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A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: Single-column plating
Injury, Int. J. Care Injured 44 (2013) 1620–1624
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: Single-column plating Gregory M. Meloy a, Matthew A. Mormino b, Peter A. Siska a, Ivan S. Tarkin a,* a b
University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Pittsburgh, PA, USA University of Nebraska Medical Center, Department of Orthopaedic Surgery, Omaha, NE, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 5 July 2013
Objectives: The study aimed (1) to examine if there are equivalent results in terms of union, alignment and elbow functionally comparing single- to dual-column plating of AO/OTA 13A2 and A3 distal humeral fractures and (2) if there are more implant-related complications in patients managed with bicolumnar plating compared to single-column plate fixation. Design: This was a multi-centred retrospective comparative study. Setting: The study was conducted at two academic level 1 trauma centres. Patients/participants: A total of 105 patients were identified to have surgical management of extraarticular distal humeral fractures Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 13A2 and AO/OTA 13A3). Intervention: Patients were treated with traditional dual-column plating or a single-column posterolateral small-fragment pre-contoured locking plate used as a neutralisation device with at least five screws in the short distal segment. Main outcome measurements: The patients’ elbow functionality was assessed in terms of range of motion, union and alignment. In addition, the rate of complications between the groups including radial nerve palsy, implant-related complications (painful prominence and/or ulnar nerve neuritis) and elbow stiffness were compared. Results: Patients treated with single-column plating had similar union rates and alignment. However, single-column plating resulted in a significantly better range of motion with less complications. Conclusions: The current study suggests that exposure/instrumentation of only the lateral column is a reliable and preferred technique. This technique allows for comparable union rates and alignment with increased elbow functionality and decreased number of complications. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Distal humeral fracture Extra-articular Single-column plating Dual-column plating
Introduction Open reconstruction of extra-articular distal humeral fracture has traditionally been performed with the use of orthogonal plating [1–4]. This strategy is typically effective in creating a biomechanical milieu of absolute stability to encourage uneventful union with optimal alignment. Further, rigid bicolumnar plating allows for aggressive early rehabilitation to optimise elbow functionality. However, dual plating in the context of a diminutive soft-tissue envelope infamously leads to implant-related complications. In fact,
* Corresponding author at: Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA. Tel.: +1 412 605 3262; fax: +1 412 687 3724. E-mail address: [email protected] (I.S. Tarkin). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.07.005
ulnar neuritis reportedly occurs in upwards of 51% of patients following open reduction and internal fixation of distal humeral fractures using the dual-plating technique [5]. As an alternative to bicolumnar plating, single plating using a fixed-angle pre-contoured device is an attractive option [6–8]. Cordero et al. reported in a multicentre study that this technique is both safe and efficacious. A union rate of 97% was reported with minimal risk of iatrogenic complication such as nerve injury [6]. However, we know of no report to date that has compared the results of single-plate fixation of extra-articular distal humerus fractures to dual plating. The purpose of this study is to compare the surgical reconstruction of extra-articular distal humerus fractures with traditional bicolumnar plating to single-plate fixation using a precontoured posterolateral-based locking plate. Two hypotheses are proposed: (1) equivalent results in terms of union, alignment and
G.M. Meloy et al. / Injury, Int. J. Care Injured 44 (2013) 1620–1624
1621
The cohorts were examined for statistical differences in demographics (paired t-test) and fracture type (chi-squared test). The paired t-test was used to compare differences in the elbow range of motion. The chi-squared test was performed to examine the differences in union rate and number of complications between patients managed with the single- or the double-plating technique. Results Demographics
Fig. 1. (a) Preop AO/OTA 13A3 distal humeral fracture. (b) Single column plating with a precontoured small fragment posterolateral locking plate used as a neuturalization device with 5 fixed angle screws in the short distal segment. Immediate rehabilitation instituted after wound healing resulting in optimal elbow functionality.
