- Email: [email protected]
Lateral Para-Olecranon Approach for the Treatment of Distal Humeral Fracture
SCIENTIFIC ARTICLE
Lateral Para-Olecranon Approach for the Treatment of Distal Humeral Fracture Takuji Iwamoto, MD, PhD,* Taku Suzuki, MD, PhD,† Noboru Matsumura, MD, PhD,* Masaya Nakamura, MD, PhD,* Morio Matsumoto, MD, PhD,* Kazuki Sato, MD, PhD*
Purpose To assess the outcomes of the lateral para-olecranon triceps-splitting approach for the treatment of distal humeral fracture. Methods Ten patients (3 males, 7 females) with a mean age of 59 years were retrospectively reviewed. There were 2 A2, 3 C1, and 5 C2 fractures according to the AO/ASIF classification. Types B3 and C3 fractures were excluded from this study because the olecranon osteotomy approach was indicated to visualize the anterior fragment. The triceps was split at the midline, and the anconeus muscle was incised from the proximal ulna. The lateral half of the triceps along with anconeus was retracted laterally as a single unit. The distal part of the humerus could be visualized from medial and lateral windows by retracting the medial half of the triceps. The articular fragment was anatomically reduced and fixed temporarily with a Kirschner wire, and the reconstructed distal articular block was then fixed to the humeral shaft with double locking plates. Results After surgery, average elbow flexion was 127 (range, 110 e145 ), and extension was e10 (range, e20 e0 ) at the average follow-up time of 12.4 months (range, 8‒20 months). Seven patients had normal muscle strength against full resistance (manual muscle testing grade 5), and the other 3 patients had slightly reduced muscle strength (grade 4). No articular stepoffs of more than 1 mm were seen on postoperative radiographs. There were no cases of triceps insufficiency and nonunion. The average ( SD) Mayo Elbow Score was 93.5 5.8 points at the final follow-up. Conclusions The lateral para-olecranon approach is useful for the management of selected fractures of the distal humerus, preserving extension strength and providing satisfactory clinical outcomes, with no risk of olecranon osteotomy-related complications. (J Hand Surg Am. 2017;-(-):-e-. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic V. Key words Distal humeral fracture, surgical approach, triceps-splitting, olecranon osteotomy.
From the *Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo; and the †Department of Orthopaedic Surgery, Fujita Health University, Aichi, Japan. Received for publication September 13, 2016; accepted in revised form February 13, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Takuji Iwamoto, MD, PhD, Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.02.004
T
is one of the most technically demanding challenges in orthopedic trauma surgery.1 To gain good functional results, various authors recommend open reduction and double column plating. An olecranon osteotomy approach is the most common method recommended for intra-articular distal humeral fractures. This approach provides good exposure of the articular surface, enabling accurate articular reduction.2,3 However, this approach is associated with several complications, including symptomatic hardware prominence, loss of REATMENT OF DISTAL HUMERAL FRACTURES
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Published by Elsevier, Inc. All rights reserved.
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PARA-OLECRANON APPROACH FOR DISTAL HUMERUS
osteotomy reduction, nonunion, or delayed union of the olecranon.4e6 To avoid these complications, various posterior approaches without olecranon osteotomy have been described.7e9 The triceps-reflecting technique described by O’Driscoll8 can preserve the continuation of the triceps tendon, but the triceps disruption from the olecranon causes weakness of extension power.10 Alonso-Llames11 described a bilaterotricipital approach, in which the distal articular surface could be approached on both sides of the triceps tendon while not disrupting the triceps insertion to the olecranon. However, preservation of the triceps tendon insertion reduces exposure of the joint surface, which makes reduction of the articular fragment difficult. Studer et al12 reported a modified triceps-splitting approach for total elbow arthroplasty, which they called the lateral paraolecranon approach. This approach preserves most of the insertion of the triceps tendon to the olecranon while providing improved visualization of the articular surface relative to the bilaterotricipital approach. The purpose of this study was to describe and evaluate the lateral para-olecranon approach for the treatment of distal humeral fractures. The functional outcome, extensor strength, and complications of this approach were evaluated.
FIGURE 1: The triceps is split next to the central triceps tendon. The anconeus muscle is also detached from the proximal ulna. Black arrow, lateral half of triceps; white arrow, medial half of triceps.
