SCIENTIFIC ARTICLE
Complications Associated With Hinged External Fixation for Chronic Elbow Dislocations Vishnu C. Potini, MD, Shade Ogunro, MD, Patrick D. G. Henry, MD, Irfan Ahmed, MD, Virak Tan, MD
Purpose To evaluate the outcomes of patients who underwent application of hinged external fixators for chronic elbow fracture-dislocations. We hypothesized that patients treated for this injury pattern can achieve satisfactory outcomes but encounter many complications and require numerous additional procedures. Methods We performed a retrospective review of 7 patients who were surgically treated with application of a hinged external fixator for chronic ulnohumeral elbow fracture-dislocation. Patients were included only if they had complete ulnohumeral dislocation of greater than 1 month’s duration. Demographics, injury pattern, and range of motion were documented. Preoperative and postoperative range of motion was recorded and any treatment complications or additional surgeries were noted. Results The interval between the initial injury and index procedure averaged 8 months. All patients underwent initial treatment with open reduction internal fixation. Average arc of ulnohumeral motion improved from 26 (range, 0 to 60 ) to 120 (range, 100 to 145 ). Overall, 4 of 7 patients developed at least one complication during treatment. Three patients required additional procedures aside from removal of the hinged external fixator. These 3 patients underwent a total of 13 additional procedures. Conclusions Although patients can achieve good outcomes, realistic expectations should be set. Patients should be aware that surgery can be associated with a high risk of complications, potential treatment failure, and a need for additional surgical procedures. (J Hand Surg Am. 2015;40(4):730e737. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Elbow dislocation, hinged external fixator, chronic dislocation.
T
joint with inherent bony stability reinforced by capsuloligamentous structures1; however, it is the second most commonly dislocated joint in adults.2 HE ELBOW IS NATURALLY A STABLE
From the Department of Orthopaedics, Rutgers UniversityeNew Jersey Medical School, Newark, NJ; the Hand and Upper Extremity Center; Dallas, TX; and the Department of Surgery, Division of Orthopaedics, University of TorontoeSunnybrook Health Science Center, Toronto, Ontario, Canada. Received for publication October 3, 2014; accepted in revised form December 23, 2014. Corresponding author: Virak Tan, MD, Department of Orthopaedics, Rutgers UniversityeNew Jersey Medical School, 140 Bergen Street, ACC D1626, Newark, NJ 07103; e-mail: [email protected]. 0363-5023/15/4004-0014$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.12.043
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Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
Bony stability of the elbow is conferred primarily by the ulnotrochlear articulation, owing to its high conformity and nearly 180 capture. The coronoid provides an additional buttress against posteriorly directed forces; 2 key stabilizing columns are the articulations between the radial head and coronoid and the coronoid facet with medial trochlea. This bony architecture is reinforced by the surrounding soft tissues, primarily the medial collateral ligament (MCL) and lateral collateral ligament (LCL). The MCL acts with the radial head as the restraint to valgus stress and the LCL prevents posterolateral instability.1,3 In simple elbow dislocations, the ligaments and soft tissues sustain substantial injury.3 A complex elbow dislocation involves disruption of soft tissues
COMPLICATIONS OF HINGED EXTERNAL FIXATORS
and periarticular fracture(s).4 Timely evaluation and reduction of elbow dislocations are important because a short duration of joint incongruity can result in erosion of the articular surface.1,5 Regaining function is the primary goal of treatment because up to 70% of patients develop severely restricted range of motion (ROM) after fracture-dislocation of the elbow.6 The chronically dislocated elbow presents a difficult problem. The ligaments and soft tissues heal in displaced positions. The presence of a fracture further complicates the situation because malunion from delayed presentation compromises the joint’s bony stability and can prevent reduction. Previous studies reported that when subluxation or dislocation persists for more than 2 weeks, direct repair of the osseous and ligamentous structures may not be sufficient for stable joint motion.1 In addition, open reduction for a chronic dislocation often requires excision of scarred tissues interposed between the joint surfaces and extensive release of ligaments, capsule, and sometimes the triceps.7e9 Altered anatomy, distorted surgical planes, and scarring make the procedure difficult. Historically, extensive reconstructive procedures required to restore elbow function were poorly tolerated owing to prolonged immobilization that caused elbow joint contracture and loss of function.10 With the use of the hinged external fixator, it is possible to reestablish the anatomic axis of the ulnohumeral joint and allow for early concentric ROM while maintaining a stable fixation construct.11 Because chronic elbow fracture-dislocations infrequently occur, there is a paucity of literature regarding their treatment and outcomes. Several reports describe the use of a hinged external fixator to treat both acute and chronic elbow dislocations successfully.5,12e16 These studies highlight the benefits of regaining joint stability and ROM in the elbow but also note a low complication incidence. Although we agree that using a hinged external fixator can improve function and motion, there are numerous complications and secondary procedures associated with treatment of chronic elbow dislocations. The purpose of this study was to report our experience and complications in the treatment of chronic ulnohumeral fracture-dislocations.
