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Perioperative Glucocorticoid Administration Improves Elbow Motion in Terrible Triad Injuries
EDITOR’S CHOICE
Perioperative Glucocorticoid Administration Improves Elbow Motion in Terrible Triad Injuries Mihir J. Desai, MD,* Andrew P. Matson, MD,† David S. Ruch, MD,† Fraser J. Leversedge, MD,† J. Mack Aldridge III, MD,‡ Marc J. Richard, MD†
Purpose Among patients who undergo surgical treatment of terrible triad elbow injuries (TTEI), we hypothesized that those who received perioperative glucocorticoid (GC) therapy would have improved postoperative pain and range of motion (ROM) and a similar complication rate compared with patients who did not receive GC therapy. Methods We retrospectively identified 26 patients who underwent surgical treatment of TTEI from 2009 to 2015. Thirteen patients received a single intraoperative dose of 10 mg intravenous dexamethasone followed with a 6-day oral methylprednisolone taper course (GC group), and 13 did not (control group). After surgery, patients were placed in an orthosis at 90 flexion with the forearm in pronation for 2 weeks, after which ROM was initiated. Patients were seen in clinic at 2, 6, 12, and 24 weeks after surgery, at which time numeric pain scale scores and ROM data were collected and any complications were noted. Results Compared with the control group, the GC group had a greater flexion-extension arc of motion at 24 weeks (132.5 vs 105.5 ); significant differences were not found at earlier time points. Supination measurements were significantly greater for the GC group at every time point with a difference at final follow-up of 23.2 (61.0 vs. 84.2 ). There were 5 complications in the control group (35.8%), 3 of which required additional surgery, and 3 complications in the GC group (23.1%), 1 of which required another surgery. No postoperative infections were found in either group. Conclusions Perioperative glucocorticoid administration is associated with improved ROM after surgical treatment of TTEI. Flexion-extension, pronosupination arc of motion, and overall supination were significantly improved. Postoperative pain scores and complication rates were similar between GC and control groups. (J Hand Surg Am. 2017;42(1):41e46. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Terrible triad, glucocorticoids, steroids, elbow dislocation, elbow trauma.
From the *Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN; and the †Department of Orthopaedic Surgery, Duke University Medical Center and ‡Triangle Orthopaedic Associates, Durham, NC.
Corresponding author: Mihir J. Desai, MD, Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, 215 Light Hall, MCE S. Tower Suite 3200, Nashville, TN 37232; e-mail: [email protected].
Received for publication May 18, 2016; accepted in revised form November 7, 2016.
0363-5023/17/4201-0008$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.11.011
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
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STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
(TTEIs) have proven to be difficult to treat.1,2 Because of the complexity of the radial head, coronoid, and ligamentous injury resulting in elbow fracturedislocation, outcomes have been poor, with longterm complications including stiffness, pain, arthritis, and joint instability.3 Overall, complications result in a 22% to 30% reoperation rate.4 Previous studies demonstrated that stiffness manifests as either limited flexion or extension occurring in 5% to 20% of patients treated surgically for terrible triad injuries.5e9 Perioperative glucocorticoid (GC) therapy has been used successfully in other orthopedic surgical procedures. Intraoperative and postoperative perioperative dexamethasone has been shown to improve postoperative pain scores,10e13 decrease hospitalization days,13 and quicken functional recovery13 after hip and knee arthroplasty. In those studies, there were no differences in wound complications or infection rates after GC therapy.10e14 The purpose of this study was to determine the effects of perioperative GC administration after surgery for TTEI. We tested the null hypothesis that intraoperative dexamethasone followed by a 6-day oral methylprednisolone taper course would have no effect on pain, range of motion (ROM), and complication rate after surgical treatment of TTEI.
on day 4, 8 mg on day 5, and 4 mg on day 6. Patients in the GC group reported 100% compliance with the oral steroid taper course upon questioning at followup. The determination to begin using GCs for TTEI was based on research in other specialties and anecdotal experience with GCs in the perioperative period. Each patient was counseled regarding the potential risks of GCs before administration and was agreeable with participating. Table 1 described the patients in each group of the study. The control group was significantly younger than the GC group (median, 41.4 vs 65.0 years; P ¼ .043). Surgical delay, dominance of affected side, mechanism of injury, and follow-up were similar between groups. All patients (26 of 26) completed at least 12 weeks of follow-up, and 88.5% patients (23 of 26) completed at least 6 months of follow-up.
