Objective To retrospectively reviewed the operative therapy of the terrible triad of the elbow. Methods From October 2003 to September 2007, 10 cases of terrible triad were treated, with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. There were 3 males and 7 females with the age of 18-66 years. The injury was caused by traffic accidents in 4 cases, fall ing from a height in 4 cases, and tumbl ing in 2 cases. The coronoid process fractures of the patients were 5 cases of type I, 3 cases of type II and 2 cases of type III according to Regan- Morrey classification. The radial head fractures of the patients were 1 case of type I, 6 cases of type II and 1 case of type IIIaccording to Mason classification, and their radial heads of the other 2 patiants were resected before they were in hospital. The general approach was to repair the damaged structures sequentially from deep to superficial, from coronoid to anterior capsule to radial head to lateral l igament complex to common extensor origin. And selected cases were repaired of the medial collateral l igaments and assisted mobile hinged external fixation to keep the forearm fixed in functional rotation position. The function of the elbows were evaluated with the criteria of the HSS2 score system. Results The other wounds healed by first intention except 1 case which had infection 7 days after operation and whose soft tissue defect in posterior elbow were repaired with the pedicle thoracoumbil ical flap. The patients were followed up 6 to 51 mouths (mean 24.9 mouths). The fracture heal ing time was 6 to 20 weeks (mean 9.6 weeks). Six mouths postoperatively, the mean flexion-extension arc of the elbow was 106.5° (85-130°), and the mean pronation-supination arc of the forearm was 138°( 100-160°) respectively. According to the criteria of the HSS2 score, the results were excellent in 4 cases, good in 4 cases, and fair in 2 cases. No compl ications such as stiffness and ulnohumeral arthrosis occurred. The radial nerve injury was found in 1 patient 1 day after operation who was treated with neurolysis, and the nerve function was recovered after 4-6 months. And heterotopic ossification occurred in 6 patients 6 months after operation and radiographic subluxation developed in 1 patient 36 months after operation, and conservative treatment weregiven. Conclusion The terrible triad of the elbow can lead to serious elbow instabil ity and should be treated with operationto restore the anatomic structures, to repair the articular capsule and the collateral l igament, using the adjuvant hinged external fixation and early exercise to avoid immobil ization and recover the articular function.
Objective To review the basic research and cl inical progress of elbow heterotopic ossification after injury. Methods The recent l iterature concerning heterotopic ossification of the elbow was reviewed. Results Heterotopic ossification was caused by variety of stimul i and conditions. The current methods of prevention and treatment were to improve surgical techniques, to reduce trauma and bleeding, to rinse the area with bone fragments with plenty of salt water, and to use non-steroidal anti-inflammatory drugs. Conclusion Once heterotopic ossification occurred, surgical treatment is unique treatment method, so emphasis is to prevent heterotopic ossification.
Objective To investigate the blood supply of the ulnar nerve in the elbow region and to design the procedure of anterior transposition of ulnar nerve accompanied with arteries for cubital tunnel syndrome.Methods The vascularity of the ulnar nerve was observed and measured in20adult cadaver upper limb specimens. And the clinical surgical procedure was imitated in 3 adult cadaver upper limb specimens. Results There were three major arteries to supply the ulnar nerve at the elbow region: the superior ulnar collateral artery, the inferior ulnar collateral artery and the posterior ulnar recurrent artery. The distances from arterial origin to the medial epicondyle were 14.2±0.9, 4.2±0.6 and 4.8±1.1 cm respectively. And the total length of the vessels travelling alone with the ulnar nerve were 15.0±1.3,5.1±0.3 and 5.6±0.9 cm. The external diameter of the arteries at the beginning spot were 1.5±0.5, 1.2±0.3 and 1.4±0.5 mm respectively. The perpendicular distance of the three arteries were 1.2±0.5,2.7±0.9 and 1.3±0.5 cm respectively.Conclusion It is feasible to perform anterior transposition of the ulnar nerve accompanied with arteries for cubital tunnel syndrome. And the procedure preserves the blood supply of the ulnar nerve following transposition.