chronic radiocapitellar dislocation without complete ulnohumeral dislocation, or who underwent operative treatment at our institution within 1 month of injury were excluded. From 2002 to 2013, 7 patients met the inclusion criteria (Table 1). The group included 2 men and 5 women, average age 37 years (range, 15e58 y; SD, 13 y). The mechanism of injury was a fall from standing height in 4, fall from a ladder in 1, and assault in 2. All patients had closed injuries. Before presentation to our institution, all patients had initial treatment elsewhere, including closed reduction and immobilization in 6 and ulna fracture plating in 1. The patient who underwent ulna fixation continued to have postoperative elbow instability that resulted in a chronic ulnohumeral dislocation. Four patients had posterior dislocation of the elbow with fractures of both the radial head and coronoid process. The remaining 3 patients had elbow dislocations associated with fracture of the proximal ulna, capitellum, or radial head. Average preoperative passive arc of ulnohumeral motion was 26 (range, 0 to 60 ) and pronation-supination was 49 (range, 0 to 160 ). Surgical technique We operated through a single posterior longitudinal incision in 6 patients17,18 and through separate medial and lateral incisions in 1. Medial and lateral fullthickness skin flaps were raised to allow access to all structures. If there was distorted and scarred anatomy, interstructure planes were followed as closely as possible. The ulnar nerve was identified and mobilized in all cases. We used the lateral column and medial “over-the-top” approaches.19 Exposure of the joint was achieved by a complete capsulectomy. Heterotopic bone was excised as part of the contracture release. We preserved the remnants of the medial and lateral collateral ligaments as much as possible by raising them as a sleeve off the distal humerus. Access to the elbow joint was improved by hyperextending the joint. Any associated radial head and coronoid fractures were addressed at this point. In the 5 patients with radial head fractures, the native radial head was replaced with a prosthesis in 2, excised in 2, and preserved in 1. One patient underwent coronoid reconstruction using a fragment of the fractured radial head. The fragment was fashioned into a wedge and fixed using a single 2.4-mm screw. After completion of bony repair, we assessed stability of the elbow to determine the need for ligamentous reconstruction. If the remnant of the ligament was stout, primary repair
MATERIALS AND METHODS We conducted an institutional review boarde approved retrospective review of patients who underwent surgical treatment by a single surgeon for a chronic ulnohumeral dislocation of 1 month’s duration or more. Patients who had chronic subluxation or J Hand Surg Am.
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60 5 Transposition Repair Repair
Evaluation We collected preoperative and postoperative data prospectively on all patients. With the patient sitting in a chair, the examiner used a goniometer to measure active flexion-extension of the elbow, using a score of 0 for full extension as the reference point. Under the same circumstances, active pronation-supination of the forearm was measured using the neutral forearm position as 0 and the plane of the hand as the reference line. Provocative maneuvers assessed the stability of the elbow to varus and valgus stress. We obtained radiographs to assess for maintenance of a concentric reduction (Fig. 1). Degenerative changes on radiographs at the final follow-up were rated based on the standardized scale created by Broberg and Morrey.20 We considered any form of infection, intraoperative or postoperative fracture, or loosening of the external fixator pin as a treatment complication. We defined any instance in which elbow joint reduction was not maintained after the index treatment as a treatment failure. Patients who had to undergo a subsequent elbow reduction or reconstruction procedure were considered treatment failures.
N/A, not available.
15 7
F
(R)
Capitellum
N/A
Repair Repair L 36 6
F
Postsurgical management After the procedure, all patients received a hands-on teaching session on performing daily ROM exercises; this was reviewed at each follow-up visit. Patients were instructed to move the elbow gradually though the maximum tolerable ROM starting the first day after surgery. Hand, wrist, and forearm mobilization was encouraged immediately. Patients were instructed on twice-daily pin site cleaning with diluted hydrogen peroxide. After the external fixator was removed, each patient continued a rehabilitation protocol involving passive and active flexionextension and pronation-supination exercises.
N/A
22 Transposition N/A
Reconstructed Reconstructed
Proximal ulna N/A
No
N/A
Reconstructed Reconstructed No surgery
Complete excision Radial head
Terrible triad (R)
L M 37 5
F 42 4
was performed. Five patients had either repair or reconstruction of both MCL and LCL. One patient required only MCL repair and one underwent LCL only repair. Five of 7 patients had anterior transposition of the ulnar nerve because of its proximity to the external fixator pins. A hinged external fixator (Compass Hinge, Smith and Nephew, Memphis, TN) was applied in every case to maintain concentric ulnohumeral reduction while allowing for mobilization of the extremity. The elbow was taken through ROM and relaxing incisions were made around pins where skin tension was noted. The initial expected duration of the fixator was 6 to 8 weeks.
