- Email: [email protected]
Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction
the surgeon xxx (xxxx) xxx
Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction M.N. Salihu a, S.A. Arojuraye a,*, A.I. Alabi a, I.U. Mustapha b, N. Okoh a, F.B. Ayeni a a b
Clinical Services & Training Department, National Orthopaedic Hospital Dala, Kano, Nigeria Surgery Department, Aminu - Kano Teaching Hospital, Bayero University, Kano, Nigeria
article info
abstract
Article history:
Introduction: Old unreduced elbow dislocation is not uncommon in developing countries.
Received 8 December 2019
Many authors have reported outcome of open reduction in the management of this
Received in revised form
problem. However, we did not find any study that document patient reported outcome.
22 January 2020
Objective: the objective of this study was to determine the patients’ perspectives of outcome
Accepted 3 March 2020
of open reduction in the management of old unreduced elbow dislocation.
Available online xxx
Methods: This was a prospective interventional study of 49 consecutive patients with old unreduced simple elbow dislocation who were treated with open reduction at the National
Keywords:
Orthopaedic Hospital, Dala e Kano, Nigeria and Albarka Clinic Kano, Nigeria between
Unreduced elbow Dislocation
January 2015 and December 2019.
Open reduction
Results: Fourty nine patients were studied with median age of 31.0 years (range: 19e60
Patients perspectives
years). The majority of the patients were within 31e40 years age group. The male to female ratio was 6:1. Using the Mayor Elbow Performance Scale (MEPS) and Patients specific Functional scale (PSFS); there are significant improvements in postoperative functional capability of the patients (P ¼ 0.000). With the short assessment for patient satisfaction (SAPS), 93.3% of patients were either satisfied or very satisfied with the outcome of open reduction. Conclusion: The outcome of open reduction for old unreduced elbow dislocation is good and is well accepted by the patients. © 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Old unreduced elbow dislocations are dislocations of elbow which are not reduced within 3 weeks of injury.1 They are rare in developed nations but often seen in developing countries where universal health coverage is either not existing or just evolving.2 This might be as a result of ignorance and or poverty that makes many patients seek traditional treatment by native bone setters; which include manipulation and splinting in the dislocated position. Old unreduced elbow dislocations can be anterior or posterior though posterior dislocations are the most common.1,2 This condition poses a huge challenge to Orthopaedic Surgeons in developing countries, where treatment
armamentarium is evolving, because it is difficult to achieve full range of motion and function after open reduction which is commonly performed for this case.3 Patients with this condition usually present with the arm fixed in extension or in very slight flexion with minimal range of motion. Pronation is usually more limited than supination because the biceps is under tension from angulation around the humeral condyles which then pulls the forearm into supination.2 This attitude of the upper limb with fixed extended elbow and lack of protonation and supination is seriously disabling for patients' activities of daily living and so the need for surgical intervention. Though none is entirely satisfactory; options available for treating old unreduced elbow dislocation include open reduction, excision arthroplasty, interposition arthroplasty, replacement arthroplasty and arthrodesis.4,5 The most
* Corresponding author. E-mail address: [email protected] (S.A. Arojuraye). https://doi.org/10.1016/j.surge.2020.03.001 1479-666X/© 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
2
the surgeon xxx (xxxx) xxx
common form of treatment for this disabling condition in our environment is open reduction. There is couple of centerbased studies on the outcome of open reduction of old unreduced elbow dislocation. Nilesh et al.3 reported a case series of 15 patients in 2017 who had neglected posterior elbow dislocation and were treated with open reduction. They found that 13 (86.7%) patients had satisfactory outcomes. Similarly, Anderson et al.6 in a retrospective review of 32 patients with chronic elbow dislocation and who were managed with open reduction and were followed up for an average of 22 months, found that 97% of the patients had good to excellent results using Mayor Elbow Performance Index. However, we did not find any study with emphasis on patients reported outcome. The aim of this study therefore was to determine the patients’ perspectives of the outcome of old unreduced elbow dislocation treated with open reduction.