Surgical technique The patient is placed in a lateral position and the arm placed on an arm support. A midline posterior incision is performed, and fasciocutaneous flaps are elevated on the deep fascia. After the ulnar nerve is identified and protected, the anconeus muscle is incised from the proximal ulna. This incision is extended proximally by splitting the triceps between the lateral triceps expansion and the central triceps tendon (Fig. 1). The insertion of the central triceps tendon to the olecranon tip is maintained. The lateral half of the triceps, along with the anconeus, is retracted laterally as a single unit, and the lateral half of the distal humerus is visualized. In this situation, we always take care not to incise the annular ligament and lateral collateral ligament, which differs from the original description of the lateral para-olecranon approach by Studer et al.12 Next, the medial half of the triceps muscle is released from the medial intermuscular septum and dorsal aspect of the distal humerus. In cases with intra-articular fracture, the joint capsule and fat pad are excised from the olecranon fossa. During capsulotomy, care is taken to preserve the anterior oblique
METHODS This retrospective study included 10 patients (3 males, 7 females) with distal humeral fractures who were treated surgically with double locking plate fixation using LCP distal humerus plates (DHPs) (DePuy Synthes, Zuchwil, Switzerland) in our institution from January 2012 to April 2015. The average age at the time of surgery was 59 years (range, 23e85 years). The average follow-up time was 12.4 months (range, 8‒20 months). The dominant extremity was involved in 6 patients. At presentation, there was a Gustilo type I open fracture13 with radial nerve injury in 1 patient. No patients had vascular injuries or compartment syndrome. Fracture types were classified according to the AO/ASIF classification.14 There were 2 A2, 3 C1, and 5 C2 fractures. During this period, 1 B3 and 4 C3 fractures were excluded from this study because the olecranon osteotomy approach was required to visualize the anterior fragment. The operative procedures were performed or supervised by the 2 senior authors (T.I. and T.S.). Institutional review board approval was obtained, and all patients gave their informed consent. J Hand Surg Am.
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FIGURE 2: A The insertion of the central triceps tendon to the olecranon tip is maintained. The lateral half of triceps along with anconeus is retracted laterally as a single unit, and the lateral half of the distal humerus can be visualized. B The medial half of the triceps muscle is released from the medial intermuscular septum, and the medial half of the distal humerus can be visualized by retracting the triceps muscle laterally.
bundle of the medial collateral ligament, which is the important stabilizer of the elbow. The distal part of the humerus is visualized from medial and lateral windows by retracting the medial half of the triceps muscle laterally and medially (Fig. 2). The articular fragment is anatomically reduced and fixed temporarily with 1.5- or 1.8-mm Kirschner wires with direct visualization and fluoroscopy assistance. The intact olecranon is used as a template for reduction. The reconstructed distal articular block is then fixed to the humeral shaft with 2 LCP DHPs (Figs. 3, 4). After the osteosynthesis is completed, the divided triceps and the fascia of anconeus is also repaired with absorbable sutures. The ulnar nerve is transposed to an anterior subcutaneous position in all patients. The wound is closed, and an orthosis applied with the elbow in 90 flexion. Active-assisted elbow motion is initiated 1 week after surgery. An above-elbow removable orthosis is applied at 90 flexion for 3 weeks. Clinical evaluation The follow-up assessment included evaluations of active range of motion of the elbow joint, extension
J Hand Surg Am.
FIGURE 3: The fragments are fixed with 2 LCP DHPs from lateral and medial windows.
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FIGURE 4: Anteroposterior radiograph A and computed tomography scan B of an intra-articular type C2 distal humeral fracture. The surgery was performed without olecranon osteotomy. Anteroposterior C and lateral D radiographs after surgery demonstrate anatomical alignment and no articular stepoff.
strength, and function. Elbow motion was assessed with a goniometer. Manual muscle testing (MMT) of elbow extension strength was graded 0 to 5 by performing resisted extension from 90 flexion and the forearm in neutral rotation. Functional results were evaluated according to the Mayo Elbow Performance Index.15 Anteroposterior and lateral elbow radiographs were obtained J Hand Surg Am.
every 2 to 4 weeks until fracture union was confirmed. RESULTS Patients’ characteristics, type of fracture, and surgical results are summarized in Table 1. Technical difficulties during surgery were not encountered in this case series. r
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93.5
100 5
Ext, extension; Flex, flexion; MEPI, Mayo Elbow Performance Index; Pro, pronation; Supi, supination.