ERRIBLE TRIAD ELBOW INJURIES
Clinical protocol One of 2 fellowship-trained hand and upper-extremity orthopedic surgeons performed the surgeries. All procedures included radial head arthroplasty (Anatomic Radial Head; AcuMed, Hillsboro, OR), fixation of the coronoid fracture, and repair of the lateral ligamentous complex. In 3 patients, the medial ligamentous complex was repaired as well. Surgical procedures were performed in accordance with previously described surgical techniques.5,15,16 After surgery, patients were placed in a plaster orthosis at 90 elbow flexion with the forearm pronated. At the 2-week postoperative visit, the orthosis was removed and patients were instructed to begin active and active-assisted ROM exercises under the guidance of a hand therapist, with restrictions including full extension only in neutral or pronation and no extension beyond 90 with the forearm supinated. Follow-up visits were scheduled at 2, 6, 12, and 24 weeks after surgery. Radiographs were checked at each postoperative visit to confirm adequate hardware positioning and joint reduction. Radiographs were also evaluated for the development of heterotopic ossification (HO). Clinical evaluation was performed at each postoperative visit including pain assessment via numeric pain scale (NPS) from 0 (no pain) to 10 (highest amount of pain) and ROM assessment by a hand-held goniometer.
MATERIALS AND METHODS Patients We obtained approval from our institutional review board before collecting data. A total of 26 patients who underwent surgical treatment for TTEI from 2009 to 2015 were retrospectively identified. Qualifying patients were selected from operative case logs and included those who sustained a closed traumatic injury of the elbow with a dislocation, radial head fracture, and coronoid fracture. Exclusion criteria included open injury, concomitant fracture to the ipsilateral upper extremity, concomitant trauma requiring hospital admission, patient age less than 18 years, or follow-up less than 12 weeks. The first 13 patients treated in this cohort did not receive perioperative steroids and thus comprised a control group. The next 13 patients treated received a single intraoperative dose of 10 mg intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course, and thus were included in the GC group. The oral methylprednisolone taper course began on the day of surgery and included 24 mg on day 1, 20 mg on day 2, 16 mg on day 3, 12 mg J Hand Surg Am.
Data collection and analysis One of 2 reviewers not directly involved with the patients’ care collected data through a review of patient charts in the medical record. All initial injury radiographs were reviewed to confirm elbow r
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STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
TABLE 1.
Descriptive Characteristics Control
n Age, y
Steroid
13
13
42.9 (32.6e74.3)
57.4 (21.1e77.0)
Surgical delay, d
7.3 (3e20)
9.0 (7e12)
Dominant side injured (%)
53.8 (7/13)
53.8 (7/13)
Fall from standing (10/13) vs fall from a height (3/13)
Fall from standing (11/13) vs fall from a height (2/13)
56.4 (13.0e154.3)
44.2 (12.0e130.0)
Mechanism Average follow-up, wk
Data are represented as mean (range) except where noted.
TABLE 2.
Postoperative Pain and Arc of Motion Control (range)
95% Confidence Interval
Steroid (range)
95% Confidence Interval
P Value
2-wk pain score (0e10)
2.9 (1e8)
1.0 to 4.7
3.2 (0e8)
1.3 to 5.1
> .05
6-wk pain score (0e10)
2.0 (0e5)
1.0 to 3.0
1.5 (0e6)
0.3 to 2.9
> .05
Flexion-extension arc (degrees)
66.7 (35e96)
54.4 to 78.9
85.2 (40e127)
12.3 to 14.5
> .05
Pronosupination arc (degrees)
81.4 (50e125)
67.2 to 95.6
127.3 (70e165)
105.6 to 149.0
< .05*
0.4 to 2.5
0.9 (0e5)
e0.2 to 1.8
> .05
98.4 (50e125)
86.9 to 109.8
115.4 (80e135)
102.6 to 128.2
> .05
122.3 (60e175)
101.4 to 143.1
145.0 (80e180)
120.3 to 162.7
> .05
12 wk Pain score (0e10) Flexion-extension arc (degrees) Pronosupination arc (degrees)
1.4 (0e5)
24 wk 1.3 (0e4)
0.2 to 2.4
e0.2 to 1.5
> .05
Flexion-extension arc (degrees)
105.5 (45e140)
85.2 to 125.9
132.5 (115e140)
124.2 to 140.8
< .05*
Pronosupination arc (degrees)
132.2 (15e180)
102.1 to 162.3
165.8 (135e180)
153.1 to 178.6
> .05
Pain score (0e10)
0.7 (0e2)
arc, arc of motion. P values were calculated using unpaired, 2-tailed Student t test. Confidence intervals were calculated with a ¼ .05. *Statistical significance interpreted as P < .05.
dislocation and the presence of a TTEI pattern, as previously described. Operative reports and postoperative films were reviewed to confirm the procedure performed, and perioperative records were reviewed to confirm the intravenous dexamethasone dose received. Postoperative clinical chart documentation was reviewed to collect information about oral steroid compliance, NPS pain scores, ROM, and complications. Complications were categorized as minor, defined by not requiring operative intervention, or major, defined as the need for operative intervention. We performed a statistical analysis using unpaired, 2-tailed Student t test to compare means for normally distributed data, Kruskal-Wallis test to compare medians of non-normally distributed data, J Hand Surg Am.