10
44
9 Left in situ
10
25
16 4
17 Transposition
7
17 2 Repair 36 3
F
L
Terrible triad
Replaced
Repair
No
Transposition
8
106
17 8
Transposition
7
2
2
Left in situ Yes
N/A Repair
No
Repair N/A Replaced
Fragment excision Terrible triad
Terrible triad L
(R) 58 2
M 38 1
F
Radial Head Management Pattern Side (Dominant) Sex Age, y Patient
TABLE 1.
Seven Patients With Chronic Elbow Dislocations
MCL
LCL
Coronoid Reconstruction
Ulnar Nerve Management
Interval Injury to Index Procedure, mo
Duration of Hinged Fixation, wk
FollowUp, mo
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FIGURE 1: A Anteroposterior and B lateral preoperative radiographs of patient 7. C Anteroposterior and D lateral radiographs of the same patient 36 months after the external fixator was removed.
least one additional procedure after removal of the fixator, 3 of whom had an infection.
Statistical analysis We calculated univariate statistical analysis on the measured variables and nominal patient data. Twotailed Student t tests were performed to compare mean preoperative and postoperative ROM scores. Statistical significance was set at P < .050.
Complications Four of 7 patients developed at least one complication during the course of treatment. In total there were 6 complications (Table 3). Four patients had complications related to infection, one of whom sustained a fracture of the ulna at a pin site. There was an average of 1.9 surgeries per patient related to complications (range, 0e5 surgeries). Three patients required additional procedures aside from removal of the hinged external fixator; these patients underwent a total of 13 additional procedures. Most of these procedures were irrigations with debridement to treat infections. Patients (n ¼ 3) who underwent additional surgeries went back to the operating room an average of 9 weeks (range, 3e13 wk) after placement of the fixator. One patient developed wound dehiscence and required radial forearm flap coverage. To date, no patients have developed recurrent infection after the initial treatment sequence.
RESULTS The interval between the injury and surgery averaged 8 months (range, 2e22 mo; SD, 8 mo). The hinged external fixator was used for 7.7 weeks (range, 4e10 wk; SD, 2 wk). Two patients required external fixator removal because of complications. Follow-up was 41 months (range, 16e106 mo; SD, 33 mo). Ulnohumeral motion improved to 120 (range, 100 to 145 ) (P < .001). Final flexion averaged 136 (range, 118 to 160 ) with an average elbow flexion contracture of 15 (range, 0 to 35 ). Postoperative pronation was 73 (range, 50 to 90 ) and supination was 47 (range, 5 to 90 ). At final radiographic evaluation, 3 patients had severe degenerative changes and 2 had moderate degenerative changes (Table 2). Overall, 4 of 7 patients required at J Hand Surg Am.
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2
Complications (no.)
Additional Procedures
1
None
0
2
Fracture through pin (1) Pin tract infection (2)
4
3
None
0
4
Incisional cellulitis
0
5
Wound dehiscence (1) Recurrent subluxation (2)
5
6
Osteomyelitis
4
7
None
0
Ultimate Failure
Conversion to TEA
Conversion to transarticular plate
DISCUSSION Chronic ulnohumeral dislocations are rare and challenging to treat. The literature is sparse regarding these injuries. No clear definition exists regarding what is considered a chronic dislocation. Prolonged dislocation of the elbow leads to contracture, shortening of ligaments, and shortening of the triceps muscle. Patients will likely develop a painful, deformed elbow with severely limited motion.1,7 After open reduction and repair of osseous and ligamentous stabilizers of the elbow, a hinged external fixator allows for immediate concentric joint motion while the soft tissues are protected and allowed to heal in the optimal position for motion.21 A number of investigators reported satisfactory results and relatively low complications treating chronic
Data are shown as degrees.
3 80 50
70
118
120
0
35 155
118 0
80 20
80
30 30
50 7
Complications and Failures
Two patients had failures related to persistent elbow instability. One patient began to report pain and instability with terminal extension and developed progressive loss of motion after 2 years. The patient ultimately developed worsening elbow pain resulting from posttraumatic arthritis and received a total elbow arthroplasty (TEA). The second patient required early removal of the external fixator at 4 weeks owing to pin track and soft tissue infection. Despite initial reconstruction of both the MCL and LCL, the patient had persistent elbow instability and subluxation after removal of the external fixator. A temporary elbow-spanning bridge plate was used to hold the ulnohumeral joint reduced. The plate was removed 4 weeks later and the patient began therapy. Range of motion was 0 to 130 at 16-month follow-up.
30
40 6
10
Patient
90
3
1
90
5 80
130
0
130
0
0 60 90 5
30
60 4
30
0
40 30
135
5
130
15
2 70 80 3
55
0 0 25
130
27
103
45
3
2 45
50
70
80
100
145 15
25 125 25
0
60
25 0
70 2
50
20 1
20
20
160
Final Pronation Final Arc Final Extension Preoperative Supination Preoperative Pronation Preoperative Arc Preoperative Extension Preoperative Flexion
Preoperative Range of Motion
TABLE 3.
Patient
TABLE 2.