Patients and methods This was a prospective interventional study of 49 consecutive patients with old unreduced simple elbow dislocation who were treated with open reduction and Kirschner wire stabilization at the National Orthopaedic Hospital, Dala e Kano, Nigeria (a tertiary government orthopaedic institution) and Albarka Clinic Kano, Nigeria (a private orthopaedic facility). The study was conducted between January 2015 and December 2019. The study was conducted after approval from Hospital Research Ethics Committee (NHREC/21/08/2008a). The inclusion criteria were ages between 18 and 64 years, simple elbow dislocation (anterior or posterior), duration of injury more than 3 weeks, patients who had open reduction and were followed up for at least 1 year, and who gave consent to participate in the study. The following categories of patients were excluded from the study: ages <18 and >64 years, fracture dislocation of the elbow, associated fracture of the humerus, radius and ulnar, injury <3 weeks, patients with incomplete data at the end of 1 year and patients who declined consent to participate in the study. Elderly patients were excluded because the outcome of surgery generally in them is usually not as good as in the young. This may be due to presence of comorbid illnesses and cognitive dysfunction that may make rehabilitation difficult.7 Patients were diagnosed using clinical history and examination, and plain radiographs (anteroposterior and lateral views) of the elbow. Informed consent was obtained
from all the patients using standard informed consent form. Mayor Elbow Performance Score (MEPS) and Patients Specific Functional Score (PSFS) were documented for all patients preoperatively and at structured follow ups. All patients were treated with open reduction and stabilization using single 3 mm Kirschner. The wire was passed through the posterior border of the ulnar 2 cm from the tip of the olecranon into the humeral medullary canal. The procedure was carried out under general anaesthesia in all cases. One gram of Ceftriaxone was use as prophylactic antibiotic in all cases. The procedure was performed using Speed “VeY triceplasty.8 Patients were discharged from the hospital on average of 6 days after surgery. Sutures were removed at 2 weeks and k-wire was removed at 3 weeks postoperatively. Elbow range of motion exercises was commenced at 3 weeks after K-wire removal and physical examination to assess integrity of collateral ligaments. The study excluded all fracture dislocations and associated humerus, radius and ulnar fractures. The fixation required therefore was temporary (not later than 3 weeks) to avoid disabling elbow stiffness. K e wire was used because its removal at 3 weeks is less technically demanding. Figures 1e4 below show preoperative, intraoperative and postoperative clinical photographs and plain radiographs of one of the patients. Patients were followed up clinically and radiologically at the surgical outpatient department at 3 weeks, 6 weeks, 3 months, 6 months and 1 year after surgery. Clinical history, physical examination including arc of elbow motion, MEPS and PSFS were documented at each follow up. Using Mayo scores elbow function was rated as excellent (90e100), good (75e89), fair (60e74), or poor (<60). Complaints and complications were documented and were appropriately managed. At the end one year postoperative, patients' perspectives of the treatment were recorded using the short assessment for patient's satisfaction (SAPS). The SAPS consist of seven items assessing the core domains of patient satisfaction which include treatment satisfaction, explanation of treatment results, clinician care, participation in medical decision making, respect by the clinician, time with the clinician, and satisfaction with hospital/clinic care. Responses scales are 5-point scales. Relevant information was recorded into Microsoft excel sheet and data was analyzed using SPSS version 23.0 for windows. The paired samples T test was used to compare the clinical outcomes as continuous variables. Statistical significance was considered at p < 0.05 (see Fig. 4).
Fig. 1 e Preoperative Clinical Photographs & Plain Radiographs. a. Elbow in extension, b. Elbow in flexion, c. Lateral radiograph, d. Anteroposterior radiograph. Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
the surgeon xxx (xxxx) xxx
3
Fig. 2 e Intraoperative Clinical Pictures: a. Left elbow after draping, b. Ulnar nerve identified and protected, c. VeY triceplasty done, d. Elbow reduced and stabilized with K-wire, e. wound closed over a suction drain.
Fig. 3 e Postoperative plain radiographs and clinical pictures: a. Postoperative AP & Lateral views radiograph with K e wire insitu, b. Elbow joint in 90 flexion 2 weeks after surgery with K wire in situ.