and chi-square test to compare proportions. Statistical significance was interpreted as P < .05. Confidence intervals were calculated indicating a confidence level of 95%. RESULTS Table 2 and Figure 1 show pain and ROM outcomes. Flexion-extension arc of motion was greater in the GC group compared with the control group at all postoperative visits, although this difference was statistically significant only at 24 weeks (132.5 vs 105.5 ; P < .05). When ROM was evaluated as flexion and extension discretely, motion was greater in both components at all time points, although the difference was only statistically significant for extension at 6 and 24 weeks. r
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STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
Postoperative Range of Motion 160 Control
Steroid
140
Range (Degrees)
120 100 80 60 40 20
6 weeks
12 weeks
*Supination
Pronation
*Extension
Flexion
*Supination
Pronation
Extension
Flexion
*Supination
Pronation
*Extension
Flexion
0
24 weeks
FIGURE 1: Comparative mean range of motion values. *Statistically significant difference between control and steroid groups (P < .05). Full extension was defined as 0 with increasing flexion resulting in higher degree values; therefore, lower extension values imply greater ROM.
Total pronosupination arc of motion was greater at all time points in the GC group; the difference at 6 weeks was statistically significant (127.3 vs 81.4 ; P < .05). Supination measurements were significantly greater for the GC group at every postoperative visit, with a difference at 24 weeks of 23.2 (84.2 vs 61 ; P < .05). Pronation measurements were also greater in the GC group at each postoperative visit, although this difference was not statistically significant. The NPS pain scores did not differ between groups at any time point after surgery. Table 3 lists complications. Overall, there were 5 complications in the control group (35.8%) and 3 in the GC group (23.1%). The most common complications were ulnar neuropathy at the elbow (n ¼ 5) and HO (n ¼ 4). Heterotopic ossification occurred only in the control group. Complications requiring surgery occurred in 3 of 13 patients in control group and 1 of 13 patients in the GC group. There were no postoperative infections in either group.
TABLE 3.
Complication
Control
Steroid
4/13 (31%), 3/4 required surgery
0
Ulnar neuropathy
3/13 (23%)
2/13 (15%)
Contracture
2/13 (15%)
0
Synostosis
1/13 (8%)
0
0
1/13 (8%) required surgery
Heterotopic ossification
Arthrofibrosis/synovitis
Previous evidence suggests that perioperative GC administration is safe and improves pain, nausea, and vomiting in thyroid, abdominal, facial plastic, and oral surgery.17e23 In addition, postoperative swelling and tissue edema are improved with perioperative GC administration with no concomitant increase in wound disturbances after facial surgery.24e27 In the orthopedic literature, Jules-Elysee et al28 evaluated perioperative intravenous steroid administration in 34 patients undergoing bilateral knee arthroplasty and found improved outcomes in terms of pain, nausea, and ROM. The study found no increase in infection between control and treatment groups, but it was underpowered to assess this outcome adequately. In 2013, Lunn and Kehlet10 showed that perioperative intravenous steroids
DISCUSSION The combination of a radial head and coronoid fracture in the setting of an elbow dislocation has earned the name of “terrible triad” owing to the complexity of treatment.1 Perioperative GC therapy is an appealing adjunct to the surgical treatment of TTEI, with the goals of improving postoperative ROM and decreasing pain during recovery. J Hand Surg Am.
Complications
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STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
improved pain in 48 patients undergoing total hip arthroplasty. Additional studies reported improvements in postoperative pain scores,10e13 decreased hospitalization days,13 and quicker functional recovery13 after hip and knee arthroplasty. The results of this study show that perioperative GC therapy resulted in improved postoperative ROM in both flexion-extension and pronosupination arc of motion. Compared with previously reported outcomes after TTEI not treated with perioperative steroids, the 132.5 flexion-extension arc in the GC group in this study was greater than the arc of motion reported by Gupta et al16 (110 ) (16), Pugh et al15 (112 ), and Garrigues et al5 (115 ). Furthermore, the 105.5 flexion-extension arc of motion in the control group in the current study was similar to the previous reports. However, the reliability of the ROM measurements from those reports is not known. The 165.8 pronosupination arc in the GC group compares favorably with the arc of motion reported by Gupta et al16 (148 ) (16) and Pugh et al15 (136 ). The 132.2 pronosupination arc of motion in the current control group is similar to these previous reports. Again, the reliability of the ROM measurements from those reports is not known and a true comparison cannot be made. Supination was greater at all time points in the GC group. Overall improvement in supination is critical because all patients were placed in an orthosis in pronation for 2 weeks and started flexion-extension exercises with the forearm in pronation. Pain and complication rate were similar in the 2 groups and no postoperative infections were seen. Average age in the GC group was 15 years older than in the control group, a statistically significant difference. The importance of this difference to the results is unknown because, to the authors’ knowledge, no studies have directly compared outcomes with age. There were no cases of HO in the GC group and 4 in the control group, 3 of which required surgery to excise the heterotopic bone. The only elbow in the GC group that required reoperation had presumed synovitis and arthrofibrosis at 6 weeks and underwent an open debridement. Heterotopic ossification presents a considerable source of morbidity after complex elbow trauma. Anatomically, the medial collateral ligament (MCL) has a cam effect at the elbow. It requires elongation to its maximum length to flex past 90 .29 It is our opinion that when the elbow does not achieve flexion early after surgery, the MCL stiffens and cannot elongate to attain flexion. We know the MCL is a common site of HO, and when it occurs flexion is limited.29 We J Hand Surg Am.