Functional and Radiographic Treatment Outcomes
Final Flexion
Final Follow-Up Range of Motion
Final Supination
Final Radiographic Arthrosis (Broberg and Morrey20)
COMPLICATIONS OF HINGED EXTERNAL FIXATORS
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elbow fracture-dislocations using hinged external fixators.5,12e16 Our results confirm that patients can eventually achieve improved, functional ROM of the elbow. However, contrary to other studies, many of our patients encountered complications over the course of treatment that resulted in numerous additional surgical procedures or treatment failure. Four patients had complications during treatment and 3 required a minimum of 4 additional procedures each. Previous reports documented that a concentric reduction can be maintained even without direct repair or reconstruction of the collateral ligaments owing to restoration of the elbow’s bony stability. Advocates of using a hinged external fixator believe that continuous, protected elbow motion allows the ligaments to heal or scar back to the epicondyles without restricting motion.13,22,23 As opposed to an acute injury, we think that restoring the ligamentous structures in chronic elbow fracture-dislocations is important to maintain a concentric reduction after removal of the hinge fixator. In our experience, despite the chronic nature of the injury we were able to perform direct repair of the collateral ligaments in many instances. It is possible that by dissecting the soft tissue from the humerus and leaving the ligaments attached to the ulna, more local tissue was preserved for repair. There is concern that open repair of ligaments in a chronic dislocation results in more fibrosis around the joint and unacceptable loss of motion.13,24,25 In our series, although many patients were not able to achieve full elbow extension after treatment, all of them ultimately achieved functional elbow motion that allowed them to perform essential daily tasks.26 The primary complication in our series was infection, occurred in 4 patients. One patient had cellulitis that resolved with antibiotics but the remaining 3 patients developed notable deep infections that required multiple operative debridements and adjunct treatments. The reason for these infections was likely multifactorial, because the combination of a thin soft tissue envelope at the elbow and the hinged external fixator device placed these patients at higher risk. Ring et al27 reported that patients treated with hinged external fixators for acute or subacute elbow instability had more adverse events compared with cross-pinning of the elbow. Other studies mentioned complications related to hinge external fixators about the elbow, including osteomyelitis, osteolysis, and purulent discharge.10,28 Cheung et al29 examined 100 patients who had placement of external fixators about the elbow and noted a 25% overall complication incidence. Most of these were related to erythema and drainage around the fixator pins, J Hand Surg Am.
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although the authors noted that the only patients who developed deep infections were those who had undergone complex elbow reconstructions. Multiple studies have shown that the risk of pin track infections increases the longer a fixator is in place.30e32 Most external fixator pins become colonized with bacteria by the time of removal, which makes pin site care critical to prevent complication.33 Relaxing skin incisions around pin sites may also have a role in decreasing colonization of the pin tracks.34 Although our goal was 6 to 8 weeks in the fixator, the logistics of follow-up and scheduling removal of the fixator sometimes resulted in the fixator being in place for up to 10 weeks. In our series, many infectious complications were related to external fixator pins despite instructions for pin care and regular clinical follow-up. Unfortunately, investigators have failed to identify a superior method to prevent external pin site infections.34e36 The risks of complex elbow reconstructive surgery include infection and skin breakdown owing to the thin soft tissue envelope. The posterior skin incision at the elbow allows the surgeon to perform multiple procedures with a single incision,18 which can be useful in the open treatment of a chronic elbow dislocation. This approach is commonly used in TEA but is associated with a 26% incidence of wound complication.37e39 Early ROM for patients treated with a hinged external fixator can also put this posterior surgical incision at risk. This tissue is over the apex of a joint with great ROM, where the tension and motion it sustains inhibit healing and increase risk of wound dehiscence.40 Six of 7 patients in our series underwent surgery via a posterior skin incision; 1 patient required an additional procedure related to surgical wound breakdown. Similar to other authors,5 we elected to perform the posterior approach in most patients to visualize both sides of the elbow joint and ensure sufficient soft tissue release and balancing. Although the posterior approach has a higher risk of wound complications, we think that developing fullthickness flaps and staying within one surgical plane minimizes the risk. In addition, the posterior approach allows for the possibility of future reconstructive procedures or conversion to TEA to be performed through the same incision. Our study had several limitations, one of which is its retrospective nature. The rare injury pattern and strict inclusion criteria of the study contributed to the small sample size and limited the applicability of our findings. However, with the lack of available literature, we believe that even with our small sample size there is useful information for clinicians who might r
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encounter this multifaceted problem. Another limitation is that the study reflected one surgeon’s experience. This may have affected treatment outcomes and failure in some circumstances. In patient 5, we decided not to perform a radial head replacement because of the intra-operative finding of capitellar wear and concern for postoperative pain. However, in retrospect, a prosthetic radial head might have conferred additional stability. Finally, our average follow-up was 41 months (range, 17e106 mo) but several patients had less than 2-year follow-up. In time, some of these patients may develop other complications or require additional salvage procedures with longer follow-up. In our opinion, there are a few general principles to consider when performing elbow surgery for a chronic elbow dislocation. As with any elbow fracturedislocation, restoration of the bony anatomy is important to regain reduction and stability of the ulnohumeral joint. In chronic injuries, reconstructing or repairing ligaments becomes important to contribute additional stability to the joint. To obtain adequate soft tissue release and visualize the elbow joint, the posterior skin incision may be the most useful. To minimize wound complications, thick skin flaps are raised without dissecting through multiple subcutaneous tissue planes. In our series, many complications were related to infections stemming from the external fixator pins. Although no good preventative measures are known, vigilant pin site care and follow-up may be most beneficial in preventing complications. Ultimately, patients can achieve meaningful improvements in ROM and function but should be counseled regarding the high risk of complications, potential treatment failure, and need for additional procedures.
