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      Does surgical approach affect outcome after fixation of intra-articular fractures of distal humerus? Retrospective cohort study from a level-1 trauma centre in a metropolitan city

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          Abstract

          Introduction

          Fractures around the distal humerus fractures make up to 2% of all fractures. Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint. Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction. Conflict still persists regarding the choice of ideal approach. In this study we compare the effect of surgical approach triceps lifting vs olecranon osteotomy on the functional outcome after fixation of distal humerus fractures.

          Methods

          Non-funded, non-commercial, retrospective cohort study was conducted on patients with closed distal humerus intra-articular fractures between 2010 and 2015 at our tertiary care level-1 trauma and university hospital. Patients >18 years of age with closed complex intra-articular distal humerus fracture were operated using one of the two surgical approaches, either triceps lifting approach (Group1) or with olecranon osteotomy (Group 2). Functional evaluation using quick DASH scores at 1 year of follow-up. Study is registered with ID:NCT03833414 and work has been reported in line with the STROCSS criteria.

          Results

          Out of 43 patients 16 were treated with triceps lifting approach and 27 with olecranon osteotomy. The difference between the mean quick DASH score for both groups was not statistically significant (p = 0.52) although higher for group 1. Complications were comparable for both groups but 2 patients suffered delayed union of osteotomy site in group 2.

          Conclusion

          Triceps lifting approach can be used equally efficiently for exposure of these complex distal humerus injuries with no comprise in visibility of articular fragments.

          Highlights

          • •

            Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint.

          • •

            Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction.

          • •

            For long time, olecranon osteotomy approach was utilized to provide clear access to the joint.

          • •

            This is at the cost of creating osteotomy and the risk of its delayed/nonunion.

          • •

            Triceps lifting approach avoids this catastrophic complication.

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          Most cited references10

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          General principles for the clinical use of the LCP.

          Michael Wagner (2003)
          The basic principles of an internal fixation procedure using a conventional plate and screw system (compression method) are direct, anatomical reduction and stable internal fixation of the fracture. Wide exposure of the bone is usually necessary to gain access to and provide good visibility of the fracture zone to allow reduction and plate fixation to be performed. This procedure requires pre-contouring of the plate to match the anatomy of the bone. The screws are tightened to fix the plate onto the bone, which then compresses the plate onto the bone. The actual stability results from the friction between the plate and the bone. Anatomical reduction of the fracture was the goal of conventional plating technique, but over time a technique for bridging plate osteosynthesis has been developed for multifragmentary shaft fractures that, thanks to a reduction of vascular damage to the bone, permits healing with callus formation, as seen after locked nailing. Since the damage to the soft tissues and the blood supply is less extensive, more rapid fracture healing can be achieved. The newly developed, so-called locked internal fixators (e.g.PC-Fix and Less Invasive Stabilization System (LISS)), consist of plate and screw systems where the screws are locked in the plate. This locking minimizes the compressive forces exerted by the plate on the bone. This method of screw-plate fixation means that the plate does not need to touch the bone at all, which is of particular advantage in so-called Minimal Invasive Percutaneous Osteosynthesis (MIPO). Precise anatomical contouring of a plate is no longer necessary thanks to these new screws and because the plate does not need to be pressed on to the bone to achieve stability. This prevents primary dislocation of the fracture caused by inexact contouring of a plate. The LISS plates are precontoured to match the average anatomical form of the relevant site and, therefore, do not have to be further adapted intraoperatively. The development of the locked internal fixator method has been based on scientific insights into bone biology especially with reference to its blood supply. The basic locked internal fixation technique aims at flexible elastic fixation to initiate spontaneous healing, including its induction of callus formation. This technology supports what is currently known as MIPO. The development of the Locking Compression Plate (LCP) has only been possible based on the experience gained with the PC-Fix and LISS. With reference to the mechanical, biomechanical and clinical results, the new AO LCP with combination holes can be used, depending on the fracture situation, as a compression plate, a locked internal fixator, or as an internal fixation system combining both techniques. The LCP with combination holes can also be used, depending on the fracture situation, in either a conventional technique (compression principle), bridging technique (internal fixator principle), or a combination technique (compression and bridging principles). A combination of both screw types offers the possibility to achieve a synergy of both internal fixation, methods. If the LCP is applied as a compression plate, the operative technique is much the same as conventional technique, in which existing instruments and screws can be used. The internal fixator method can be applied through an open but less invasive or an MIPO approach. An indirect closed reduction is necessary when using the LCP in the internal fixator method bridging the fracture zone. A combination of both plating techniques is possible and valuable, depending on the indication. It is important to command a knowledge of both techniques and their different features.
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            A clinical comparison of two different double plating methods for intraarticular distal humerus fractures.