45
hypothesize that the prevention of the HO contributes to gains in elbow flexion. Historically, a concern about perioperative steroid therapy is the risk of wound-healing disturbance and infection. However, data from plastic surgery, general surgery, oral surgery, and orthopedic surgery suggest no increase in wound complications from perioperative GC administration.30e34 Taken together, the literature showed that low-dose, shortcourse, intravenous and oral corticosteroid regimens appear to be safe with regard to wound healing and infection. The primary limitations of this study are those inherent in its retrospective design. An observer bias may be present and must be considered when looking at the data presented here. In addition, TTEI represents a spectrum of injury and it is difficult to control for the relative severity of the individual injuries. Each injury required radial head replacement, coronoid fixation or capsular repair, and lateral ulnar collateral ligament repair. Most injuries occurred from a fall from a standing height. Despite the similar mechanism and surgical treatment, it is difficult to control for other capsular/ligamentous injuries that may have occurred. These soft tissue injuries often are not diagnosed because they are not key determinants to elbow stability and not repaired. Because of the extent of injury, the initial trauma would seem to be a key determinant of ultimate outcome and we cannot quantify the extent of the trauma exposed to the injured structures; thus, there is inherent sampling error. Furthermore, this was a relatively small sample size with 13 patients in each group. A better study design would be a true case-control design to minimize the possible effects of the surgeon and low sample size. The durability of the steroid effect is also unknown. We saw few patients beyond 6 months and thus could not perform an analysis between groups at 1 year or longer. Our results support the use of perioperative GCs for the treatment of TTEIs. As of this publication, we have adopted this protocol for these injuries at our institution. REFERENCES 1. Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009;17(3): 137e151. 2. Dodds SD, Fishler T. Terrible triad of the elbow. Orthop Clin North Am. 2013;44(1):47e58. 3. Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, Larrainzar-Garijo R. Outcomes after terrible triads of the elbow
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treated with the current surgical protocols: a review. Int Orthop. 2011;35(6):851e860. Chen HW, Liu GD, Wu LJ. Complications of treating terrible triad injury of the elbow: a systematic review. PLoS ONE. 2014;9(5): e97476. Garrigues GE, Wray WH III, Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 2011;93(20):1873e1881. Toros T, Ozaksar K, Sugun TS, Kayalar M, Bal E, Ada S. The effect of medial side repair in terrible triad injury of the elbow. Acta Orthop Traumatol Turc. 2012;46(2):96e101. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg. 2012;21(10):1336e1341. Lindenhovius AL, Jupiter JB, Ring D. Comparison of acute versus subacute treatment of terrible triad injuries of the elbow. J Hand Surg Am. 2009;33(6):920e926. Forthman C, Henket M, Ring DC. Elbow dislocation with intraarticular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am. 2007;32(8): 1200e1209. Lunn TH, Andersen LO, Kristensen BB, et al. Effect of high-dose preoperative methylprednisolone on recovery after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Br J Anaesth. 2013;110(1):66e73. Koh IJ, Chang BS, Lee JH, Jeon YT, Kim TK. Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study. Clin Orthop Relat Res. 2013;471(9): 3010e3020. Lunn TH, Kehlet H. Perioperative glucocorticoids in hip and knee surgery—benefit vs. harm? A review of randomized clinical trials. Acta Anaesthesiol Scand. 2013;57(7):823e834. Backes JR, Bentley JC, Politi JR, Chambers BT. Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective randomized controlled trial. J Arthroplasty. 2013;28(8):11e17. Richardson AB, Bala A, Wellman SS, Attarian DE, Bolognesi MP, Grant SA. Perioperative dexamethasone administration does not increase the incidence of postoperative infection in total hip and knee arthroplasty: a retrospective analysis. J Arthroplasty. 2016;31(8):1784e1787. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86(6):1122e1130. Gupta A, Barei D, Khwaja A, Beingessner D. Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. Clin Orthop Relat Res. 2014;472(7):2075e2083. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg. 1997;85(4):808e816. Chen CC, Siddiqui FJ, Chen TL, Chan ES, Tam KW. Dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing thyroidectomy: meta-analysis of randomized controlled trials. World J Surg. 2012;36(1):61e68. Worni M, Schudel HH, Seifert E, et al. Randomized controlled trial on single dose steroid before thyroidectomy for benign disease to