9. Naidoo KS. Unreduced posterior dislocations of the elbow. J Bone Joint Surg Br. 1982;64(5):603e606. 10. Cobb TK, Morrey BF. Use of distraction arthroplasty in unstable fracture dislocations of the elbow. Clin Orthop Relat Res. 1995;(312):201e210. 11. Madey SM, Bottlang M, Steyers CM, et al. Hinged external fixation of the elbow: optimal axis alignment to minimize motion resistance. J Orthop Trauma. 2000;14(1):41e47. 12. Ivo R, Mader K, Dargel J, Pennig D. Treatment of chronically unreduced complex dislocations of the elbow. Strategies Trauma Limb Reconstr. 2009;4(2):49e55. 13. Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am. 2002;84(9): 1630e1635. 14. Degreef I, De Smet L. Chronic elbow dislocation: a rare complication of tennis elbow surgery: successful treatment by open reduction and external fixator. Chir Main. 2007;26(3):150e153. 15. Lo CY, Chang YP. Neglected elbow dislocation in a young man: treatment by open reduction and elbow fixator. J Shoulder Elbow Surg. 2004;13(1):101e104. 16. Ohno Y, Shimizu K, Ohnishi K. Surgically treated chronic unreduced medial dislocation of the elbow in a 70-year-old man: a case report. J Shoulder Elbow Surg. 2005;14(5):549e553. 17. Dowdy PA, Bain GI, King GJ, Patterson SD. The midline posterior elbow incision: an anatomical appraisal. J Bone Joint Surg Br. 1995;77(5):696e699. 18. Patterson SD, Bain GI, Mehta JA. Surgical approaches to the elbow. Clin Orthop Relat Res. 2000;(370):19e33. 19. Hotchkiss R. Elbow Contracture. In: Green DP HR, Pederson WC, eds. Green’s Operative Hand Surgery. Vol. 1. 4th ed. Philadelphia, PA: Churchill Livingstone; 1999:667e682. 20. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am. 1986;68(5):669e674. 21. Tan V, Daluiski A, Capo J, et al. Hinged elbow external fixators: indications and uses. J Am Acad Orthop Surg. 2005;13(8):503e514. 22. Pennig D, Gausepohl T, Mader K. Transarticular fixation with the capacity for motion in fracture dislocations of the elbow. Injury. 2000;31(suppl 1):35e44. 23. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint: a prospective randomized study. J Bone Joint Surg Am. 1987;69(4):605e608. 24. Arafiles RP. Neglected posterior dislocation of the elbow: a reconstruction operation. J Bone Joint Surg Br. 1987;69(2):199e202. 25. Fowles JV, Kassab MT, Douik M. Untreated posterior dislocation of the elbow in children. J Bone Joint Surg Am. 1984;66(6):921e926. 26. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6): 872e877. 27. Ring D, Bruinsma WE, Jupiter JB. Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability. Clin Orthop Relat Res. 2014;472(7):2044e2048. 28. Nielsen D, Nowinski RJ, Bamberger HB. Indications, alternatives, and complications of external fixation about the elbow. Hand Clin. 2002;18(1):87e97. 29. Cheung EV, O’Driscoll SW, Morrey BF. Complications of hinged external fixators of the elbow. J Shoulder Elbow Surg. 2008;17(3): 447e453. 30. Hutson JJ Jr, Zych GA. Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators. J Orthop Trauma. 1998;12(3):214e218. 31. Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract infection with contemporary external fixation: how much of a problem? J Orthop Trauma. 2003;17(7):503e507. 32. Antoci V, Ono CM, Antoci V Jr, Raney EM. Pin-tract infection during limb lengthening using external fixation. Am J Orthop (Belle Mead NJ). 2008;37(9):E150eE154. 33. Mahan J, Seligson D, Henry SL, et al. Factors in pin tract infections. Orthopedics. 1991;14(3):305e308.