90 90
85
145
127
e8
e10
C2 12.4
15 F
58.9
36 10
Average
5
No articular stepoffs of more than 1 mm were seen on postoperative radiographs. All 10 fractures healed primarily, with no cases of nonunion. Average elbow flexion was 127 (range, 110 e145 ), and average elbow extension was e10 (range, e20 e0 ). Average supination was 85 (range, 80 e90 ), and average pronation was 85 (range, 70 e90 ). Seven patients had normal muscle strength against full resistance (MMT grade 5), and the other 3 cases had slightly reduced muscle strength (MMT grade 4). There was no obvious clinical strength loss due to triceps insufficiency. Subcutaneous prominence of the hardware of the plates was observed in 2 cases, and removal of the implant was required. The patient who presented with radial nerve palsy at the time of injury had complete resolution by 6 months. Transient postoperative ulnar nerve palsy was observed in 2 cases, but they resolved completely within 6 months. There were no cases of postoperative infection or heterotopic ossification. At the final follow-up, 8 patients achieved an excellent result, and 2 patients had a good result according to the Mayo Elbow Performance Index. The average score was 93.5 points (range, 85e100 points).
85
90
90 5 80 120 F 71 9
8
C2
e10
84
85 5
4 88 118
82
88 124 e8
C1 8 85 8
F
80 7
M
12
C1
e12
90
100
95 4
5 90 90 125
82 134
0 12
C1 F
23 6
M
78 5
10
C2
e15
78
95
95 5
5 90
80 80
e5
88
122
140
e12 A2
C2 20 F 58 4
F 81 3
12
85
100 4
5 70
90
110
80
90 132 e5
C2 15
12
41 2
F 36 1
M
A2
e20
Pro Supi Flex Ext AO/ASIF Classification Follow-Up (mo) Sex Age (y) Case No.
TABLE 1.
Patients’ Characteristics and Surgical Results
Postoperative Active Range of Motion ( )
MMT of Elbow Extension
MEPI
PARA-OLECRANON APPROACH FOR DISTAL HUMERUS
J Hand Surg Am.
DISCUSSION It is generally accepted that a posterior approach provides the most appropriate exposure of the articular surface of the distal humerus, and multiple posterior exposures have been described. Olecranon osteotomy is regarded as the gold standard because it exposes more articular surface than tricepssplitting and triceps-reflecting approaches.2,3 Wilkinson and Stanley3 demonstrated in a cadaver model that the exposed articular surface for the triceps-splitting, triceps-reflecting, and olecranon osteotomy approaches were 35%, 46%, and 57%, respectively. However, osteotomy-related complications, including hardware failure and irritation, are reported at a rate of 6% to 80%.4,16e18 Furthermore, osteotomy nonunion and early revision osteosynthesis for a loss of osteotomy reduction have also been reported.4,17 To avoid these complications, several posterior exposures without olecranon osteotomy have been used for distal humeral fracture. Iselin et al19 reported 24 cases of distal humeral fractures treated with the triceps-reflecting approach described by Bryan and Morrey,7 with no significant difference between the r
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extension force of the normal side and that of the injured side. However, detachment of the extensor mechanism enables good visualization of the articular surfaces, but with an increased risk of complications, including triceps rupture. The bilaterotricipital “2-window” approach was described by Alonso-Llames11 for treatment of pediatric supracondylar fractures. This approach was later used in the treatment of intra-articular distal humeral fractures.9 Erpelding et al20 reported that elbow extension strength was maintained at 90% of the unaffected elbow in 37 cases treated with this approach. Theoretically, this triceps-on approach is less invasive for the extensor apparatus, but sometimes technical difficulties are encountered with a bulky triceps muscle in well-muscled male patients. Dakoure et al2 showed that the exposed articular surface using the bilaterotricipital approach was 26%, which is almost half of the olecranon osteotomy approach. No data quantifying the amount of the exposed articular surface for the para-olecranon approach were available in the present study; however, nearly half of the triceps can be mobilized laterally with the lateral para-olecranon approach, thereby increasing the overall exposure compared with the bilaterotricipital approach. Because the attachment of the triceps tendon can be kept intact, triceps strength is maintained, and triceps disruption can be avoided. Studer et al12 reported that no cases of triceps rupture were identified, and the extension force of the affected elbow was similar to that of the contralateral elbow in the lateral para-olecranon approach for total elbow arthroplasty. Preserving the extensor mechanism not only reduces the risk of triceps insufficiency but also allows early active range of motion exercises. Although the remaining olecranon and half of the triceps muscle inhibit the exposure of the center of the articular surface, we found that flexion of the elbow over 90 provides visualization of half of the posterior articular surface. In addition, the normal olecranon can be used as a template for reduction of the articular surface. In this study, good reduction was achieved in cases with intra-articular fractures (types C1 and C2). If wide exposure of the articular surface is necessary, this approach can be converted to a combined olecranon osteotomy and posterior triceps-splitting approach.21 However, we do not use this approach for C3 fractures and type B3 coronal shear fractures because this conversion is more invasive for the extensor mechanisms than the olecranon osteotomy approach. J Hand Surg Am.