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improve postoperative nausea, pain, and vocal function. Ann Surg. 2008;248(6):1060e1066. Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial. Ann Surg. 2003;238(5):651e660. Fukami Y, Terasaki M, Okamoto Y, et al. Efficacy of preoperative dexamethasone in patients with laparoscopic cholecystectomy: a prospective randomized double-blind study. J Hepatobiliary Pancreat Surg. 2009;16(3):367e371. Buyukkurt MC, Gungormus M, Kaya O. The effect of a single dose prednisolone with and without diclofenac on pain, trismus, and swelling after removal of mandibular third molars. J Oral Maxillofac Surg. 2006;64(12):1761e1766. Markiewicz MR, Brady MF, Ding EL, Dodson TB. Corticosteroids reduce postoperative morbidity after third molar surgery: a systematic review and meta-analysis. J Oral Maxillofac Surg. 2008;66(9):1881e1894. Tiigimae-Saar J, Leibur E, Tamme T. The effect of prednisolone on reduction of complaints after impacted third molar removal. Stomatologija. 2010;12(1):17e22. Clune JE, Greene AK, Guo CY, et al. Perioperative corticosteroid reduces hospital stay after fronto-orbital advancement. J Craniofac Surg. 2010;21(2):344e348. Hatef DA, Ellsworth WA, Allen JN, Bullocks JM, Hollier LH Jr, Stal S. Perioperative steroids for minimizing edema and ecchymosis after rhinoplasty: a meta-analysis. Aesthet Surg J. 2011;31(6): 648e657. Tuncel U, Turan A, Bayraktar MA, Erkorkmaz U, Kostakoglu N. Efficacy of dexamethasone with controlled hypotension on intraoperative bleeding, postoperative oedema and ecchymosis in rhinoplasty. J Craniomaxillofac Surg. 2013;41(2):124e128. Jules-Elysee KM, Wilfred SE, Memstoudis SG, et al. Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective, double-blind, randomized controlled trial. J Bone Joint Surg Am. 2012;94(23):2120e2127. Ruch DS, Shen J, Chloros GD, Krings E, Papadonikolakis A. Release of the medial collateral ligament to improve flexion in posttraumatic elbow stiffness. J Bone Joint Surg Br. 2008;90(5): 614e618. Hyrkas T. Effect of preoperative single doses of diclofenac and methylprednisolone on wound healing. Scand J Plast Reconstr Surg Hand Surg. 1994;28(4):275e278. Pien LC, Grammer LC, Patterson R. Minimal complications in a surgical population with severe asthma receiving prophylactic corticosteroids. J Allergy Clin Immunol. 1988;82(4):696e700. Ziv Y, Church JM, Fazio VW, King TM, Lavery IC. Effect of systemic steroids on ileal pouch-anal anastomosis in patients with ulcerative colitis. Dis Colon Rectum. 1996;39(5):504e508. Thoren H, Snall J, Kormi E, et al. Does perioperative glucocorticosteroid treatment correlate with disturbance in surgical wound healing after treatment of facial fractures? A retrospective study. J Oral Maxillofac Surg. 2009;67(9):1884e1888. Salerno A, Hermann R. Efficacy and safety of steroid use for postoperative pain relief: update and review of the medical literature. J Bone Joint Surg Am. 2006;88(6):1361e1372.
Vol. 42, January 2017
Perioperative Glucocorticoid Administration Improves Elbow Motion in Terrible Triad Injuries Mihir J. Desai, MD,* Andrew P. Matson, MD,† David S. Ruch, MD,† Fraser J. Leversedge, MD,† J. Mack Aldridge III, MD,‡ Marc J. Richard, MD†
Purpose Among patients who undergo surgical treatment of terrible triad elbow injuries (TTEI), we hypothesized that those who received perioperative glucocorticoid (GC) therapy would have improved postoperative pain and range of motion (ROM) and a similar complication rate compared with patients who did not receive GC therapy. Methods We retrospectively identified 26 patients who underwent surgical treatment of TTEI from 2009 to 2015. Thirteen patients received a single intraoperative dose of 10 mg intravenous dexamethasone followed with a 6-day oral methylprednisolone taper course (GC group), and 13 did not (control group). After surgery, patients were placed in an orthosis at 90 flexion with the forearm in pronation for 2 weeks, after which ROM was initiated. Patients were seen in clinic at 2, 6, 12, and 24 weeks after surgery, at which time numeric pain scale scores and ROM data were collected and any complications were noted. Results Compared with the control group, the GC group had a greater flexion-extension arc of motion at 24 weeks (132.5 vs 105.5 ); significant differences were not found at earlier time points. Supination measurements were significantly greater for the GC group at every time point with a difference at final follow-up of 23.2 (61.0 vs. 84.2 ). There were 5 complications in the control group (35.8%), 3 of which required additional surgery, and 3 complications in the GC group (23.1%), 1 of which required another surgery. No postoperative infections were found in either group. Conclusions Perioperative glucocorticoid administration is associated with improved ROM after surgical treatment of TTEI. Flexion-extension, pronosupination arc of motion, and overall supination were significantly improved. Postoperative pain scores and complication rates were similar between GC and control groups. (J Hand Surg Am. 2017;42(1):41e46. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Terrible triad, glucocorticoids, steroids, elbow dislocation, elbow trauma.
From the *Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN; and the †Department of Orthopaedic Surgery, Duke University Medical Center and ‡Triangle Orthopaedic Associates, Durham, NC.