Results During the study period, a total of 56 patients were managed for old elbow dislocation. Four patients had fracture dislocation and were excluded from the study. Three patients were lost to follow up after removal of K e wire at 3 weeks after surgery and were also excluded. The remaining 49 patients were followed up for a minimum of 1 year and the finding is as documented below. The mean age of the patients was 31.9 ± 8.5 year. There were 42 (85.7%) male patients and 7 (14.3%) female patients, with male to female ratio of 6: 1. All patients were righthanded and majority of them 35 (71.4%) had dislocation in non-dominant elbow. Majority of the patients 47 (95.9%) had initial traditional bone setter treatment before seeking
orthodox intervention. The mode of injury was road traffic accident in 34 (69.4%) of cases, fall from height in 13 (26.5%), physical assault in 1 (2%) and gun rosette in 1 (2%). Table 1 below summarizes the demographic characteristics of the patients. The median duration before presentation was 11 weeks, ranges from 4 to 32 weeks. Most patients presented within 3e12 weeks after the injury. Majority of the patients 47 (95.9%) had traditional bone setter treatment before seeking orthodox intervention. Figure 5 below shows the duration of presentation since injury of all the patients. Table 2 below compares the functional capabilities of the patients preoperatively and one year after surgery. There were significant improvements in the overall arc of elbow motion, MEPS and PSFS after surgery (P ¼ 0.000). The average preoperative MEPS was poor while postoperatively average MEPS became excellent. The mean preoperative arc of motion was 20.1 ± 5.9 , while 1year postoperative mean arc was 86.6 ± 10.4 . The perioperative complications recorded include ulnar neuropraxia in 1 (2%) patient who recovered completely within 6 weeks, recurrent dislocation in 1 (2%) patient who subsequently had elbow arthrodesis and wound dehiscence in 2 (4.1%) patients, both were managed successfully with local wound care (see Fig. 6). Late complications seen at 1 year after surgery were radiologic (asymptomatic) osteoarthritis of the elbow in 34 (69.4%) patients and symptomatic osteoarthritis (evidenced by pain during elbow motion) in 6 (12.2%) patients. It was noted that all the 6 patients with symptomatic osteoarthritis presented after 6 months since injury. They were being managed nonoperatively with oral analgesics and physiotherapy.
Fig. 4 e One-year postoperative radiograph and clinical pictures: a. Plain radiographs (AP & Lateral), b. Elbow in extension with fixed flexion deformity, c. Elbow in full flexion. Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
4
the surgeon xxx (xxxx) xxx
Table 1 e Patients characteristics. Frequency Age range 11e20 21e30 31e40 41e50 51e60 Gender Male Female Laterality Right Left Occupation C/Servant Soldier Police Student Trader Housewife Mode of Injury Assault Road traffic injury Gun Rosette Fall from height
Percentage
Table 2 e Comparing preoperative and postoperative Arc of elbow motion, MEPS and PSFS. Functional Scales Preoperative
3 19 21 5 1
6.1 38.8 42.9 10.2 2.0
42 7
85.7 14.3
14 35
28.6 71.4
10 5 7 15 11 1
20.4 10.2 14.3 30.6 22.4 2.0
1 34 1 13
2.0 69.5 2.0 26.5
Fig. 5 e Duration of presentation since injury.
One year postoperatively, the patients' level of satisfaction with the treatment was determined using the short assessment for patient satisfaction (SAPS). Figure 7 below demonstrates patients' level of satisfaction. The mean Short Assessment of Patient Satisfaction (SAPS) score was 23.0 ± 2.5 depicting in general, patients were satisfied. Three patients (6.1%) were not satisfied with overall treatment. However, 40 patients accounting for 81.6% of the patients were satisfied while the remaining 6 patients (12.2%) were very satisfied. The mean Short Assessment of Patient Satisfaction (SAPS) score for patients who presented between within 3 month and after 3 months since injury are 24.22 ± 1.76 and 22.18 ± 2.89 respectively. There is no
MEPS (mean ± SD) PSFS (mean ± SD) Arc of elbow motion (mean ± SD)
24.8 ± 9.9 2.9 ± 1.1 20.1 ± 5.9
1 year P - values Postoperative 92.6 ± 5.5 9.1 ± 0.6 86.6 ± 10.4
0.000 0.000 0.000
MEPS: Mayo Elbow Performance Score, PSFS: Patients' Specific Functional Scale, SD: Standard deviation.