ObjectiveTo investigate the feasibility of modified classification of terrible triad of the elbow and the effectiveness of treatment strategy which was chosen by modified classification results. MethodsBetween March 2007 and November 2013, 12 cases of terrible triad of the elbow were treated by operation. There were 5 males and 7 females with an average age of 37.2 years (range, 26-74 years). The mechanism of injury was falling from height in 8 cases and traffic accident in 4 cases. The time from injury to operation was 4 to 11 days (mean, 6.8 days). According to the radial head, coronoid process, olecranon, and medial and lateral collateral ligament complexes injury situation, and based on Mason classification standard and O'Driscoll criteria, the classification standard of terrible triad of the elbow was improved. According to classification results, the approach was determined. The fracture reduction and fixation were performed and soft tissue was repaired. ResultsDehiscence of incision occurred in 1 case and was cured after dressing change; primary healing was obtained in the other patients. All the cases were followed up 19-35 months (mean, 21.6 months). The X-ray films showed fracture healing at 10-17 weeks (mean 12.8 weeks). At last follow-up, the mean flexion-extension arc of the elbow was 117.9° (range, 95-135°) and the mean forearm pronation and supination were 77.1° (range, 70-85°) and 62.5° (range, 45-75°). According to Mayo elbow performance score (MEPS), the results were excellent in 4 cases, good in 5 cases, and fair in 3 cases. One patient had valgus deformity of elbow who refused radial head replacement, and 5 cases had heterotopic ossification of the elbow on the X-ray films. ConclusionThe modified classification of the terrible triad of the elbow is simple and practical, based on the damage assessment of bony structures (radial head, coronoid process, and olecranon) and the soft tissue (medial and lateral collateral ligament complexes). The modified classification can be used effectively for guiding treatment decisions.
ObjectiveTo explore the effectiveness and safety of open arthrolysis combined with internal fixator removal for post-traumatic elbow stiffness. MethodsA retrospective analysis was made on the data of 80 cases treated by open arthrolysis for elbow stiffness between January 2010 and December 2011. The patients were divided into 2 groups:no internal fixation group (group A, n=39) and internal fixation group (group B, n=41) according to whether they underwent internal fixator removal at the same time. No significant difference was found in age, gender, affected side, injury time, elbow rigidity grade, and severity of heterotopic ossification (HO) between 2 groups (P>0.05) except for original injury type (P<0.05). The effectiveness was evaluated by the occurrence of complications including ulnar nerve symptoms, HO recurrence and re-fracture, the elbow range of motion (ROM) and the Mayo elbow performance score (MEPS). ResultsThe mean follow-up duration was 15.7 months (range, 12-18 months) in group A and 16.1 months (range, 12-20 months) in group B. Ulnar nerve symptoms in 5 cases (12.8%) and HO reccurrence in 1 case (2.6%) occurred in group A, while ulnar nerve symptoms in 4 cases (9.8%), HO recurrence 1 case (2.4%), and refracture in 1 case (2.4%) occurred in group B. The incidence of each complication showed no significant difference between 2 groups (P>0.05). Both the ROM and the MEPS at last follow-up increased significantly when compared with preoperative ones in 2 groups (P<0.05). Besides, MEPS of group A was significantly higher than that of group B (t=2.36, P=0.02), but no significant difference was found in the ROM between 2 groups at last follow-up (t=0.40, P=0.69). Based on MEPS, the results were excellent in 16 cases, good in 16 cases, fair in 6 cases, and poor in 1 case in group A with an excellent and good rate of 82.1%;the results were excellent in 10 cases, good in 25 cases, fair in 4 cases, and poor in 2 cases in group B with an excellent and good rate of 85.4%. There was no significant difference in excellent and good rate between 2 groups (χ2=0.16, P=0.69). ConclusionOpen elbow arthrolysis combined with internal fixator removal for post-traumatic elbow stiffness is safe and effective. However, measures for prevention of re-fracture should always be taken into consideration.