This study has a number of limitations. First, it was a retrospective case series without a control group, and the number of patients was small. Further comparative study is needed to evaluate the superiority of the lateral para-olecranon approach over olecranon osteotomy. Second, extension strength of the elbow was evaluated only by a qualitative method using MMT. More precise evaluation should be done using quantitative methods, such as with dynamometers. Based on our experience with the lateral paraolecranon approach, we suggest the following treatment algorithm for distal humeral fracture: For the management of type A fracture, the bilaterotricipital approach would be useful and less invasive to the triceps muscle. A lateral para-olecranon approach would be indicated for types C1 and C2 fractures, and an olecranon osteotomy would be recommended for type C3 fractures. ACKNOWLEDGMENTS The authors would like to thank all members of the Department of Orthopaedic Surgery, Keio University School of Medicine. REFERENCES 1. Sela Y, Baratz ME. Distal humerus fractures in the elderly population. J Hand Surg Am. 2015;40(3):599e601. 2. Dakouré PW, Ndiaye A, Ndoye JM, et al. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat. 2007;29(8):671e674. 3. Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow: a comparative anatomic study. J Shoulder Elbow Surg. 2001;10(4):380e382. 4. Coles CP, Barei DP, Nork SE, et al. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20(3):164e171. 5. Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985;67(2):226e239. 6. Södergård J, Sandelin J, Böstman O. Postoperative complications of distal humeral fractures. 27/96 adults followed up for 6 (2e10) years. Acta Orthop Scand. 1992;63(1):85e89. 7. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188e192. 8. O’Driscoll SW. The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions. Orthop Clin North Am. 2000;31(1):91e101. 9. Schildhauer TA, Nork SE, Mills WJ, Henley MB. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma. 2003;17(5):374e378. 10. Guerroudj M, de Longueville JC, Rooze M, et al. Biomechanical properties of triceps brachii tendon after in vitro simulation of different posterior surgical approaches. J Shoulder Elbow Surg. 2007;16(6):849e853. 11. Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand. 1972;43(6):479e490.
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12. Studer A, Athwal GS, Macdermid JC, Faber KJ, King GJ. The lateral para-olecranon approach for total elbow arthroplasty. J Hand Surg Am. 2013;38(11):2219e2226.e2213. 13. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453e458. 14. Muller ME, Nazarian S, Koch P. The AO Classification of Long Bones Fractures. New York: Springer; 1990. 15. Morrey BF, An KN. Functional evaluation of the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. 2nd ed. Philadelphia: WB Saunders; 1993:86e89. 16. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am. 1985;67(9):1396e1401. 17. Schmidt-Horlohé K, Wilde P, Bonk A, Becker L, Hofmann R. Onethird tubular-hook-plate osteosynthesis for olecranon osteotomies in
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18.
19.
20.
21.
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distal humerus type-C fractures: a preliminary report of results and complications. Injury. 2012;43(3):295e300. Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21(1):58e62. Iselin LD, Mett T, Babst R, Jakob M, Rikli D. The triceps reflecting approach (Bryan-Morrey) for distal humerus fracture osteosynthesis. BMC Musculoskelet Disord. 2014;15:406. Erpelding JM, Mailander A, High R, Mormino MA, Fehringer EV. Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach. J Bone Joint Surg Am. 2012;94(6):548e553. Archdeacon MT. Combined olecranon osteotomy and posterior triceps splitting approach for complex fractures of the distal humerus. J Orthop Trauma. 2003;17(5):368e373.