REFERENCES 1. Ebrahimzadeh MH, Amadzadeh-Chabock H, Ring D. Traumatic elbow instability. J Hand Surg Am. 2010;35(7):1220e1225. 2. Josefsson PO, Nilsson BE. Incidence of elbow dislocation. Acta Orthop Scand. 1986;57(6):537e538. 3. Bell S. Mini-symposium: Adult elbow problems: (iii) Elbow instability, mechanism and management. Curr Orthop. 2008;22(2):90e103. 4. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations: simple and complex. Orthop Clin North Am. 1999;30(1):63e79. 5. Ring D, Hannouche D, Jupiter JB. Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow. J Hand Surg Am. 2004;29(3): 470e480. 6. Ball CM, Galatz LM, Yamaguchi K. Elbow instability: treatment strategies and emerging concepts. Instr Course Lect. 2002;51:53e61. 7. Billett DM. Unreduced posterior dislocation of the elbow. J Trauma. 1979;19(3):186e188. 8. Bruce C, Laing P, Dorgan J, Klenerman L. Unreduced dislocation of the elbow: case report and review of the literature. J Trauma. 1993;35(6):962e965.
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38. McKee MD, Veillette CJ, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reductioneinternal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18(1):3e12. 39. Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am. 2004;86(5): 940e947. 40. Patel KM, Higgins JP. Posterior elbow wounds: soft tissue coverage options and techniques. Orthop Clin North Am. 2013;44(3): 409e417.
34. Bibbo C, Brueggeman J. Prevention and management of complications arising from external fixation pin sites. J Foot Ankle Surg. 2010;49(1):87e92. 35. Lethaby A, Temple J, Santy-Tomlinson J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev. 2013;12:CD004551. 36. Jennison T, McNally M, Pandit H. Prevention of infection in external fixator pin sites. Acta Biomater. 2014;10(2):595e603. 37. Ali A, Shahane S, Stanley D. Total elbow arthroplasty for distal humeral fractures: indications, surgical approach, technical tips, and outcome. J Shoulder Elbow Surg. 2010;19(2 suppl):53e58.
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Complications Associated With Hinged External Fixation for Chronic Elbow Dislocations Vishnu C. Potini, MD, Shade Ogunro, MD, Patrick D. G. Henry, MD, Irfan Ahmed, MD, Virak Tan, MD
Purpose To evaluate the outcomes of patients who underwent application of hinged external fixators for chronic elbow fracture-dislocations. We hypothesized that patients treated for this injury pattern can achieve satisfactory outcomes but encounter many complications and require numerous additional procedures. Methods We performed a retrospective review of 7 patients who were surgically treated with application of a hinged external fixator for chronic ulnohumeral elbow fracture-dislocation. Patients were included only if they had complete ulnohumeral dislocation of greater than 1 month’s duration. Demographics, injury pattern, and range of motion were documented. Preoperative and postoperative range of motion was recorded and any treatment complications or additional surgeries were noted. Results The interval between the initial injury and index procedure averaged 8 months. All patients underwent initial treatment with open reduction internal fixation. Average arc of ulnohumeral motion improved from 26 (range, 0 to 60 ) to 120 (range, 100 to 145 ). Overall, 4 of 7 patients developed at least one complication during treatment. Three patients required additional procedures aside from removal of the hinged external fixator. These 3 patients underwent a total of 13 additional procedures. Conclusions Although patients can achieve good outcomes, realistic expectations should be set. Patients should be aware that surgery can be associated with a high risk of complications, potential treatment failure, and a need for additional surgical procedures. (J Hand Surg Am. 2015;40(4):730e737. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Elbow dislocation, hinged external fixator, chronic dislocation.
T
joint with inherent bony stability reinforced by capsuloligamentous structures1; however, it is the second most commonly dislocated joint in adults.2 HE ELBOW IS NATURALLY A STABLE
From the Department of Orthopaedics, Rutgers UniversityeNew Jersey Medical School, Newark, NJ; the Hand and Upper Extremity Center; Dallas, TX; and the Department of Surgery, Division of Orthopaedics, University of TorontoeSunnybrook Health Science Center, Toronto, Ontario, Canada. Received for publication October 3, 2014; accepted in revised form December 23, 2014. Corresponding author: Virak Tan, MD, Department of Orthopaedics, Rutgers UniversityeNew Jersey Medical School, 140 Bergen Street, ACC D1626, Newark, NJ 07103; e-mail: [email protected]. 0363-5023/15/4004-0014$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.12.043
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Published by Elsevier, Inc. All rights reserved.