significant difference in patients’ satisfaction between the two groups (p ¼ 0.75)
Discussion Old unreduced elbow dislocation is still common in developing countries where universal health coverage is still evolving. Late presentation to the hospital is due to many factors; including poverty, ignorance, and unhealthy cultural believes.2,3,9 Many authors recommend open reduction for patients presenting within 3 weeks to 3 months and total elbow replacement, excision arthroplasty and arthrodesis for those presenting later than 3 months.10,11 In our study all patients were treated by open reduction, regardless of time since injury and we achieved satisfactory results as evidenced by significant improvement in overall arc of elbow motion, Mayor Elbow Performance Score (MEPS) and Patients Specific Functional Score (PSFS) postoperatively (p ¼ 0.000). This is consistent with other studies that treated old unreduced dislocation of up to 2 years with open reduction.3,12,13 In our study, the perioperative complications noted was ulnar neuropraxia in one patient; it managed by physical therapy and recovered within 3 weeks. The other complication was wound dehiscence in 2 patients; they were managed by wound care and they were healed by secondary intention before K e wire removal in 3 weeks. One patient had redislocation after K e wire removal at 3weeks. He had repeat surgery with stabilization for 6 weeks; he however developed stiffness with less satisfactory outcome. These complications are within the spectrum of complications recorded in the previous studies.6 Complications recorded by other authors include superficial surgical site infection, flap necrosis and elbow stiffness.3,14 We did not find any study that determines patients’ perspectives of the outcome of open reduction. In our study, three patients (6.1%) were not satisfied with the overall outcome; the first developed severe stiffness and ulnar entrapment postoperatively due to myositis ossificans. The second patient had recurrent dislocation and the 3rd unsatisfied patient developed symptomatic osteoarthritis of the elbow. However, the remaining 46 patients (93.3%) were either satisfied or very satisfied.
Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
the surgeon xxx (xxxx) xxx
5
Fig. 6 e Perioperative complications.
Fig. 7 e Patients' satisfaction.
Strengths of the current study are that this is one of the largest prospective study of surgically treated old unreduced elbow dislocations in the literature. In addition, this is probably the first to objectively document the patient perspectives of the outcome of treatment. Although surgeries were not performed by a single surgeon; the same protocol was used for all the cases and we demonstrated consistent results with simple technique that permits early function of the elbow with a low perioperative complication rate.
Outcome of open reduction is good and well accepted by the patients. There is however need to determine the long-term outcome of open reduction in these patients.
Declaration of Competing Interest None to declare.
references
Conclusion Old unreduced elbow dislocation is still common in developing countries due to activities of traditional bone setters which lead to late presentation of patients to the hospital.
1. Daphne MB, Whitcomb P, Graham JW. Elbow fractures and dislocations. In: Charles MC, James DH, Margaret MM, Williams MR, Paul T, editors. Rockwood and green's fractures in adults. 8th ed., vol. 34. Wolters Kluwer; 2015. p. 1180e90.
Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
6
the surgeon xxx (xxxx) xxx
2. Andrew HC. Old unreduced dislocations. In: Frederick M, James HB, Canale ST, editors. Campbell's operative orthopaedics. 13th ed., vol. 61. Elsevier Inc.; 2017. p. 3155e9. 3. Nilesh IK, Nikhil L, Sharad S. Neglected old posterior dislocation of elbow: treatment and results of open reduction. IJOS 2017;3(3):1062e6. 4. Elzohairy MM. Neglected posterior dislocation of the elbow. Injury 2009;40:197e200. 5. Naidoo KS. Unreduced posterior dislocations of the elbow. J Bone Joint Surg Br 1982;64:603e6. 6. Anderson DR, Haller JM, Anderson LA, Hailu S, Chala A, O'Driscoll SW. Surgical treatment of chronic elbow dislocation allowing for early range of motion: operative technique and clinical results. J Orthop Trauma 2017:1e8. 00. 7. Derya K. Surgery of the elderly patient. Int Surg 2016;101(3):161e6. 8. Speed JS. An operation for unreduced post dislocation of elbow. South Med J 1925;18:193e8.