Corresponding author: Mihir J. Desai, MD, Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, 215 Light Hall, MCE S. Tower Suite 3200, Nashville, TN 37232; e-mail: [email protected].
Received for publication May 18, 2016; accepted in revised form November 7, 2016.
0363-5023/17/4201-0008$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.11.011
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
41
42
T
STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
(TTEIs) have proven to be difficult to treat.1,2 Because of the complexity of the radial head, coronoid, and ligamentous injury resulting in elbow fracturedislocation, outcomes have been poor, with longterm complications including stiffness, pain, arthritis, and joint instability.3 Overall, complications result in a 22% to 30% reoperation rate.4 Previous studies demonstrated that stiffness manifests as either limited flexion or extension occurring in 5% to 20% of patients treated surgically for terrible triad injuries.5e9 Perioperative glucocorticoid (GC) therapy has been used successfully in other orthopedic surgical procedures. Intraoperative and postoperative perioperative dexamethasone has been shown to improve postoperative pain scores,10e13 decrease hospitalization days,13 and quicken functional recovery13 after hip and knee arthroplasty. In those studies, there were no differences in wound complications or infection rates after GC therapy.10e14 The purpose of this study was to determine the effects of perioperative GC administration after surgery for TTEI. We tested the null hypothesis that intraoperative dexamethasone followed by a 6-day oral methylprednisolone taper course would have no effect on pain, range of motion (ROM), and complication rate after surgical treatment of TTEI.
on day 4, 8 mg on day 5, and 4 mg on day 6. Patients in the GC group reported 100% compliance with the oral steroid taper course upon questioning at followup. The determination to begin using GCs for TTEI was based on research in other specialties and anecdotal experience with GCs in the perioperative period. Each patient was counseled regarding the potential risks of GCs before administration and was agreeable with participating. Table 1 described the patients in each group of the study. The control group was significantly younger than the GC group (median, 41.4 vs 65.0 years; P ¼ .043). Surgical delay, dominance of affected side, mechanism of injury, and follow-up were similar between groups. All patients (26 of 26) completed at least 12 weeks of follow-up, and 88.5% patients (23 of 26) completed at least 6 months of follow-up.
ERRIBLE TRIAD ELBOW INJURIES
Clinical protocol One of 2 fellowship-trained hand and upper-extremity orthopedic surgeons performed the surgeries. All procedures included radial head arthroplasty (Anatomic Radial Head; AcuMed, Hillsboro, OR), fixation of the coronoid fracture, and repair of the lateral ligamentous complex. In 3 patients, the medial ligamentous complex was repaired as well. Surgical procedures were performed in accordance with previously described surgical techniques.5,15,16 After surgery, patients were placed in a plaster orthosis at 90 elbow flexion with the forearm pronated. At the 2-week postoperative visit, the orthosis was removed and patients were instructed to begin active and active-assisted ROM exercises under the guidance of a hand therapist, with restrictions including full extension only in neutral or pronation and no extension beyond 90 with the forearm supinated. Follow-up visits were scheduled at 2, 6, 12, and 24 weeks after surgery. Radiographs were checked at each postoperative visit to confirm adequate hardware positioning and joint reduction. Radiographs were also evaluated for the development of heterotopic ossification (HO). Clinical evaluation was performed at each postoperative visit including pain assessment via numeric pain scale (NPS) from 0 (no pain) to 10 (highest amount of pain) and ROM assessment by a hand-held goniometer.
MATERIALS AND METHODS Patients We obtained approval from our institutional review board before collecting data. A total of 26 patients who underwent surgical treatment for TTEI from 2009 to 2015 were retrospectively identified. Qualifying patients were selected from operative case logs and included those who sustained a closed traumatic injury of the elbow with a dislocation, radial head fracture, and coronoid fracture. Exclusion criteria included open injury, concomitant fracture to the ipsilateral upper extremity, concomitant trauma requiring hospital admission, patient age less than 18 years, or follow-up less than 12 weeks. The first 13 patients treated in this cohort did not receive perioperative steroids and thus comprised a control group. The next 13 patients treated received a single intraoperative dose of 10 mg intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course, and thus were included in the GC group. The oral methylprednisolone taper course began on the day of surgery and included 24 mg on day 1, 20 mg on day 2, 16 mg on day 3, 12 mg J Hand Surg Am.
Data collection and analysis One of 2 reviewers not directly involved with the patients’ care collected data through a review of patient charts in the medical record. All initial injury radiographs were reviewed to confirm elbow r
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STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
TABLE 1.
Descriptive Characteristics Control
n Age, y
Steroid
13
13
42.9 (32.6e74.3)
57.4 (21.1e77.0)
Surgical delay, d
7.3 (3e20)
9.0 (7e12)
Dominant side injured (%)
53.8 (7/13)
53.8 (7/13)
Fall from standing (10/13) vs fall from a height (3/13)
Fall from standing (11/13) vs fall from a height (2/13)
56.4 (13.0e154.3)
44.2 (12.0e130.0)
Mechanism Average follow-up, wk
Data are represented as mean (range) except where noted.
