I have nothing to disclose Samantha Piper, MD Jennifer - - PowerPoint PPT Presentation

5/10/2013 1

Samantha Piper, MD Jennifer Tangtiphaiboontana, BA Lisa Lattanza, MD UCSF Inman Abbott Conference May 10, 2013

I have nothing to disclose Background

Chronic post-traumatic elbow dislocation is rare and

functionally devastating.

Missed or untreated initial dislocation Failed reduction or reconstruction with recurrent

dislocation Restoring a stable, painless elbow with a functional arc of motion is challenging even in acute injury.

• Osseous reconstruction & restored joint congruency

Radial head, Coronoid, Olecranon

• Ligamentous reconstruction

LUCL, MCL

• Also must address: arthrosis, ulnar neuropathy, H.O.,

contracture

McKee et al, JBJS, 2004; Forthman et al, JHS, 2007; Rodriguez-Martin et al, SICOT, 2011

Background

There is limited literature describing surgical

treatment of chronic elbow dislocations.

Jupiter 2002: 5 pts, simple DL

OR & hinged ex fix only

Ring 2004: 13 pts, complex DL or SL

ORIF coronoid, radial head, LUCL, hinged ex fix

Majima 2007: 3 pts, 2 simple 1 complex DL

OR, MCL and LUCL, LAC x 2 weeks

Ivo 2009: 3 pts, complex DL

OR, revision ORIF, ex fix. No ligament reconstruction.

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Study Aims

Identify patterns of injury that might lead to

chronic elbow dislocation

Evaluate outcomes of surgical treatment of

chronic elbow dislocations

Methods

Retrospective review of all elbow stabilization

procedures after dislocation to identify chronic elbow dislocations.

Single surgeon at a single institution January 2003 - September 2012 Chronic dislocation >4 weeks (c/w literature) Exclusion criteria: < 4wks DL, immediate conversion

to TEA

IRB approved study

Methods

9 patients fit criteria of chronic complete elbow

dislocation.

Mean duration of dislocation 39.7 weeks (4-230.1) 4 women & 5 men Mean age 37.4 years (24-47) 5 injured dominant side 3 MCA, 2 MVA, 1 fall from standing, 1 fall from

horse, 1 fall from bike, 1 assault

1 cranial injury with ICU stay

Mean UCSF follow up 20.8 months (1.8-30.1)

Surgical and Rehab Protocol

A standard surgical protocol was used to restore a

concentrically reduced elbow through a full ROM.

• Incision based on pathology/previous incisions

Open reduction Radial head ORIF/arthroplasty Coronoid fixation or reconstruction LUCL reconstruction MCL reconstruction

• If remains unstable

Hinged external fixation

• Protect ligament reconstruction

Post-op rehab consisted of:

3-5 days post-op: PNI (while inpatient) 1 day-4 weeks post-op: Elbow CPM 4 weeks post-op: PT for progressive ROM/strengthening 6 weeks post-op: Static progressive elbow splint

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Methods

2 Simple, 7 Complex 2 Open 7 Coronoid fx

• 2 Type I, 2 Type II, 3 Type III (Morrey)
• 4 Anteromedial (O’Driscoll II)

5 Terrible Triad 3 Monteggia 2 Essex-Lopresti 5 had one or more stabilization procedures prior to

presentation to UCSF

Methods

4 radial head arthroplasty, 1 revision arthroplasty, 1 radial neck

shortening, 1 excision

• At OSH: 1 ORIF, 1 prior excision, 3 no prior tx

2 coronoid fixation (1 ORIF buttress plate, 1 patellar allograft

buttress plate)

• At OSH: 2 treated- 1 healed, 1 failed

9 LUCL reconstruction

• At OSH: 2 LUCL reconstruction- failed

5 MCL reconstruction (2 in TT, 2 in anteromedial coronoid fx)

• At OSH: 1 MCL reconstruction- failed

8 ex fix, avg. duration 6.2 weeks

• At OSH: 2 ex fix at OSH (4 wks), 1 transhumeral pin (3wks)

3 interposition arthroplasty

Results

• At final follow up:
• All pts had a significant improvement in ROM
• Mean pre-op flexion/extension arc 44.1°, mean post-op 119.9°

(p=0.0013)

• Mean pre-op pronation/supination arc 92.5°, mean post-op 143.8°

(p=0.038)

• 7 maintained concentrically reduced, stable joints
• 8 were pain free with all activities

Results

Complications:

1 conversion to TEA (failed coronoid allograft

during aggressive PT)

Type III coronoid

1 re-dislocated secondary to patient seizure

Type III coronoid not re-constructible

1 revised LUCL at 3 weeks post op 2 superficial infections treated with antibiotics only 3 heterotopic ossification

2 required resection

3 ulnar neuropraxias

All resolved by final follow up without treatment

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Conclusions

In this small case series, chronic elbow dislocations with a

Type III coronoid fracture that could not be reconstructed failed stabilization.

56% required MCL reconstruction to maintain stability. A stable and painless elbow with a functional arc of motion

can be restored after a chronic elbow dislocation.

Patients should be counseled regarding the high rate of

complications with chronic elbow stabilization.

THANK YOU! Results

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Pre-op

Post-op

Neglegted medial elbow- MCL and medial bony injuries? Can still make elbow functionaly after 4 years dl BIf no coronoid left to fix, stability will be difficult even with soft tissue reconst. May need to allograft coronoid, but this has poor results. Subcategory of elbow dl/fx/dl that do not remain stable after reduction and treatment with standard protocol or standard protocol is not followed

• 9 pts, sought to identify characteristics of this subcategory
• Anertomedial, not just the anterior coronoid fx that can lead to instability if not fixed.
• Simple soft tissue injury if fully stripped
• Gram King ppr
• 8 complex, 1 simple (but type $ so no soft tissue attachments)