Bony stability of the elbow is conferred primarily by the ulnotrochlear articulation, owing to its high conformity and nearly 180 capture. The coronoid provides an additional buttress against posteriorly directed forces; 2 key stabilizing columns are the articulations between the radial head and coronoid and the coronoid facet with medial trochlea. This bony architecture is reinforced by the surrounding soft tissues, primarily the medial collateral ligament (MCL) and lateral collateral ligament (LCL). The MCL acts with the radial head as the restraint to valgus stress and the LCL prevents posterolateral instability.1,3 In simple elbow dislocations, the ligaments and soft tissues sustain substantial injury.3 A complex elbow dislocation involves disruption of soft tissues
COMPLICATIONS OF HINGED EXTERNAL FIXATORS
and periarticular fracture(s).4 Timely evaluation and reduction of elbow dislocations are important because a short duration of joint incongruity can result in erosion of the articular surface.1,5 Regaining function is the primary goal of treatment because up to 70% of patients develop severely restricted range of motion (ROM) after fracture-dislocation of the elbow.6 The chronically dislocated elbow presents a difficult problem. The ligaments and soft tissues heal in displaced positions. The presence of a fracture further complicates the situation because malunion from delayed presentation compromises the joint’s bony stability and can prevent reduction. Previous studies reported that when subluxation or dislocation persists for more than 2 weeks, direct repair of the osseous and ligamentous structures may not be sufficient for stable joint motion.1 In addition, open reduction for a chronic dislocation often requires excision of scarred tissues interposed between the joint surfaces and extensive release of ligaments, capsule, and sometimes the triceps.7e9 Altered anatomy, distorted surgical planes, and scarring make the procedure difficult. Historically, extensive reconstructive procedures required to restore elbow function were poorly tolerated owing to prolonged immobilization that caused elbow joint contracture and loss of function.10 With the use of the hinged external fixator, it is possible to reestablish the anatomic axis of the ulnohumeral joint and allow for early concentric ROM while maintaining a stable fixation construct.11 Because chronic elbow fracture-dislocations infrequently occur, there is a paucity of literature regarding their treatment and outcomes. Several reports describe the use of a hinged external fixator to treat both acute and chronic elbow dislocations successfully.5,12e16 These studies highlight the benefits of regaining joint stability and ROM in the elbow but also note a low complication incidence. Although we agree that using a hinged external fixator can improve function and motion, there are numerous complications and secondary procedures associated with treatment of chronic elbow dislocations. The purpose of this study was to report our experience and complications in the treatment of chronic ulnohumeral fracture-dislocations.
chronic radiocapitellar dislocation without complete ulnohumeral dislocation, or who underwent operative treatment at our institution within 1 month of injury were excluded. From 2002 to 2013, 7 patients met the inclusion criteria (Table 1). The group included 2 men and 5 women, average age 37 years (range, 15e58 y; SD, 13 y). The mechanism of injury was a fall from standing height in 4, fall from a ladder in 1, and assault in 2. All patients had closed injuries. Before presentation to our institution, all patients had initial treatment elsewhere, including closed reduction and immobilization in 6 and ulna fracture plating in 1. The patient who underwent ulna fixation continued to have postoperative elbow instability that resulted in a chronic ulnohumeral dislocation. Four patients had posterior dislocation of the elbow with fractures of both the radial head and coronoid process. The remaining 3 patients had elbow dislocations associated with fracture of the proximal ulna, capitellum, or radial head. Average preoperative passive arc of ulnohumeral motion was 26 (range, 0 to 60 ) and pronation-supination was 49 (range, 0 to 160 ). Surgical technique We operated through a single posterior longitudinal incision in 6 patients17,18 and through separate medial and lateral incisions in 1. Medial and lateral fullthickness skin flaps were raised to allow access to all structures. If there was distorted and scarred anatomy, interstructure planes were followed as closely as possible. The ulnar nerve was identified and mobilized in all cases. We used the lateral column and medial “over-the-top” approaches.19 Exposure of the joint was achieved by a complete capsulectomy. Heterotopic bone was excised as part of the contracture release. We preserved the remnants of the medial and lateral collateral ligaments as much as possible by raising them as a sleeve off the distal humerus. Access to the elbow joint was improved by hyperextending the joint. Any associated radial head and coronoid fractures were addressed at this point. In the 5 patients with radial head fractures, the native radial head was replaced with a prosthesis in 2, excised in 2, and preserved in 1. One patient underwent coronoid reconstruction using a fragment of the fractured radial head. The fragment was fashioned into a wedge and fixed using a single 2.4-mm screw. After completion of bony repair, we assessed stability of the elbow to determine the need for ligamentous reconstruction. If the remnant of the ligament was stout, primary repair
MATERIALS AND METHODS We conducted an institutional review boarde approved retrospective review of patients who underwent surgical treatment by a single surgeon for a chronic ulnohumeral dislocation of 1 month’s duration or more. Patients who had chronic subluxation or J Hand Surg Am.
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60 5 Transposition Repair Repair
Evaluation We collected preoperative and postoperative data prospectively on all patients. With the patient sitting in a chair, the examiner used a goniometer to measure active flexion-extension of the elbow, using a score of 0 for full extension as the reference point. Under the same circumstances, active pronation-supination of the forearm was measured using the neutral forearm position as 0 and the plane of the hand as the reference line. Provocative maneuvers assessed the stability of the elbow to varus and valgus stress. We obtained radiographs to assess for maintenance of a concentric reduction (Fig. 1). Degenerative changes on radiographs at the final follow-up were rated based on the standardized scale created by Broberg and Morrey.20 We considered any form of infection, intraoperative or postoperative fracture, or loosening of the external fixator pin as a treatment complication. We defined any instance in which elbow joint reduction was not maintained after the index treatment as a treatment failure. Patients who had to undergo a subsequent elbow reduction or reconstruction procedure were considered treatment failures.
