Session III - Upper Extremity
Fri., 10/8/04 Upper Extremity, Paper #18, 3:19 pm
Revision Surgery in Fracture Dislocation of the Elbow: Capitulation or Concept?
Purpose: After insufficient primary treatment of complex fracture-dislocations of the elbow joint, the results very often present a combination of painful and highly restricted range of motion in the joint due to subluxation with or without joint instability. The present concept of total elbow joint replacement is a very questionable long-term solution, especially because the majority of affected patients are young. However, a fusion of the elbow joint should, because of the lack of a possible compensation in lost function, be only considered an ultima ratio. The main issue is to restore joint stability and at the same time to preserve function to the highest possible extent by using the remaining joint structures. Our concept used to reach this aim will be described by demonstration in the following evaluation.
Methods: During the period from January, 2000 through November, 2001 we performed revision surgery on 13 patients an average of 4 months after fracture-dislocation of their elbow. In nine patients, the radial head had been initially removed and replaced by prostheses. In 12 patients, we found an avulsion of the coronoid process that had not been reattached to its origin. Four joints were stiff with only minimal and painful remaining range of motion, the rest showing severely restricted mobility. Eight of them were in a position of subluxation. In three patients, we found a persisting ulnar instability, two of them even bilateral. In one case a wound infection had developed. Two patients also had accompanying lesions of neurologic structures. The surgical reconstructions were made to measure individually following the requirements of the injury. After an open revision of the joint and neurolysis of the ulnar nerve the coronoid process was reconstructed by autologous iliac crest graft in 10 patients. In seven patients, a prosthetic replacement of the radial head was implanted. In three patients, a revision of the previous internal fixation of the ulna had to be performed, on four locations with autologous bone graft. The collateral ligaments were additionally reconstructed in cases of persisting instability. In six patients, a dynamic external fixator was applied for 6 weeks. The follow-up extended at least 6 months, with regular intermittent clinical evaluation.
Results: All operated joints were stable. In three patients, an open-joint revision with resection of restricting periarticular calcifications was necessary, during which two of the previously implanted radial head protheses could be removed because the joint was stable. Active range of movement had been improved considerably in all directions. Assuming an original mobility of 0 to 41.5 - 83.5° in extension/flexion and 33.5 - 0 - 35.8° in pronation/supination, an average postoperative range of motion of 0 - 31.9 - 111.9° and 66.5 - 0 - 65.3° was achieved. Two patients developed temporary postoperative loss of sensation due to neurapraxia of the ulnar and radial nerve. In the case of the infected elbow joint, the complete eradication was not achieved, despite the successful stabilizing joint reconstruction.
Conclusion: Even the unfavorable results of an unhappy triad lesion in fracture-dislocations of the elbow joint can be successfully surgically treated with secondary revision, even if late. The primary requirement for a successful treatment is a firm surgical concept of reestablishing the former joint stability and mobility. Satisfactory range of movement of the elbow joint can be restored in this way. Especially for young patients, this is a recommendable alternative to joint replacement or fusion.