elbow functionally will be realised on comparing single- to dualcolumn plating and (2) more implant-related complications will occur in patients managed with bicolumnar plating. Materials and methods The orthopaedic trauma databases at two academic level-1 trauma centres was used to identify all patients who had undergone operative fixation for closed distal humeral fracture. All extraarticular fractures (Arbeitsgemeinschaft fu¨r Osteosynthesefragen/ Orthopaedic Trauma Association, AO/OTA 13A2 and A3) from 2006 to present were included for further review. All patients included in the study were followed up at least until fracture union. During the study period, single-column locked posterolateral plating through a lateral paratricipital approach (Fig. 1) evolved into the preferred treatment paradigm. This group of patients has previously been reported in a study identifying the safety and efficacy of this technique [6]. In the current study, this new treatment strategy was compared to the more traditional bicolumnar plating technique using either triceps splitting or preserving exposures. For purposes of this study, fracture union was defined by bridging bone noted on three of four cortices on orthogonal radiographs by 4 months by an independent reviewer not involved with the initial surgical management of the patient. The elbow range of motion was recorded. Further, specific complications such as nonunion, malunion, radial nerve palsy and implant-related complications (painful prominence and or ulnar nerve neuritis) were recorded.
A total of 105 patients with an extra-articular distal humeral fracture comprised the study group (Table 1). Group 1 was managed with dual-column plating while single plating was performed for group 2. No statistical difference was found between the groups’ age and fracture type. The mean duration of follow-up was 6.1 months (range 2–24 months). Group 1 consisted of 53 extra-articular distal humeral fractures treated with dual-column plating. Of those, 43 had an A3 fracture and five had an A2 fracture. Five patients were excluded due to inadequate follow-up, leaving 48 in Group 1. The mean age of the dual-plating cohort was 43 22.16 years. Group 2 comprised 51 patients who were managed with a single pre-contoured posterolateral locking plate. Thirty seven patients had an A3 fracture, and eight had an A2 fracture. The mean age of the single-plating cohort was 35 19.4 years. Six of those patients had inadequate follow-up for evaluation of outcomes. Fracture union and alignment Comparable union rates were realised for both groups. All patients in Group 1 went on to union, while the union rate in Group 2 was 97.8%. The difference in union rates was not statistically significant (p = 0.15). One patient in Group 2 sustained a highenergy fall 1 month postoperatively resulting in hardware failure. She was revised to a double-plating strategy. Another patient in Group 2 had delayed union with 118 malunion in the sagittal plane secondary to postoperative bending of the plate without catastrophic failure. The rest of the cases in both groups (97.8% of the total) were aligned within 58 of the anatomical axis. Elbow range of motion In comparing the range of motion between the two cohorts, Group 2 (single plating) had better overall range of motion than Group 1. In Group 1 (dual plating), the mean elbow flexion achieved was 127.09 14.968 and the mean elbow extension was – 12.44 10.848. In Group 2, the mean elbow flexion achieved was 136.1 7.78 and the mean elbow extension was – 3.62 4.968. The difference between the groups in both elbow flexion and extension was found to be statistically significant (p < 0.05). Complications The overall complication rate was significantly greater in Group 1 (dual plating) compared to Group 2 (single plating) (p = 0.002).
Table 1 Patient characteristics. Number included
Number excluded
Age
Sex
Fracture type
Implant irritation
Elbow stiffness
Tricep rupture
Premature hardware failure
Iatrogenic radial nerve injury
Dual plating
48
5
43 22.16
3
1
0
6
45
6
35 19.4
A2-5 A3-43 A2-8 A3-37
5
Single plating
31f 18m 23F 22M
1
0
0
1
0
1622
G.M. Meloy et al. / Injury, Int. J. Care Injured 44 (2013) 1620–1624
Fig. 2. (a) Follow up film at 2 months with radiographic evidence of noncatastrophic plate and lag screw failure (bending). (b)–(d) Fortunately, patient uneventfully united fracture with optimal functional result by the 6 month follow up visit.