9. Mehta S, Sud A, Tiwari A, Kapoor SK. Open reduction for late presenting posterior dislocation of the elbow. J Orthop Surg 2007;15:15e21. 10. Bruce C, Laing P, Dorang J, Kleneman L. Unreduced dislocation of the elbow: case report and review of literature. J Trauma 1993;35:962e5. 11. Allende G, Freyetes M. Old dislocation of the elbow. J Bone Joint Surg 1944;26:691e706. 12. Rockwood CA. Treatment of old unreduced posterior dislocation of elbow. In: Rockwood CA, editor. Rockwood and Green's fracture in adults. 4th ed., vol. I. Philadelphia: LippincotRaven; 1996. p. 975e6. 13. Coulibaly NF, Tiemdjo H, Sane AD, Sarr YF, Ndiaye A, Seye S. Posterior approach for surgical treatment of neglected elbow dislocation. J Orthop Traumatol: Surg Res 2012;98:552e8. 14. Maheswaran KS, Kamalanathan MK. Management of old unreduced posterior dislocations of elbow: results of open reduction. IOSR-JDMS 2016;15(4):8e11.
Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction M.N. Salihu a, S.A. Arojuraye a,*, A.I. Alabi a, I.U. Mustapha b, N. Okoh a, F.B. Ayeni a a b
Clinical Services & Training Department, National Orthopaedic Hospital Dala, Kano, Nigeria Surgery Department, Aminu - Kano Teaching Hospital, Bayero University, Kano, Nigeria
article info
abstract
Article history:
Introduction: Old unreduced elbow dislocation is not uncommon in developing countries.
Received 8 December 2019
Many authors have reported outcome of open reduction in the management of this
Received in revised form
problem. However, we did not find any study that document patient reported outcome.
22 January 2020
Objective: the objective of this study was to determine the patients’ perspectives of outcome
Accepted 3 March 2020
of open reduction in the management of old unreduced elbow dislocation.
Available online xxx
Methods: This was a prospective interventional study of 49 consecutive patients with old unreduced simple elbow dislocation who were treated with open reduction at the National
Keywords:
Orthopaedic Hospital, Dala e Kano, Nigeria and Albarka Clinic Kano, Nigeria between
Unreduced elbow Dislocation
January 2015 and December 2019.
Open reduction
Results: Fourty nine patients were studied with median age of 31.0 years (range: 19e60
Patients perspectives
years). The majority of the patients were within 31e40 years age group. The male to female ratio was 6:1. Using the Mayor Elbow Performance Scale (MEPS) and Patients specific Functional scale (PSFS); there are significant improvements in postoperative functional capability of the patients (P ¼ 0.000). With the short assessment for patient satisfaction (SAPS), 93.3% of patients were either satisfied or very satisfied with the outcome of open reduction. Conclusion: The outcome of open reduction for old unreduced elbow dislocation is good and is well accepted by the patients. © 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Old unreduced elbow dislocations are dislocations of elbow which are not reduced within 3 weeks of injury.1 They are rare in developed nations but often seen in developing countries where universal health coverage is either not existing or just evolving.2 This might be as a result of ignorance and or poverty that makes many patients seek traditional treatment by native bone setters; which include manipulation and splinting in the dislocated position. Old unreduced elbow dislocations can be anterior or posterior though posterior dislocations are the most common.1,2 This condition poses a huge challenge to Orthopaedic Surgeons in developing countries, where treatment
armamentarium is evolving, because it is difficult to achieve full range of motion and function after open reduction which is commonly performed for this case.3 Patients with this condition usually present with the arm fixed in extension or in very slight flexion with minimal range of motion. Pronation is usually more limited than supination because the biceps is under tension from angulation around the humeral condyles which then pulls the forearm into supination.2 This attitude of the upper limb with fixed extended elbow and lack of protonation and supination is seriously disabling for patients' activities of daily living and so the need for surgical intervention. Though none is entirely satisfactory; options available for treating old unreduced elbow dislocation include open reduction, excision arthroplasty, interposition arthroplasty, replacement arthroplasty and arthrodesis.4,5 The most
* Corresponding author. E-mail address: [email protected] (S.A. Arojuraye). https://doi.org/10.1016/j.surge.2020.03.001 1479-666X/© 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
2
the surgeon xxx (xxxx) xxx
common form of treatment for this disabling condition in our environment is open reduction. There is couple of centerbased studies on the outcome of open reduction of old unreduced elbow dislocation. Nilesh et al.3 reported a case series of 15 patients in 2017 who had neglected posterior elbow dislocation and were treated with open reduction. They found that 13 (86.7%) patients had satisfactory outcomes. Similarly, Anderson et al.6 in a retrospective review of 32 patients with chronic elbow dislocation and who were managed with open reduction and were followed up for an average of 22 months, found that 97% of the patients had good to excellent results using Mayor Elbow Performance Index. However, we did not find any study with emphasis on patients reported outcome. The aim of this study therefore was to determine the patients’ perspectives of the outcome of old unreduced elbow dislocation treated with open reduction.