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Lateral Para-Olecranon Approach for the Treatment of Distal Humeral Fracture Takuji Iwamoto, MD, PhD,* Taku Suzuki, MD, PhD,† Noboru Matsumura, MD, PhD,* Masaya Nakamura, MD, PhD,* Morio Matsumoto, MD, PhD,* Kazuki Sato, MD, PhD*
Purpose To assess the outcomes of the lateral para-olecranon triceps-splitting approach for the treatment of distal humeral fracture. Methods Ten patients (3 males, 7 females) with a mean age of 59 years were retrospectively reviewed. There were 2 A2, 3 C1, and 5 C2 fractures according to the AO/ASIF classification. Types B3 and C3 fractures were excluded from this study because the olecranon osteotomy approach was indicated to visualize the anterior fragment. The triceps was split at the midline, and the anconeus muscle was incised from the proximal ulna. The lateral half of the triceps along with anconeus was retracted laterally as a single unit. The distal part of the humerus could be visualized from medial and lateral windows by retracting the medial half of the triceps. The articular fragment was anatomically reduced and fixed temporarily with a Kirschner wire, and the reconstructed distal articular block was then fixed to the humeral shaft with double locking plates. Results After surgery, average elbow flexion was 127 (range, 110 e145 ), and extension was e10 (range, e20 e0 ) at the average follow-up time of 12.4 months (range, 8‒20 months). Seven patients had normal muscle strength against full resistance (manual muscle testing grade 5), and the other 3 patients had slightly reduced muscle strength (grade 4). No articular stepoffs of more than 1 mm were seen on postoperative radiographs. There were no cases of triceps insufficiency and nonunion. The average ( SD) Mayo Elbow Score was 93.5 5.8 points at the final follow-up. Conclusions The lateral para-olecranon approach is useful for the management of selected fractures of the distal humerus, preserving extension strength and providing satisfactory clinical outcomes, with no risk of olecranon osteotomy-related complications. (J Hand Surg Am. 2017;-(-):-e-. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic V. Key words Distal humeral fracture, surgical approach, triceps-splitting, olecranon osteotomy.
From the *Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo; and the †Department of Orthopaedic Surgery, Fujita Health University, Aichi, Japan. Received for publication September 13, 2016; accepted in revised form February 13, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Takuji Iwamoto, MD, PhD, Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.02.004
T
is one of the most technically demanding challenges in orthopedic trauma surgery.1 To gain good functional results, various authors recommend open reduction and double column plating. An olecranon osteotomy approach is the most common method recommended for intra-articular distal humeral fractures. This approach provides good exposure of the articular surface, enabling accurate articular reduction.2,3 However, this approach is associated with several complications, including symptomatic hardware prominence, loss of REATMENT OF DISTAL HUMERAL FRACTURES
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
PARA-OLECRANON APPROACH FOR DISTAL HUMERUS
osteotomy reduction, nonunion, or delayed union of the olecranon.4e6 To avoid these complications, various posterior approaches without olecranon osteotomy have been described.7e9 The triceps-reflecting technique described by O’Driscoll8 can preserve the continuation of the triceps tendon, but the triceps disruption from the olecranon causes weakness of extension power.10 Alonso-Llames11 described a bilaterotricipital approach, in which the distal articular surface could be approached on both sides of the triceps tendon while not disrupting the triceps insertion to the olecranon. However, preservation of the triceps tendon insertion reduces exposure of the joint surface, which makes reduction of the articular fragment difficult. Studer et al12 reported a modified triceps-splitting approach for total elbow arthroplasty, which they called the lateral paraolecranon approach. This approach preserves most of the insertion of the triceps tendon to the olecranon while providing improved visualization of the articular surface relative to the bilaterotricipital approach. The purpose of this study was to describe and evaluate the lateral para-olecranon approach for the treatment of distal humeral fractures. The functional outcome, extensor strength, and complications of this approach were evaluated.
FIGURE 1: The triceps is split next to the central triceps tendon. The anconeus muscle is also detached from the proximal ulna. Black arrow, lateral half of triceps; white arrow, medial half of triceps.