Objective To evaluate the clinical effect of periosteal autograft in repair of ankylosis of elbow joint. Methods From May 1985 to November 1999, 18 cases of elbow joints ankylosis (6 cases of osteo-ankylosis, 12 cases of fibroankylosis) were treated by repairing articular surface with periosteal autografting. Out of 18 cases, 13 were caused by old dislocation and fracture of elbow joints, 3 by late rheumatoid arthritis, and 2 by old total joint tuberculosis. In this surgical approach, periosteum from upper end of tibia was transplanted into articular surface after correction of the elbow joint from ankylosis deformity, and continuous passive or active movement of the operated joint was adopted with skeletal traction through olecranon of ulna for 4 weeks after operation. All of the cases were followed up for 1-9 years, 5.2 years on average, before clinical evaluation. Results The elbow joints in 11 cases were restored to normal, the joints in 4 cases obtained active movement in the range of 100°-0°, and thejoints in the other 3 cases could only have limited movement because of severe muscular atrophy. Conclusion The articular surface in arthroplasty of elbow joint ankylosis could be effectively repaired by periosteal autograft, and the function of the joints could be obviously improved by continuous movement of the joints after operation with skeletal traction.
ObjectiveTo summarize the research progress of heterotopic ossification of the elbow joint after trauma. MethodsThe recent domestic and foreign literature concerning heterotopic ossification of the elbow joint after trauma was analysed and summarized. ResultsThe mechanism of heterotopic ossification of the elbow joint after trauma is mainly related to bone morphogenetic protein signal transduction disorder. Now there are many treatments of heterotopic ossification, including non-surgical treatment, prevention, and surgical treatment. Non-surgical treatment and prevention mainly aim at patients who have no elbow heterotopic ossification or who have mild limited elbow motion because of elbow heterotopic ossification after trauma, including drug therapy, radiation therapy, Chinese medicine therapy, and rehabilitation treatment. For patients with invalid non-surgical treatment, choosing surgical treatment is a must. Surgical treatment includes surgical resection, arthroscopic resection, and joint replacement, priority should be given first to surgical resection. ConclusionHeterotopic ossification of the elbow joint is common and there is not a recognized standard treatment, comprehensive use of non-surgical treatment and surgical treatment is the future direction.
Objective To summarize the research progress in posteromedial rotatory instability (PMRI) of the elbow joint. Methods The recent researches about the management of PMRI of the elbow joint from the aspects of pathological anatomy, biomechanics, diagnosis, and therapy were analyzed and summarized. Results The most important factors related to PMRI of the elbow joint are lateral collateral ligament complex (LCLC) lesion, posterior bundle of the medial collateral ligament complex (MCLC) lesion, and anteromedial coronoid fracture. Clinical physical examination include varus and valgus stress test of the elbow joint. X-ray examination, computed tomography, particularly three-dimensional reconstruction, are particularly useful to diagnose the fracture. Also MRI, arthroscopy, and dynamic ultrasound can assistantly evaluate the affiliated injury of the parenchyma. It is important to repair and reconstruct LCLC and MCLC and fix coronoid process fracture for recovering stability of the elbow joint. There are such ways to repair ligament injury as in situ repairation and functional reconstruction, which include direct suturation, borehole repairation, wire anchor repairation, and transplantation repairation etc. The methods for fixation of coronal fracture include screw fixation, plate fixation, unabsorbable suture fixation, and arthroscopy technology. Conclusion It is crucial that recovering the stability of the elbow joint and early functional exercise for the treatment of PMRI. Individual treatment is favorable to protect soft tissue, reduce surgical complications, and improve the functional recovery and the quality of life.