Patients and methods This was a prospective interventional study of 49 consecutive patients with old unreduced simple elbow dislocation who were treated with open reduction and Kirschner wire stabilization at the National Orthopaedic Hospital, Dala e Kano, Nigeria (a tertiary government orthopaedic institution) and Albarka Clinic Kano, Nigeria (a private orthopaedic facility). The study was conducted between January 2015 and December 2019. The study was conducted after approval from Hospital Research Ethics Committee (NHREC/21/08/2008a). The inclusion criteria were ages between 18 and 64 years, simple elbow dislocation (anterior or posterior), duration of injury more than 3 weeks, patients who had open reduction and were followed up for at least 1 year, and who gave consent to participate in the study. The following categories of patients were excluded from the study: ages <18 and >64 years, fracture dislocation of the elbow, associated fracture of the humerus, radius and ulnar, injury <3 weeks, patients with incomplete data at the end of 1 year and patients who declined consent to participate in the study. Elderly patients were excluded because the outcome of surgery generally in them is usually not as good as in the young. This may be due to presence of comorbid illnesses and cognitive dysfunction that may make rehabilitation difficult.7 Patients were diagnosed using clinical history and examination, and plain radiographs (anteroposterior and lateral views) of the elbow. Informed consent was obtained
from all the patients using standard informed consent form. Mayor Elbow Performance Score (MEPS) and Patients Specific Functional Score (PSFS) were documented for all patients preoperatively and at structured follow ups. All patients were treated with open reduction and stabilization using single 3 mm Kirschner. The wire was passed through the posterior border of the ulnar 2 cm from the tip of the olecranon into the humeral medullary canal. The procedure was carried out under general anaesthesia in all cases. One gram of Ceftriaxone was use as prophylactic antibiotic in all cases. The procedure was performed using Speed “VeY triceplasty.8 Patients were discharged from the hospital on average of 6 days after surgery. Sutures were removed at 2 weeks and k-wire was removed at 3 weeks postoperatively. Elbow range of motion exercises was commenced at 3 weeks after K-wire removal and physical examination to assess integrity of collateral ligaments. The study excluded all fracture dislocations and associated humerus, radius and ulnar fractures. The fixation required therefore was temporary (not later than 3 weeks) to avoid disabling elbow stiffness. K e wire was used because its removal at 3 weeks is less technically demanding. Figures 1e4 below show preoperative, intraoperative and postoperative clinical photographs and plain radiographs of one of the patients. Patients were followed up clinically and radiologically at the surgical outpatient department at 3 weeks, 6 weeks, 3 months, 6 months and 1 year after surgery. Clinical history, physical examination including arc of elbow motion, MEPS and PSFS were documented at each follow up. Using Mayo scores elbow function was rated as excellent (90e100), good (75e89), fair (60e74), or poor (<60). Complaints and complications were documented and were appropriately managed. At the end one year postoperative, patients' perspectives of the treatment were recorded using the short assessment for patient's satisfaction (SAPS). The SAPS consist of seven items assessing the core domains of patient satisfaction which include treatment satisfaction, explanation of treatment results, clinician care, participation in medical decision making, respect by the clinician, time with the clinician, and satisfaction with hospital/clinic care. Responses scales are 5-point scales. Relevant information was recorded into Microsoft excel sheet and data was analyzed using SPSS version 23.0 for windows. The paired samples T test was used to compare the clinical outcomes as continuous variables. Statistical significance was considered at p < 0.05 (see Fig. 4).
