperative range of motion (posttraumatic stiffness, 123°, and degenerative stiffness, 121°). In 2011, Cefo and Eygendaal [17] reported their experience with 27 patients with posttraumatic stiff elbow treated by arthroscopic release. The mean preoperative range of motion was 99°, and after surgery, improved significantly to 125°, they reported one postoperative superficial infection of the lateral portal but no vascular or neurological complications. The conclusion of the study was that arthroscopic capsular release of the elbow is a safe and reliable option for patients with posttraumatic elbow stiffness without intrinsic broad deformity.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