Surgical technique The patient is placed in a lateral position and the arm placed on an arm support. A midline posterior incision is performed, and fasciocutaneous flaps are elevated on the deep fascia. After the ulnar nerve is identified and protected, the anconeus muscle is incised from the proximal ulna. This incision is extended proximally by splitting the triceps between the lateral triceps expansion and the central triceps tendon (Fig. 1). The insertion of the central triceps tendon to the olecranon tip is maintained. The lateral half of the triceps, along with the anconeus, is retracted laterally as a single unit, and the lateral half of the distal humerus is visualized. In this situation, we always take care not to incise the annular ligament and lateral collateral ligament, which differs from the original description of the lateral para-olecranon approach by Studer et al.12 Next, the medial half of the triceps muscle is released from the medial intermuscular septum and dorsal aspect of the distal humerus. In cases with intra-articular fracture, the joint capsule and fat pad are excised from the olecranon fossa. During capsulotomy, care is taken to preserve the anterior oblique
METHODS This retrospective study included 10 patients (3 males, 7 females) with distal humeral fractures who were treated surgically with double locking plate fixation using LCP distal humerus plates (DHPs) (DePuy Synthes, Zuchwil, Switzerland) in our institution from January 2012 to April 2015. The average age at the time of surgery was 59 years (range, 23e85 years). The average follow-up time was 12.4 months (range, 8‒20 months). The dominant extremity was involved in 6 patients. At presentation, there was a Gustilo type I open fracture13 with radial nerve injury in 1 patient. No patients had vascular injuries or compartment syndrome. Fracture types were classified according to the AO/ASIF classification.14 There were 2 A2, 3 C1, and 5 C2 fractures. During this period, 1 B3 and 4 C3 fractures were excluded from this study because the olecranon osteotomy approach was required to visualize the anterior fragment. The operative procedures were performed or supervised by the 2 senior authors (T.I. and T.S.). Institutional review board approval was obtained, and all patients gave their informed consent. J Hand Surg Am.
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PARA-OLECRANON APPROACH FOR DISTAL HUMERUS
3
FIGURE 2: A The insertion of the central triceps tendon to the olecranon tip is maintained. The lateral half of triceps along with anconeus is retracted laterally as a single unit, and the lateral half of the distal humerus can be visualized. B The medial half of the triceps muscle is released from the medial intermuscular septum, and the medial half of the distal humerus can be visualized by retracting the triceps muscle laterally.
bundle of the medial collateral ligament, which is the important stabilizer of the elbow. The distal part of the humerus is visualized from medial and lateral windows by retracting the medial half of the triceps muscle laterally and medially (Fig. 2). The articular fragment is anatomically reduced and fixed temporarily with 1.5- or 1.8-mm Kirschner wires with direct visualization and fluoroscopy assistance. The intact olecranon is used as a template for reduction. The reconstructed distal articular block is then fixed to the humeral shaft with 2 LCP DHPs (Figs. 3, 4). After the osteosynthesis is completed, the divided triceps and the fascia of anconeus is also repaired with absorbable sutures. The ulnar nerve is transposed to an anterior subcutaneous position in all patients. The wound is closed, and an orthosis applied with the elbow in 90 flexion. Active-assisted elbow motion is initiated 1 week after surgery. An above-elbow removable orthosis is applied at 90 flexion for 3 weeks. Clinical evaluation The follow-up assessment included evaluations of active range of motion of the elbow joint, extension
J Hand Surg Am.
FIGURE 3: The fragments are fixed with 2 LCP DHPs from lateral and medial windows.
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FIGURE 4: Anteroposterior radiograph A and computed tomography scan B of an intra-articular type C2 distal humeral fracture. The surgery was performed without olecranon osteotomy. Anteroposterior C and lateral D radiographs after surgery demonstrate anatomical alignment and no articular stepoff.
strength, and function. Elbow motion was assessed with a goniometer. Manual muscle testing (MMT) of elbow extension strength was graded 0 to 5 by performing resisted extension from 90 flexion and the forearm in neutral rotation. Functional results were evaluated according to the Mayo Elbow Performance Index.15 Anteroposterior and lateral elbow radiographs were obtained J Hand Surg Am.
every 2 to 4 weeks until fracture union was confirmed. RESULTS Patients’ characteristics, type of fracture, and surgical results are summarized in Table 1. Technical difficulties during surgery were not encountered in this case series. r
Vol. -, - 2017
93.5
100 5
Ext, extension; Flex, flexion; MEPI, Mayo Elbow Performance Index; Pro, pronation; Supi, supination.