Fig. 1 e Preoperative Clinical Photographs & Plain Radiographs. a. Elbow in extension, b. Elbow in flexion, c. Lateral radiograph, d. Anteroposterior radiograph. Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
the surgeon xxx (xxxx) xxx
3
Fig. 2 e Intraoperative Clinical Pictures: a. Left elbow after draping, b. Ulnar nerve identified and protected, c. VeY triceplasty done, d. Elbow reduced and stabilized with K-wire, e. wound closed over a suction drain.
Fig. 3 e Postoperative plain radiographs and clinical pictures: a. Postoperative AP & Lateral views radiograph with K e wire insitu, b. Elbow joint in 90 flexion 2 weeks after surgery with K wire in situ.
Results During the study period, a total of 56 patients were managed for old elbow dislocation. Four patients had fracture dislocation and were excluded from the study. Three patients were lost to follow up after removal of K e wire at 3 weeks after surgery and were also excluded. The remaining 49 patients were followed up for a minimum of 1 year and the finding is as documented below. The mean age of the patients was 31.9 ± 8.5 year. There were 42 (85.7%) male patients and 7 (14.3%) female patients, with male to female ratio of 6: 1. All patients were righthanded and majority of them 35 (71.4%) had dislocation in non-dominant elbow. Majority of the patients 47 (95.9%) had initial traditional bone setter treatment before seeking
orthodox intervention. The mode of injury was road traffic accident in 34 (69.4%) of cases, fall from height in 13 (26.5%), physical assault in 1 (2%) and gun rosette in 1 (2%). Table 1 below summarizes the demographic characteristics of the patients. The median duration before presentation was 11 weeks, ranges from 4 to 32 weeks. Most patients presented within 3e12 weeks after the injury. Majority of the patients 47 (95.9%) had traditional bone setter treatment before seeking orthodox intervention. Figure 5 below shows the duration of presentation since injury of all the patients. Table 2 below compares the functional capabilities of the patients preoperatively and one year after surgery. There were significant improvements in the overall arc of elbow motion, MEPS and PSFS after surgery (P ¼ 0.000). The average preoperative MEPS was poor while postoperatively average MEPS became excellent. The mean preoperative arc of motion was 20.1 ± 5.9 , while 1year postoperative mean arc was 86.6 ± 10.4 . The perioperative complications recorded include ulnar neuropraxia in 1 (2%) patient who recovered completely within 6 weeks, recurrent dislocation in 1 (2%) patient who subsequently had elbow arthrodesis and wound dehiscence in 2 (4.1%) patients, both were managed successfully with local wound care (see Fig. 6). Late complications seen at 1 year after surgery were radiologic (asymptomatic) osteoarthritis of the elbow in 34 (69.4%) patients and symptomatic osteoarthritis (evidenced by pain during elbow motion) in 6 (12.2%) patients. It was noted that all the 6 patients with symptomatic osteoarthritis presented after 6 months since injury. They were being managed nonoperatively with oral analgesics and physiotherapy.
Fig. 4 e One-year postoperative radiograph and clinical pictures: a. Plain radiographs (AP & Lateral), b. Elbow in extension with fixed flexion deformity, c. Elbow in full flexion. Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
4
the surgeon xxx (xxxx) xxx
Table 1 e Patients characteristics. Frequency Age range 11e20 21e30 31e40 41e50 51e60 Gender Male Female Laterality Right Left Occupation C/Servant Soldier Police Student Trader Housewife Mode of Injury Assault Road traffic injury Gun Rosette Fall from height
Percentage
Table 2 e Comparing preoperative and postoperative Arc of elbow motion, MEPS and PSFS. Functional Scales Preoperative
3 19 21 5 1
6.1 38.8 42.9 10.2 2.0
42 7
85.7 14.3
14 35
28.6 71.4
10 5 7 15 11 1
20.4 10.2 14.3 30.6 22.4 2.0
1 34 1 13
2.0 69.5 2.0 26.5
Fig. 5 e Duration of presentation since injury.