            Sang-Jin Shin, Hoon-Sang Sohn, Nam-Hoon Do (2010)
            This study compared clinical outcomes in patients with intraarticular distal humerus fractures treated using 2 different double plating methods. Seventeen patients were treated by perpendicular plating (group I) and 18 by parallel plating (group II) methods. Arc of flexion averaged 106 degrees +/-23 degrees in group I and 112 degrees +/-19 degrees in group II. Eleven patients in group I recovered full arc of flexion and 13 patients in group II achieved full arc of flexion. All patients obtained bone union, except 2 patients in group I. Nonunion in these patients developed in the supracondylar area. Complications developed in 6 patients in group I and in 8 in group II. No significant differences were found between the clinical outcomes of the 2o plating methods. Although more patients failed to achieve bony union in the perpendicular plating group, both parallel and orthogonal plates positioning can provide adequate stability and anatomic reconstruction of the distal humerus fractures. 2.
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              Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus.

              Gang Chen, DA ZHONG, Wei Luo … (2011)
              The purpose of this study was to compare the triceps-sparing approach with olecranon osteotomy regarding their effects on the functional outcomes of intercondylar fractures of the distal humerus managed with open reduction and internal fixation (ORIF), by reviewing 67 cases of intercondylar distal humerus fractures surgically managed with either of the approaches during 2001-2009. The medical records and radiographs of 30 male and 37 female patients, with a mean age of 44.5 years (range, 16-77) and a mean follow-up time of 34.3 months (range, 6-89), were retrospectively reviewed. Flexion, extension, arc of flexion/extension, pronation, supination, arc of pronation/supination and the Mayo Elbow Performance Score (MEPS) were used to assess the functional outcomes of intercondylar distal humerus fractures treated with ORIF through the triceps-sparing approach or olecranon osteotomy. According to the AO Foundation (AO) classification, there were 10 cases of C1, 28 cases of C2 and 29 cases of C3 fractures. At the time of review, all fractures had united. Although there was no overall statistically significant difference in the average flexion, extension, arc of flexion/extension, pronation, supination and arc of pronation/supination between the triceps-sparing group (n=34) and the olecranon osteotomy group (n=33), patients above 60 years of age tended to have more extension loss (mean 22.9°, range 0-55°) after ORIF via the triceps-sparing approach, compared with any other surgical approach/age combination group. In the triceps-sparing group, although only 37.5% of patients over the age of 60 years obtained excellent/good MEPS, the rate increased to 100% in patients aged less than 40 years of age (P<0.05). By contrast, the rate of excellent/good MEPS remained above 80% in all age groups of patients treated with ORIF via olecranon osteotomy. In conclusion, ORIF via the triceps-sparing approach confers inferior functional outcomes for intercondylar distal humerus fractures in patients over the age of 60 years, for whom the olecranon osteotomy approach may be a better choice. However, for patients less than 60 years of age, especially those less than 40 years of age, either approach confers satisfactory outcomes. Copyright © 2010 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Mohammad Atif
                Obada Hasan
                Yasir Mohib
                Rizwan Haroon Rashid
                Pervaiz Hashmi
                Journal
                Journal ID (nlm-ta): Ann Med Surg (Lond)
                Journal ID (iso-abbrev): Ann Med Surg (Lond)
                Title: Annals of Medicine and Surgery
                Publisher: Elsevier
                ISSN (Electronic): 2049-0801
                Publication date PMC-release: 03 June 2019
                Publication date Collection: July 2019
                Publication date (Electronic): 03 June 2019
                Volume: 43
                Pages: 48-51
                Affiliations
                [a ]Central Park Medical College, Lahore, Pakistan
                [b ]Department of Surgery, Section of Orthopedics, The Aga Khan University Hospital, Pakistan
                Author notes
                [∗ ]Corresponding author. The Aga Khan University Hospital, Surgery department, National stadium road P.O, Box 3500. Karachi 74800, Pakistan. obada.husseinali@ 123456gmail.com
                Article
                Publisher ID: S2049-0801(19)30047-0
                DOI: 10.1016/j.amsu.2019.05.012
                PMC ID: 6556481
                PubMed ID: 31198551
                SO-VID: 1953d544-cbe7-46f1-9b3f-1d6e0238b988
                Copyright © © 2019 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
                License:

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 8 February 2019
                Date revision received : 23 May 2019
                Date accepted : 24 May 2019
                Categories
                Subject: Original Research

                Keywords: intra-articular fractures,humerus,osteotomy,elbow joint
                Data availability:
                Keywords: intra-articular fractures, humerus, osteotomy, elbow joint

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