A total of 15 complications were noted in Group 1, of which a majority were implant related. Five patients complained of pain that was attributed to implant irritation and ulnar neuritis. Two insisted on removal of the hardware. The other three patients chose not to undergo a second operation after the risks of surgery were detailed. Three patients had significant elbow stiffness necessitating secondary operative intervention. One patient sustained a triceps rupture, requiring repair. Six patients sustained iatrogenic radial nerve palsies. Of those, four patients partially recovered and two did not recover. There were three complications in Group 2. As noted previously, one patient had catastrophic hardware failure requiring operative revision. One patient had delayed union and subsequent malunion (Fig. 2). Only one patient complained of pain due to the hardware and subsequently underwent removal of hardware procedure. There were no cases of iatrogenic radial nerve palsies. Discussion The purpose of this study was to compare outcomes after surgical reconstruction of extra-articular distal humerus fractures using two different surgical strategies. Results after traditional bicolumnar plating were compared to a more modern protocol using a single pre-contoured posterolateral locking plate. Comparable union rates and alignments were realised. However, improved elbow functionality was realised with single-column fixed-angle plating versus dual-column plating. Further, more surgical complications were noted when bicolumnar plating was used, including painful hardware/ulnar neuritis, elbow stiffness and radial nerve palsy. Traditionally, dual-column plating has been the standard of care for surgical reconstruction of distal humeral fractures (Fig. 3) [1–4]. Two plates were deemed necessary to provide multiple points of fixation into the short distal segment in order to achieve fracture union and preserved alignment. This study refutes the concept that dual-column fixation is needed in select AO/OTA 13 A2 and A3 fractures as comparable union rates and alignments were seen using single-column plate fixation. In all cases in our
series, at least five fixed-angle screws into the distal block through a single posterolateral plate were sufficient to promote rigid fixation to union. The high incidence of implant-related complications and ulnar neuritis infamously plagues the dual-column plating technique. The incidence of ulnar neuritis following surgical reconstruction of the distal humerus has been reported to occur as high as 51% of the time [5,9–13]. Exposure of the medial column and placement of an implant adjacent to the cubital tunnel is presumably causative. Ulnar nerve transposition has been recommended to decrease the incidence of this problem; yet, Chen et al. report neuritis in approximately 10% of cases despite this technique [5]. Limited exposure and instrumentation of the medial column would presumably decrease implant-related problems after operation for distal humerus fracture. The prospect of singlecolumn posterolateral plating has been explored. Moran et al. examined seven distal humeral fractures with single-column plating using a 4.5 plate that was intra-operatively contoured to fit the posterolateral humerus. All seven cases went on to uneventful union with optimal alignment with preserved shoulder and elbow function [7]. Levy et al. examined single-plate fixation with a posterolateral plate using a customised 4.5 plate designed for the tibia to match the anatomy of the distal humerus to gain necessary fixation into the short distal segment [8]. In their series, all 15 patients had an uneventful union, with no complications noted [8]. Tejwani et al. further investigated the biomechanics of singleversus double-plate fixation in a cadaveric distal humerus injury model [14]. They noted a significantly stiffer construct in anterior, posterior and lateral bending with dual plating, but no difference in axial compression or torsion, with both constructs having similar failure strengths [14]. The current study suggests that exposure/ instrumentation of only the lateral column is a reliable and preferred technique as the ulnar nerve is left undisturbed. An unexpected, yet further positive outcome of single versus double plating is regarding iatrogenic radial nerve injury. With dual plating, six patients sustained iatrogenic radial nerve palsies. We potentially attribute this to the surgical approach for single-column
G.M. Meloy et al. / Injury, Int. J. Care Injured 44 (2013) 1620–1624
1623
less hardware-related tension on the radial nerve with this technique. Despite the success we report of single-plating- versus dualplating constructs, one important caveat needs further description. All comminuted distal humerus cases in this report managed with a single locked posterolateral plate were initially fixated with direct reduction and interfragmentary compression using lag screws. The plate was applied as a neutralisation device; it was not examined as a bridging device. Further, in excessively comminuted AO/OTA 13A3 fractures, the surgeon should always supplement fixation with an orthogonal plate in order to enhance stability to promote uneventful union and rehabilitation. Despite the comparative nature of this study, certain limitations must be addressed. The study is retrospective in nature and the choice of the surgical approach including fixation strategy was at the discretion of the treating surgeon. For instance, surgical exposure was not controlled for in this study. This potentially could be a dependent variable influencing results. Although a paratricipetal approach was used exclusively in the single-plated group, a triceps splitting or reflecting technique was used in the double-column plating group. Tarkin et al. have shown that triceps-sparing approaches versus splitting techniques positively influence ultimate elbow function in terms of motion and strength [15]. Further, in the current study residual pain was attributed to implant irritation. Pain, however, certainly can be multifactorial in origin and not directly attributable to indwelling implants. Future prospective studies would be able to overcome the limitations of this study. Conclusion
Fig. 3. Traditional dual column plating through triceps splitting exposure. This technique statistically associated with higher incidence of complication especially implant irritation and nerve injury.