90 90
85
145
127
e8
e10
C2 12.4
15 F
58.9
36 10
Average
5
No articular stepoffs of more than 1 mm were seen on postoperative radiographs. All 10 fractures healed primarily, with no cases of nonunion. Average elbow flexion was 127 (range, 110 e145 ), and average elbow extension was e10 (range, e20 e0 ). Average supination was 85 (range, 80 e90 ), and average pronation was 85 (range, 70 e90 ). Seven patients had normal muscle strength against full resistance (MMT grade 5), and the other 3 cases had slightly reduced muscle strength (MMT grade 4). There was no obvious clinical strength loss due to triceps insufficiency. Subcutaneous prominence of the hardware of the plates was observed in 2 cases, and removal of the implant was required. The patient who presented with radial nerve palsy at the time of injury had complete resolution by 6 months. Transient postoperative ulnar nerve palsy was observed in 2 cases, but they resolved completely within 6 months. There were no cases of postoperative infection or heterotopic ossification. At the final follow-up, 8 patients achieved an excellent result, and 2 patients had a good result according to the Mayo Elbow Performance Index. The average score was 93.5 points (range, 85e100 points).
85
90
90 5 80 120 F 71 9
8
C2
e10
84
85 5
4 88 118
82
88 124 e8
C1 8 85 8
F
80 7
M
12
C1
e12
90
100
95 4
5 90 90 125
82 134
0 12
C1 F
23 6
M
78 5
10
C2
e15
78
95
95 5
5 90
80 80
e5
88
122
140
e12 A2
C2 20 F 58 4
F 81 3
12
85
100 4
5 70
90
110
80
90 132 e5
C2 15
12
41 2
F 36 1
M
A2
e20
Pro Supi Flex Ext AO/ASIF Classification Follow-Up (mo) Sex Age (y) Case No.
TABLE 1.
Patients’ Characteristics and Surgical Results
Postoperative Active Range of Motion ( )
MMT of Elbow Extension
MEPI
PARA-OLECRANON APPROACH FOR DISTAL HUMERUS
J Hand Surg Am.
DISCUSSION It is generally accepted that a posterior approach provides the most appropriate exposure of the articular surface of the distal humerus, and multiple posterior exposures have been described. Olecranon osteotomy is regarded as the gold standard because it exposes more articular surface than tricepssplitting and triceps-reflecting approaches.2,3 Wilkinson and Stanley3 demonstrated in a cadaver model that the exposed articular surface for the triceps-splitting, triceps-reflecting, and olecranon osteotomy approaches were 35%, 46%, and 57%, respectively. However, osteotomy-related complications, including hardware failure and irritation, are reported at a rate of 6% to 80%.4,16e18 Furthermore, osteotomy nonunion and early revision osteosynthesis for a loss of osteotomy reduction have also been reported.4,17 To avoid these complications, several posterior exposures without olecranon osteotomy have been used for distal humeral fracture. Iselin et al19 reported 24 cases of distal humeral fractures treated with the triceps-reflecting approach described by Bryan and Morrey,7 with no significant difference between the r
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extension force of the normal side and that of the injured side. However, detachment of the extensor mechanism enables good visualization of the articular surfaces, but with an increased risk of complications, including triceps rupture. The bilaterotricipital “2-window” approach was described by Alonso-Llames11 for treatment of pediatric supracondylar fractures. This approach was later used in the treatment of intra-articular distal humeral fractures.9 Erpelding et al20 reported that elbow extension strength was maintained at 90% of the unaffected elbow in 37 cases treated with this approach. Theoretically, this triceps-on approach is less invasive for the extensor apparatus, but sometimes technical difficulties are encountered with a bulky triceps muscle in well-muscled male patients. Dakoure et al2 showed that the exposed articular surface using the bilaterotricipital approach was 26%, which is almost half of the olecranon osteotomy approach. No data quantifying the amount of the exposed articular surface for the para-olecranon approach were available in the present study; however, nearly half of the triceps can be mobilized laterally with the lateral para-olecranon approach, thereby increasing the overall exposure compared with the bilaterotricipital approach. Because the attachment of the triceps tendon can be kept intact, triceps strength is maintained, and triceps disruption can be avoided. Studer et al12 reported that no cases of triceps rupture were identified, and the extension force of the affected elbow was similar to that of the contralateral elbow in the lateral para-olecranon approach for total elbow arthroplasty. Preserving the extensor mechanism not only reduces the risk of triceps insufficiency but also allows early active range of motion exercises. Although the remaining olecranon and half of the triceps muscle inhibit the exposure of the center of the articular surface, we found that flexion of the elbow over 90 provides visualization of half of the posterior articular surface. In addition, the normal olecranon can be used as a template for reduction of the articular surface. In this study, good reduction was achieved in cases with intra-articular fractures (types C1 and C2). If wide exposure of the articular surface is necessary, this approach can be converted to a combined olecranon osteotomy and posterior triceps-splitting approach.21 However, we do not use this approach for C3 fractures and type B3 coronal shear fractures because this conversion is more invasive for the extensor mechanisms than the olecranon osteotomy approach. J Hand Surg Am.