TABLE 2.
Postoperative Pain and Arc of Motion Control (range)
95% Confidence Interval
Steroid (range)
95% Confidence Interval
P Value
2-wk pain score (0e10)
2.9 (1e8)
1.0 to 4.7
3.2 (0e8)
1.3 to 5.1
> .05
6-wk pain score (0e10)
2.0 (0e5)
1.0 to 3.0
1.5 (0e6)
0.3 to 2.9
> .05
Flexion-extension arc (degrees)
66.7 (35e96)
54.4 to 78.9
85.2 (40e127)
12.3 to 14.5
> .05
Pronosupination arc (degrees)
81.4 (50e125)
67.2 to 95.6
127.3 (70e165)
105.6 to 149.0
< .05*
0.4 to 2.5
0.9 (0e5)
e0.2 to 1.8
> .05
98.4 (50e125)
86.9 to 109.8
115.4 (80e135)
102.6 to 128.2
> .05
122.3 (60e175)
101.4 to 143.1
145.0 (80e180)
120.3 to 162.7
> .05
12 wk Pain score (0e10) Flexion-extension arc (degrees) Pronosupination arc (degrees)
1.4 (0e5)
24 wk 1.3 (0e4)
0.2 to 2.4
e0.2 to 1.5
> .05
Flexion-extension arc (degrees)
105.5 (45e140)
85.2 to 125.9
132.5 (115e140)
124.2 to 140.8
< .05*
Pronosupination arc (degrees)
132.2 (15e180)
102.1 to 162.3
165.8 (135e180)
153.1 to 178.6
> .05
Pain score (0e10)
0.7 (0e2)
arc, arc of motion. P values were calculated using unpaired, 2-tailed Student t test. Confidence intervals were calculated with a ¼ .05. *Statistical significance interpreted as P < .05.
dislocation and the presence of a TTEI pattern, as previously described. Operative reports and postoperative films were reviewed to confirm the procedure performed, and perioperative records were reviewed to confirm the intravenous dexamethasone dose received. Postoperative clinical chart documentation was reviewed to collect information about oral steroid compliance, NPS pain scores, ROM, and complications. Complications were categorized as minor, defined by not requiring operative intervention, or major, defined as the need for operative intervention. We performed a statistical analysis using unpaired, 2-tailed Student t test to compare means for normally distributed data, Kruskal-Wallis test to compare medians of non-normally distributed data, J Hand Surg Am.
and chi-square test to compare proportions. Statistical significance was interpreted as P < .05. Confidence intervals were calculated indicating a confidence level of 95%. RESULTS Table 2 and Figure 1 show pain and ROM outcomes. Flexion-extension arc of motion was greater in the GC group compared with the control group at all postoperative visits, although this difference was statistically significant only at 24 weeks (132.5 vs 105.5 ; P < .05). When ROM was evaluated as flexion and extension discretely, motion was greater in both components at all time points, although the difference was only statistically significant for extension at 6 and 24 weeks. r
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STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
Postoperative Range of Motion 160 Control
Steroid
140
Range (Degrees)
120 100 80 60 40 20
6 weeks
12 weeks
*Supination
Pronation
*Extension
Flexion
*Supination
Pronation
Extension
Flexion
*Supination
Pronation
*Extension
Flexion
0
24 weeks
FIGURE 1: Comparative mean range of motion values. *Statistically significant difference between control and steroid groups (P < .05). Full extension was defined as 0 with increasing flexion resulting in higher degree values; therefore, lower extension values imply greater ROM.
Total pronosupination arc of motion was greater at all time points in the GC group; the difference at 6 weeks was statistically significant (127.3 vs 81.4 ; P < .05). Supination measurements were significantly greater for the GC group at every postoperative visit, with a difference at 24 weeks of 23.2 (84.2 vs 61 ; P < .05). Pronation measurements were also greater in the GC group at each postoperative visit, although this difference was not statistically significant. The NPS pain scores did not differ between groups at any time point after surgery. Table 3 lists complications. Overall, there were 5 complications in the control group (35.8%) and 3 in the GC group (23.1%). The most common complications were ulnar neuropathy at the elbow (n ¼ 5) and HO (n ¼ 4). Heterotopic ossification occurred only in the control group. Complications requiring surgery occurred in 3 of 13 patients in control group and 1 of 13 patients in the GC group. There were no postoperative infections in either group.
TABLE 3.