plating. A lateral paratricipital approach was used, which allowed for improved mobilisation and protection of the radial nerve from the level of the lateral intermuscular septum through the spiral groove (Fig. 4). Further, in comparison to dual plating, there was
Surgical reconstruction of extra-articular distal humeral fractures has traditionally been performed with rigid fixation using a bicolumnar plating technique. However, hardware irritation and ulnar neuritis are common. Single-column plating with a pre-contoured posterolateral locking plate offers similar union rates to dual-column plating and in addition has significantly fewer complications with improved elbow range of motion. Single-column plating can safely be performed using a lateral paratricipital approach, which was associated with no iatrogenic radial nerve palsies in our series. Conflicts of interests The authors have no conflicts of interests to disclose, and there was no external funding provided for this research. Acknowledgement Special thanks to Dana Farrell for her dedication to orthopaedic trauma research and preparation of the data for this manuscript. References
Fig. 4. No iatrogenic radial nerve injuries associated with single plating cohort. Lateral paratricipital approach used in all cases. This exposure allows for complete neurolysis and mobilisation of the radial nerve (yellow vessel loop). (For interpretation of the references to color in figure legend, the reader is referred to the web version of the article.)
[1] Anglen J. Distal humerus fractures. J Am Acad Orthop Surg 2005;13:291–7. [2] Galano BJ, Ahmad CS, Levine WN. Current strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg 2010;18(1):20–30. [3] Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am 2011;93(7):686–700. [4] Ring D, Jupiter JB. Fractures of the distal humerus. Orthop Clin North Am 2000;31:103–13. [5] Chen RC, Harris DJ, Leduc S, Borrelli Jr JJ, Tornetta III P, Ricci WM. Is ulnar nerve transposition beneficial during open reduction and internal fixation of distal humerus fractures? J Orthop Trauma 2010;24(7):391–4. [6] Cordero GX, Daccarett MS, Fehringer EV, Siska PA, Evans AR, Sands S, et al. Operative treatment of extra-articular distal humerus fractures utilizing single-column plating. In: Presented at Orthopedic Trauma Association; 2011. [7] Moran MC. Modified lateral approach to the distal humerus for internal fixation. Clin Orthop Relat Res 1997;340:190–7.
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[8] Levy JC, Kalandiak SP, Hutson JJ, Zych G. An alternative method of osteosynthesis for distal humeral shaft fractures. J Orthop Trauma 2005;18:43– 7. [9] Worden A, Ilyas AM. Ulnar neuropathy following distal humerus fracture fixation. Orthop Clin North Am 2012 Oct;43(4):509–14. [10] Vazquez O, Rutgers M, Ring DC, Walsh M, Egol KA. Fate of the ulnar nerve after operative fixation of distal humerus fractures. J Orthop Trauma 2010;24(7):395–9. [11] Wang KC, Shih HN, Hsu KY, Shih CH. Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach. J Trauma 1994;36:770–3.
[12] McKee MD, Jupiter JB, Bosse G, Goodman L. Outcome of ulnar neurolysis during posttraumatic reconstruction of the elbow. J Bone Joint Surg Br 1998;80:100–5. [13] Ruan HJ, Liu JJ, Fan CY, Jiang J, Zeng BF. Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus. J Trauma 2009;67:1397–401. [14] Tejwani NC, Murthy A, Park J, McLaurin TIM, Egol KA, Kummer FJ. Fixation of extra-articular distal humerus fractures using one locking pate versus two reconstruction plates: a laboratory study. J Trauma 2009;66(3):795–9. [15] Illical EM, Siska PA, Evans AR, Tarkin IS. Comparison of outcomes after triceps split vs. sparing surgery for extra-articular distal humeral fracture. In: Presented at American Academy of Orthopedic Surgeons; 2013.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
A paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: Single-column plating Gregory M. Meloy a, Matthew A. Mormino b, Peter A. Siska a, Ivan S. Tarkin a,* a b
University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Pittsburgh, PA, USA University of Nebraska Medical Center, Department of Orthopaedic Surgery, Omaha, NE, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 5 July 2013
Objectives: The study aimed (1) to examine if there are equivalent results in terms of union, alignment and elbow functionally comparing single- to dual-column plating of AO/OTA 13A2 and A3 distal humeral fractures and (2) if there are more implant-related complications in patients managed with bicolumnar plating compared to single-column plate fixation. Design: This was a multi-centred retrospective comparative study. Setting: The study was conducted at two academic level 1 trauma centres. Patients/participants: A total of 105 patients were identified to have surgical management of extraarticular distal humeral fractures Arbeitsgemeinschaft fu¨r Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 13A2 and AO/OTA 13A3). Intervention: Patients were treated with traditional dual-column plating or a single-column posterolateral small-fragment pre-contoured locking