One year postoperatively, the patients' level of satisfaction with the treatment was determined using the short assessment for patient satisfaction (SAPS). Figure 7 below demonstrates patients' level of satisfaction. The mean Short Assessment of Patient Satisfaction (SAPS) score was 23.0 ± 2.5 depicting in general, patients were satisfied. Three patients (6.1%) were not satisfied with overall treatment. However, 40 patients accounting for 81.6% of the patients were satisfied while the remaining 6 patients (12.2%) were very satisfied. The mean Short Assessment of Patient Satisfaction (SAPS) score for patients who presented between within 3 month and after 3 months since injury are 24.22 ± 1.76 and 22.18 ± 2.89 respectively. There is no
MEPS (mean ± SD) PSFS (mean ± SD) Arc of elbow motion (mean ± SD)
24.8 ± 9.9 2.9 ± 1.1 20.1 ± 5.9
1 year P - values Postoperative 92.6 ± 5.5 9.1 ± 0.6 86.6 ± 10.4
0.000 0.000 0.000
MEPS: Mayo Elbow Performance Score, PSFS: Patients' Specific Functional Scale, SD: Standard deviation.
significant difference in patients’ satisfaction between the two groups (p ¼ 0.75)
Discussion Old unreduced elbow dislocation is still common in developing countries where universal health coverage is still evolving. Late presentation to the hospital is due to many factors; including poverty, ignorance, and unhealthy cultural believes.2,3,9 Many authors recommend open reduction for patients presenting within 3 weeks to 3 months and total elbow replacement, excision arthroplasty and arthrodesis for those presenting later than 3 months.10,11 In our study all patients were treated by open reduction, regardless of time since injury and we achieved satisfactory results as evidenced by significant improvement in overall arc of elbow motion, Mayor Elbow Performance Score (MEPS) and Patients Specific Functional Score (PSFS) postoperatively (p ¼ 0.000). This is consistent with other studies that treated old unreduced dislocation of up to 2 years with open reduction.3,12,13 In our study, the perioperative complications noted was ulnar neuropraxia in one patient; it managed by physical therapy and recovered within 3 weeks. The other complication was wound dehiscence in 2 patients; they were managed by wound care and they were healed by secondary intention before K e wire removal in 3 weeks. One patient had redislocation after K e wire removal at 3weeks. He had repeat surgery with stabilization for 6 weeks; he however developed stiffness with less satisfactory outcome. These complications are within the spectrum of complications recorded in the previous studies.6 Complications recorded by other authors include superficial surgical site infection, flap necrosis and elbow stiffness.3,14 We did not find any study that determines patients’ perspectives of the outcome of open reduction. In our study, three patients (6.1%) were not satisfied with the overall outcome; the first developed severe stiffness and ulnar entrapment postoperatively due to myositis ossificans. The second patient had recurrent dislocation and the 3rd unsatisfied patient developed symptomatic osteoarthritis of the elbow. However, the remaining 46 patients (93.3%) were either satisfied or very satisfied.
Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001
the surgeon xxx (xxxx) xxx
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Fig. 6 e Perioperative complications.
Fig. 7 e Patients' satisfaction.
Strengths of the current study are that this is one of the largest prospective study of surgically treated old unreduced elbow dislocations in the literature. In addition, this is probably the first to objectively document the patient perspectives of the outcome of treatment. Although surgeries were not performed by a single surgeon; the same protocol was used for all the cases and we demonstrated consistent results with simple technique that permits early function of the elbow with a low perioperative complication rate.
Outcome of open reduction is good and well accepted by the patients. There is however need to determine the long-term outcome of open reduction in these patients.
Declaration of Competing Interest None to declare.
references
Conclusion Old unreduced elbow dislocation is still common in developing countries due to activities of traditional bone setters which lead to late presentation of patients to the hospital.
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the surgeon xxx (xxxx) xxx
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Please cite this article as: Salihu MN et al., Old unreduced elbow dislocation: Patients’ perspectives on outcome of open reduction, The Surgeon, https://doi.org/10.1016/j.surge.2020.03.001