ObjectiveTo evaluate the mid-term effectiveness of arthrolysis and hinged external fixation for the treatment of stiff elbow caused by heterotrophic ossification.MethodsBetween January 2014 and December 2017, 11 patients with stiff elbow caused by heterotrophic ossification were admitted. There were 9 males and 2 females with an average age of 32 years (range, 14-48 years), and left side in 6 cases and right side in 5 cases. The cause of stiff elbow included humerus fracture in 5 cases, ulna fracture in 2 cases, fracture of capitulum radii in 1 case, dislocation of capitulum radii in 1 case, terrible triad of the elbow in 1 case, and soft tissue injury in 1 case. The disease duration ranged from 7 to 18 months (mean, 11 months). Preoperative active range of motion of elbow was (19.6±17.5)° and Mayo score was 34.1±9.7. All patients received the treatment of arthrolysis and debridement of heterotrophic ossification lesion combining hinged external fixator, and active and passive rehabilitation with the help of hinged external fixator. The hinged external fixators were removed after 2 months.ResultsAll patients were followed up 13-36 months (mean, 19.1 months). All incisions healed by first intention, and no complication of infection or nerve lesion occurred postoperatively. At last follow-up, the results of X-ray films showed that no heterotrophic ossification recurred. The active range of motion of elbow was (116.4±16.6)° and Mayo score was 93.2±7.8, showing significant differences when compared with preoperative ones (t=17.508, P=0.000; t=16.618, P=0.000).ConclusionThe application of arthrolysis and debridement of heterotrophic ossification lesion combining hinged external fixator can improve the elbow’s range of motion significantly and obtain a good mid-term effectiveness.
Objective To analyze the effectiveness of binocular loupe assisted mini-lateral and medial incisions in lateral position for the release of elbow stiffness. Methods The clinical data of 16 patients with elbow stiffness treated with binocular loupe assisted mini-internal and external incisions in lateral position release between January 2021 and December 2022 were retrospectively analyzed. There were 9 males and 7 females, aged from 19 to 57 years, with a median age of 33.5 years. Etiologies included olecranon fracture in 6 cases, elbow dislocation in 4 cases, medial epicondyle fracture in 2 cases, radial head fracture in 4 cases, terrible triad of elbow joint in 2 cases, supracondylar fracture of humerus in 1 case, coronoid process fracture of ulna in 1 case, and humerus fracture in 1 case, with 5 cases presenting a combination of two etiologies. The duration of symptoms ranged from 5 to 60 months, with a median of 8 months. Preoperatively, 12 cases had concomitant ulnar nerve numbness, and 6 cases exhibited ectopic ossification. The preoperative range of motion for elbow flexion and extension was (58.63±22.30)°, the visual analogue scale (VAS) score was 4.3±1.6, and the Mayo score was 71.9±7.5. Incision lengths for both lateral and medial approaches were recorded, as well as the occurrence of complications. Clinical outcomes were evaluated using Mayo scores, VAS scores, and elbow range of motion both preoperatively and postoperatively. Results The lateral incision lengths for all patients ranged from 3.0 to 4.8 cm, with an average of 4.1 cm. The medial incision lengths ranged from 2.4 to 4.2 cm, with an average of 3.0 cm. The follow-up duration ranged from 6 to 19 months and a mean of 9.2 months. At last follow-up, 1 patient reported moderate elbow joint pain, and 3 cases exhibited residual mild ulnar nerve numbness. The other patients had no complications such as new heterotopic ossification and ulnar nerve paralysis, which hindered the movement of elbow joint. At last follow-up, the elbow range of motion was (130.44±9.75)°, the VAS score was 1.1±1.0, and the Mayo score was 99.1±3.8, which significantly improved when compared to the preoperative ones (t=?12.418, P<0.001; t=6.419, P<0.001; t=?13.330, P<0.001). ConclusionThe binocular loupe assisted mini-lateral and medial incisions in lateral position integrated the advantages of traditional open and arthroscopic technique, which demonstrated satisfying safety and effectivity for the release of elbow contracture, but it is not indicated for patients with posterior medial heterolateral heterotopic ossification.