plate used as a neutralisation device with at least five screws in the short distal segment. Main outcome measurements: The patients’ elbow functionality was assessed in terms of range of motion, union and alignment. In addition, the rate of complications between the groups including radial nerve palsy, implant-related complications (painful prominence and/or ulnar nerve neuritis) and elbow stiffness were compared. Results: Patients treated with single-column plating had similar union rates and alignment. However, single-column plating resulted in a significantly better range of motion with less complications. Conclusions: The current study suggests that exposure/instrumentation of only the lateral column is a reliable and preferred technique. This technique allows for comparable union rates and alignment with increased elbow functionality and decreased number of complications. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Distal humeral fracture Extra-articular Single-column plating Dual-column plating
Introduction Open reconstruction of extra-articular distal humeral fracture has traditionally been performed with the use of orthogonal plating [1–4]. This strategy is typically effective in creating a biomechanical milieu of absolute stability to encourage uneventful union with optimal alignment. Further, rigid bicolumnar plating allows for aggressive early rehabilitation to optimise elbow functionality. However, dual plating in the context of a diminutive soft-tissue envelope infamously leads to implant-related complications. In fact,
* Corresponding author at: Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA. Tel.: +1 412 605 3262; fax: +1 412 687 3724. E-mail address: [email protected] (I.S. Tarkin). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.07.005
ulnar neuritis reportedly occurs in upwards of 51% of patients following open reduction and internal fixation of distal humeral fractures using the dual-plating technique [5]. As an alternative to bicolumnar plating, single plating using a fixed-angle pre-contoured device is an attractive option [6–8]. Cordero et al. reported in a multicentre study that this technique is both safe and efficacious. A union rate of 97% was reported with minimal risk of iatrogenic complication such as nerve injury [6]. However, we know of no report to date that has compared the results of single-plate fixation of extra-articular distal humerus fractures to dual plating. The purpose of this study is to compare the surgical reconstruction of extra-articular distal humerus fractures with traditional bicolumnar plating to single-plate fixation using a precontoured posterolateral-based locking plate. Two hypotheses are proposed: (1) equivalent results in terms of union, alignment and
G.M. Meloy et al. / Injury, Int. J. Care Injured 44 (2013) 1620–1624
1621
The cohorts were examined for statistical differences in demographics (paired t-test) and fracture type (chi-squared test). The paired t-test was used to compare differences in the elbow range of motion. The chi-squared test was performed to examine the differences in union rate and number of complications between patients managed with the single- or the double-plating technique. Results Demographics
Fig. 1. (a) Preop AO/OTA 13A3 distal humeral fracture. (b) Single column plating with a precontoured small fragment posterolateral locking plate used as a neuturalization device with 5 fixed angle screws in the short distal segment. Immediate rehabilitation instituted after wound healing resulting in optimal elbow functionality.
elbow functionally will be realised on comparing single- to dualcolumn plating and (2) more implant-related complications will occur in patients managed with bicolumnar plating. Materials and methods The orthopaedic trauma databases at two academic level-1 trauma centres was used to identify all patients who had undergone operative fixation for closed distal humeral fracture. All extraarticular fractures (Arbeitsgemeinschaft fu¨r Osteosynthesefragen/ Orthopaedic Trauma Association, AO/OTA 13A2 and A3) from 2006 to present were included for further review. All patients included in the study were followed up at least until fracture union. During the study period, single-column locked posterolateral plating through a lateral paratricipital approach (Fig. 1) evolved into the preferred treatment paradigm. This group of patients has previously been reported in a study identifying the safety and efficacy of this technique [6]. In the current study, this new treatment strategy was compared to the more traditional bicolumnar plating technique using either triceps splitting or preserving exposures. For purposes of this study, fracture union was defined by bridging bone noted on three of four cortices on orthogonal radiographs by 4 months by an independent reviewer not involved with the initial surgical management of the patient. The elbow range of motion was recorded. Further, specific complications such as nonunion, malunion, radial nerve palsy and implant-related complications (painful prominence and or ulnar nerve neuritis) were recorded.