Complication
Control
Steroid
4/13 (31%), 3/4 required surgery
0
Ulnar neuropathy
3/13 (23%)
2/13 (15%)
Contracture
2/13 (15%)
0
Synostosis
1/13 (8%)
0
0
1/13 (8%) required surgery
Heterotopic ossification
Arthrofibrosis/synovitis
Previous evidence suggests that perioperative GC administration is safe and improves pain, nausea, and vomiting in thyroid, abdominal, facial plastic, and oral surgery.17e23 In addition, postoperative swelling and tissue edema are improved with perioperative GC administration with no concomitant increase in wound disturbances after facial surgery.24e27 In the orthopedic literature, Jules-Elysee et al28 evaluated perioperative intravenous steroid administration in 34 patients undergoing bilateral knee arthroplasty and found improved outcomes in terms of pain, nausea, and ROM. The study found no increase in infection between control and treatment groups, but it was underpowered to assess this outcome adequately. In 2013, Lunn and Kehlet10 showed that perioperative intravenous steroids
DISCUSSION The combination of a radial head and coronoid fracture in the setting of an elbow dislocation has earned the name of “terrible triad” owing to the complexity of treatment.1 Perioperative GC therapy is an appealing adjunct to the surgical treatment of TTEI, with the goals of improving postoperative ROM and decreasing pain during recovery. J Hand Surg Am.
Complications
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STEROIDS FOR TERRIBLE TRIAD ELBOW INJURIES
improved pain in 48 patients undergoing total hip arthroplasty. Additional studies reported improvements in postoperative pain scores,10e13 decreased hospitalization days,13 and quicker functional recovery13 after hip and knee arthroplasty. The results of this study show that perioperative GC therapy resulted in improved postoperative ROM in both flexion-extension and pronosupination arc of motion. Compared with previously reported outcomes after TTEI not treated with perioperative steroids, the 132.5 flexion-extension arc in the GC group in this study was greater than the arc of motion reported by Gupta et al16 (110 ) (16), Pugh et al15 (112 ), and Garrigues et al5 (115 ). Furthermore, the 105.5 flexion-extension arc of motion in the control group in the current study was similar to the previous reports. However, the reliability of the ROM measurements from those reports is not known. The 165.8 pronosupination arc in the GC group compares favorably with the arc of motion reported by Gupta et al16 (148 ) (16) and Pugh et al15 (136 ). The 132.2 pronosupination arc of motion in the current control group is similar to these previous reports. Again, the reliability of the ROM measurements from those reports is not known and a true comparison cannot be made. Supination was greater at all time points in the GC group. Overall improvement in supination is critical because all patients were placed in an orthosis in pronation for 2 weeks and started flexion-extension exercises with the forearm in pronation. Pain and complication rate were similar in the 2 groups and no postoperative infections were seen. Average age in the GC group was 15 years older than in the control group, a statistically significant difference. The importance of this difference to the results is unknown because, to the authors’ knowledge, no studies have directly compared outcomes with age. There were no cases of HO in the GC group and 4 in the control group, 3 of which required surgery to excise the heterotopic bone. The only elbow in the GC group that required reoperation had presumed synovitis and arthrofibrosis at 6 weeks and underwent an open debridement. Heterotopic ossification presents a considerable source of morbidity after complex elbow trauma. Anatomically, the medial collateral ligament (MCL) has a cam effect at the elbow. It requires elongation to its maximum length to flex past 90 .29 It is our opinion that when the elbow does not achieve flexion early after surgery, the MCL stiffens and cannot elongate to attain flexion. We know the MCL is a common site of HO, and when it occurs flexion is limited.29 We J Hand Surg Am.
45
hypothesize that the prevention of the HO contributes to gains in elbow flexion. Historically, a concern about perioperative steroid therapy is the risk of wound-healing disturbance and infection. However, data from plastic surgery, general surgery, oral surgery, and orthopedic surgery suggest no increase in wound complications from perioperative GC administration.30e34 Taken together, the literature showed that low-dose, shortcourse, intravenous and oral corticosteroid regimens appear to be safe with regard to wound healing and infection. The primary limitations of this study are those inherent in its retrospective design. An observer bias may be present and must be considered when looking at the data presented here. In addition, TTEI represents a spectrum of injury and it is difficult to control for the relative severity of the individual injuries. Each injury required radial head replacement, coronoid fixation or capsular repair, and lateral ulnar collateral ligament repair. Most injuries occurred from a fall from a standing height. Despite the similar mechanism and surgical treatment, it is difficult to control for other capsular/ligamentous injuries that may have occurred. These soft tissue injuries often are not diagnosed because they are not key determinants to elbow stability and not repaired. Because of the extent of injury, the initial trauma would seem to be a key determinant of ultimate outcome and we cannot quantify the extent of the trauma exposed to the injured structures; thus, there is inherent sampling error. Furthermore, this was a relatively small sample size with 13 patients in each group. A better study design would be a true case-control design to minimize the possible effects of the surgeon and low sample size. The durability of the steroid effect is also unknown. We saw few patients beyond 6 months and thus could not perform an analysis between groups at 1 year or longer. Our results support the use of perioperative GCs for the treatment of TTEIs. As of this publication, we have adopted this protocol for these injuries at our institution. REFERENCES 1. Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009;17(3): 137e151. 2. Dodds SD, Fishler T. Terrible triad of the elbow. Orthop Clin North Am. 2013;44(1):47e58. 3. Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, Larrainzar-Garijo R. Outcomes after terrible triads of the elbow
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