This study has a number of limitations. First, it was a retrospective case series without a control group, and the number of patients was small. Further comparative study is needed to evaluate the superiority of the lateral para-olecranon approach over olecranon osteotomy. Second, extension strength of the elbow was evaluated only by a qualitative method using MMT. More precise evaluation should be done using quantitative methods, such as with dynamometers. Based on our experience with the lateral paraolecranon approach, we suggest the following treatment algorithm for distal humeral fracture: For the management of type A fracture, the bilaterotricipital approach would be useful and less invasive to the triceps muscle. A lateral para-olecranon approach would be indicated for types C1 and C2 fractures, and an olecranon osteotomy would be recommended for type C3 fractures. ACKNOWLEDGMENTS The authors would like to thank all members of the Department of Orthopaedic Surgery, Keio University School of Medicine. REFERENCES 1. Sela Y, Baratz ME. Distal humerus fractures in the elderly population. J Hand Surg Am. 2015;40(3):599e601. 2. Dakouré PW, Ndiaye A, Ndoye JM, et al. Posterior surgical approaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat. 2007;29(8):671e674. 3. Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow: a comparative anatomic study. J Shoulder Elbow Surg. 2001;10(4):380e382. 4. Coles CP, Barei DP, Nork SE, et al. The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma. 2006;20(3):164e171. 5. Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am. 1985;67(2):226e239. 6. Södergård J, Sandelin J, Böstman O. Postoperative complications of distal humeral fractures. 27/96 adults followed up for 6 (2e10) years. Acta Orthop Scand. 1992;63(1):85e89. 7. Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188e192. 8. O’Driscoll SW. The triceps-reflecting anconeus pedicle (TRAP) approach for distal humeral fractures and nonunions. Orthop Clin North Am. 2000;31(1):91e101. 9. Schildhauer TA, Nork SE, Mills WJ, Henley MB. Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma. 2003;17(5):374e378. 10. Guerroudj M, de Longueville JC, Rooze M, et al. Biomechanical properties of triceps brachii tendon after in vitro simulation of different posterior surgical approaches. J Shoulder Elbow Surg. 2007;16(6):849e853. 11. Alonso-Llames M. Bilaterotricipital approach to the elbow. Its application in the osteosynthesis of supracondylar fractures of the humerus in children. Acta Orthop Scand. 1972;43(6):479e490.
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12. Studer A, Athwal GS, Macdermid JC, Faber KJ, King GJ. The lateral para-olecranon approach for total elbow arthroplasty. J Hand Surg Am. 2013;38(11):2219e2226.e2213. 13. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453e458. 14. Muller ME, Nazarian S, Koch P. The AO Classification of Long Bones Fractures. New York: Springer; 1990. 15. Morrey BF, An KN. Functional evaluation of the elbow. In: Morrey BF, ed. The Elbow and Its Disorders. 2nd ed. Philadelphia: WB Saunders; 1993:86e89. 16. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am. 1985;67(9):1396e1401. 17. Schmidt-Horlohé K, Wilde P, Bonk A, Becker L, Hofmann R. Onethird tubular-hook-plate osteosynthesis for olecranon osteotomies in
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distal humerus type-C fractures: a preliminary report of results and complications. Injury. 2012;43(3):295e300. Hewins EA, Gofton WT, Dubberly J, MacDermid JC, Faber KJ, King GJ. Plate fixation of olecranon osteotomies. J Orthop Trauma. 2007;21(1):58e62. Iselin LD, Mett T, Babst R, Jakob M, Rikli D. The triceps reflecting approach (Bryan-Morrey) for distal humerus fracture osteosynthesis. BMC Musculoskelet Disord. 2014;15:406. Erpelding JM, Mailander A, High R, Mormino MA, Fehringer EV. Outcomes following distal humeral fracture fixation with an extensor mechanism-on approach. J Bone Joint Surg Am. 2012;94(6):548e553. Archdeacon MT. Combined olecranon osteotomy and posterior triceps splitting approach for complex fractures of the distal humerus. J Orthop Trauma. 2003;17(5):368e373.
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