A total of 105 patients with an extra-articular distal humeral fracture comprised the study group (Table 1). Group 1 was managed with dual-column plating while single plating was performed for group 2. No statistical difference was found between the groups’ age and fracture type. The mean duration of follow-up was 6.1 months (range 2–24 months). Group 1 consisted of 53 extra-articular distal humeral fractures treated with dual-column plating. Of those, 43 had an A3 fracture and five had an A2 fracture. Five patients were excluded due to inadequate follow-up, leaving 48 in Group 1. The mean age of the dual-plating cohort was 43 22.16 years. Group 2 comprised 51 patients who were managed with a single pre-contoured posterolateral locking plate. Thirty seven patients had an A3 fracture, and eight had an A2 fracture. The mean age of the single-plating cohort was 35 19.4 years. Six of those patients had inadequate follow-up for evaluation of outcomes. Fracture union and alignment Comparable union rates were realised for both groups. All patients in Group 1 went on to union, while the union rate in Group 2 was 97.8%. The difference in union rates was not statistically significant (p = 0.15). One patient in Group 2 sustained a highenergy fall 1 month postoperatively resulting in hardware failure. She was revised to a double-plating strategy. Another patient in Group 2 had delayed union with 118 malunion in the sagittal plane secondary to postoperative bending of the plate without catastrophic failure. The rest of the cases in both groups (97.8% of the total) were aligned within 58 of the anatomical axis. Elbow range of motion In comparing the range of motion between the two cohorts, Group 2 (single plating) had better overall range of motion than Group 1. In Group 1 (dual plating), the mean elbow flexion achieved was 127.09 14.968 and the mean elbow extension was – 12.44 10.848. In Group 2, the mean elbow flexion achieved was 136.1 7.78 and the mean elbow extension was – 3.62 4.968. The difference between the groups in both elbow flexion and extension was found to be statistically significant (p < 0.05). Complications The overall complication rate was significantly greater in Group 1 (dual plating) compared to Group 2 (single plating) (p = 0.002).
Table 1 Patient characteristics. Number included
Number excluded
Age
Sex
Fracture type
Implant irritation
Elbow stiffness
Tricep rupture
Premature hardware failure
Iatrogenic radial nerve injury
Dual plating
48
5
43 22.16
3
1
0
6
45
6
35 19.4
A2-5 A3-43 A2-8 A3-37
5
Single plating
31f 18m 23F 22M
1
0
0
1
0
1622
G.M. Meloy et al. / Injury, Int. J. Care Injured 44 (2013) 1620–1624
Fig. 2. (a) Follow up film at 2 months with radiographic evidence of noncatastrophic plate and lag screw failure (bending). (b)–(d) Fortunately, patient uneventfully united fracture with optimal functional result by the 6 month follow up visit.
A total of 15 complications were noted in Group 1, of which a majority were implant related. Five patients complained of pain that was attributed to implant irritation and ulnar neuritis. Two insisted on removal of the hardware. The other three patients chose not to undergo a second operation after the risks of surgery were detailed. Three patients had significant elbow stiffness necessitating secondary operative intervention. One patient sustained a triceps rupture, requiring repair. Six patients sustained iatrogenic radial nerve palsies. Of those, four patients partially recovered and two did not recover. There were three complications in Group 2. As noted previously, one patient had catastrophic hardware failure requiring operative revision. One patient had delayed union and subsequent malunion (Fig. 2). Only one patient complained of pain due to the hardware and subsequently underwent removal of hardware procedure. There were no cases of iatrogenic radial nerve palsies. Discussion The purpose of this study was to compare outcomes after surgical reconstruction of extra-articular distal humerus fractures using two different surgical strategies. Results after traditional bicolumnar plating were compared to a more modern protocol using a single pre-contoured posterolateral locking plate. Comparable union rates and alignments were realised. However, improved elbow functionality was realised with single-column fixed-angle plating versus dual-column plating. Further, more surgical complications were noted when bicolumnar plating was used, including painful hardware/ulnar neuritis, elbow stiffness and radial nerve palsy. Traditionally, dual-column plating has been the standard of care for surgical reconstruction of distal humeral fractures (Fig. 3) [1–4]. Two plates were deemed necessary to provide multiple points of fixation into the short distal segment in order to achieve fracture union and preserved alignment. This study refutes the concept that dual-column fixation is needed in select AO/OTA 13 A2 and A3 fractures as comparable union rates and alignments were seen using single-column plate fixation. In all cases in our
series, at least five fixed-angle screws into the distal block through a single posterolateral plate were sufficient to promote rigid fixation to union. The high incidence of implant-related complications and ulnar neuritis infamously plagues the dual-column plating technique. The incidence of ulnar neuritis following surgical reconstruction of the distal humerus has been reported to occur as high as 51% of the time [5,9–13]. Exposure of the medial column and placement of an implant adjacent to the cubital tunnel is presumably causative. Ulnar nerve transposition has been recommended to decrease the incidence of this problem; yet, Chen et al. report neuritis in approximately 10% of cases despite this technique [5]. Limited exposure and instrumentation of the medial column would presumably decrease implant-related problems after operation for distal humerus fracture. The prospect of singlecolumn posterolateral plating has been explored. Moran et al. examined seven distal humeral fractures with single-column plating using a 4.5 plate that was intra-operatively contoured to fit the posterolateral humerus. All seven cases went on to uneventful union with optimal alignment with preserved shoulder and elbow function [7]. Levy et al. examined single-plate fixation with a posterolateral plate using a customised 4.5 plate designed for the tibia to match the anatomy of the distal humerus to gain necessary fixation into the short distal segment [8]. In their series, all 15 patients had an uneventful union, with no complications noted [8]. Tejwani et al. further investigated the biomechanics of singleversus double-plate fixation in a cadaveric distal humerus injury model [14]. They noted a significantly stiffer construct in anterior, posterior and lateral bending with dual plating, but no difference in axial compression or torsion, with both constructs having similar failure strengths [14]. The current study suggests that exposure/ instrumentation of only the lateral column is a reliable and preferred technique as the ulnar nerve is left undisturbed. An unexpected, yet further positive outcome of single versus double plating is regarding iatrogenic radial nerve injury. With dual plating, six patients sustained iatrogenic radial nerve palsies. We potentially attribute this to the surgical approach for single-column
G.M. Meloy et al. / Injury, Int. J. Care Injured 44 (2013) 1620–1624
1623
less hardware-related tension on the radial nerve with this technique. Despite the success we report of single-plating- versus dualplating constructs, one important caveat needs further description. All comminuted distal humerus cases in this report managed with a single locked posterolateral plate were initially fixated with direct reduction and interfragmentary compression using lag screws. The plate was applied as a neutralisation device; it was not examined as a bridging device. Further, in excessively comminuted AO/OTA 13A3 fractures, the surgeon should always supplement fixation with an orthogonal plate in order to enhance stability to promote uneventful union and rehabilitation. Despite the comparative nature of this study, certain limitations must be addressed. The study is retrospective in nature and the choice of the surgical approach including fixation strategy was at the discretion of the treating surgeon. For instance, surgical exposure was not controlled for in this study. This potentially could be a dependent variable influencing results. Although a paratricipetal approach was used exclusively in the single-plated group, a triceps splitting or reflecting technique was used in the double-column plating group. Tarkin et al. have shown that triceps-sparing approaches versus splitting techniques positively influence ultimate elbow function in terms of motion and strength [15]. Further, in the current study residual pain was attributed to implant irritation. Pain, however, certainly can be multifactorial in origin and not directly attributable to indwelling implants. Future prospective studies would be able to overcome the limitations of this study. Conclusion
Fig. 3. Traditional dual column plating through triceps splitting exposure. This technique statistically associated with higher incidence of complication especially implant irritation and nerve injury.
plating. A lateral paratricipital approach was used, which allowed for improved mobilisation and protection of the radial nerve from the level of the lateral intermuscular septum through the spiral groove (Fig. 4). Further, in comparison to dual plating, there was
Surgical reconstruction of extra-articular distal humeral fractures has traditionally been performed with rigid fixation using a bicolumnar plating technique. However, hardware irritation and ulnar neuritis are common. Single-column plating with a pre-contoured posterolateral locking plate offers similar union rates to dual-column plating and in addition has significantly fewer complications with improved elbow range of motion. Single-column plating can safely be performed using a lateral paratricipital approach, which was associated with no iatrogenic radial nerve palsies in our series. Conflicts of interests The authors have no conflicts of interests to disclose, and there was no external funding provided for this research. Acknowledgement Special thanks to Dana Farrell for her dedication to orthopaedic trauma research and preparation of the data for this manuscript. References
Fig. 4. No iatrogenic radial nerve injuries associated with single plating cohort. Lateral paratricipital approach used in all cases. This exposure allows for complete neurolysis and mobilisation of the radial nerve (yellow vessel loop). (For interpretation of the references to color in figure legend, the reader is referred to the web version of the article.)
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