N/A, not available.
15 7
F
(R)
Capitellum
N/A
Repair Repair L 36 6
F
Postsurgical management After the procedure, all patients received a hands-on teaching session on performing daily ROM exercises; this was reviewed at each follow-up visit. Patients were instructed to move the elbow gradually though the maximum tolerable ROM starting the first day after surgery. Hand, wrist, and forearm mobilization was encouraged immediately. Patients were instructed on twice-daily pin site cleaning with diluted hydrogen peroxide. After the external fixator was removed, each patient continued a rehabilitation protocol involving passive and active flexionextension and pronation-supination exercises.
N/A
22 Transposition N/A
Reconstructed Reconstructed
Proximal ulna N/A
No
N/A
Reconstructed Reconstructed No surgery
Complete excision Radial head
Terrible triad (R)
L M 37 5
F 42 4
was performed. Five patients had either repair or reconstruction of both MCL and LCL. One patient required only MCL repair and one underwent LCL only repair. Five of 7 patients had anterior transposition of the ulnar nerve because of its proximity to the external fixator pins. A hinged external fixator (Compass Hinge, Smith and Nephew, Memphis, TN) was applied in every case to maintain concentric ulnohumeral reduction while allowing for mobilization of the extremity. The elbow was taken through ROM and relaxing incisions were made around pins where skin tension was noted. The initial expected duration of the fixator was 6 to 8 weeks.
10
44
9 Left in situ
10
25
16 4
17 Transposition
7
17 2 Repair 36 3
F
L
Terrible triad
Replaced
Repair
No
Transposition
8
106
17 8
Transposition
7
2
2
Left in situ Yes
N/A Repair
No
Repair N/A Replaced
Fragment excision Terrible triad
Terrible triad L
(R) 58 2
M 38 1
F
Radial Head Management Pattern Side (Dominant) Sex Age, y Patient
TABLE 1.
Seven Patients With Chronic Elbow Dislocations
MCL
LCL
Coronoid Reconstruction
Ulnar Nerve Management
Interval Injury to Index Procedure, mo
Duration of Hinged Fixation, wk
FollowUp, mo
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FIGURE 1: A Anteroposterior and B lateral preoperative radiographs of patient 7. C Anteroposterior and D lateral radiographs of the same patient 36 months after the external fixator was removed.
least one additional procedure after removal of the fixator, 3 of whom had an infection.
Statistical analysis We calculated univariate statistical analysis on the measured variables and nominal patient data. Twotailed Student t tests were performed to compare mean preoperative and postoperative ROM scores. Statistical significance was set at P < .050.
Complications Four of 7 patients developed at least one complication during the course of treatment. In total there were 6 complications (Table 3). Four patients had complications related to infection, one of whom sustained a fracture of the ulna at a pin site. There was an average of 1.9 surgeries per patient related to complications (range, 0e5 surgeries). Three patients required additional procedures aside from removal of the hinged external fixator; these patients underwent a total of 13 additional procedures. Most of these procedures were irrigations with debridement to treat infections. Patients (n ¼ 3) who underwent additional surgeries went back to the operating room an average of 9 weeks (range, 3e13 wk) after placement of the fixator. One patient developed wound dehiscence and required radial forearm flap coverage. To date, no patients have developed recurrent infection after the initial treatment sequence.
RESULTS The interval between the injury and surgery averaged 8 months (range, 2e22 mo; SD, 8 mo). The hinged external fixator was used for 7.7 weeks (range, 4e10 wk; SD, 2 wk). Two patients required external fixator removal because of complications. Follow-up was 41 months (range, 16e106 mo; SD, 33 mo). Ulnohumeral motion improved to 120 (range, 100 to 145 ) (P < .001). Final flexion averaged 136 (range, 118 to 160 ) with an average elbow flexion contracture of 15 (range, 0 to 35 ). Postoperative pronation was 73 (range, 50 to 90 ) and supination was 47 (range, 5 to 90 ). At final radiographic evaluation, 3 patients had severe degenerative changes and 2 had moderate degenerative changes (Table 2). Overall, 4 of 7 patients required at J Hand Surg Am.
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2
Complications (no.)
Additional Procedures
1
None
0
2
Fracture through pin (1) Pin tract infection (2)
4
3
None
0
4
Incisional cellulitis
0
5
Wound dehiscence (1) Recurrent subluxation (2)
5
6
Osteomyelitis
4
7
None
0
Ultimate Failure
Conversion to TEA
Conversion to transarticular plate
DISCUSSION Chronic ulnohumeral dislocations are rare and challenging to treat. The literature is sparse regarding these injuries. No clear definition exists regarding what is considered a chronic dislocation. Prolonged dislocation of the elbow leads to contracture, shortening of ligaments, and shortening of the triceps muscle. Patients will likely develop a painful, deformed elbow with severely limited motion.1,7 After open reduction and repair of osseous and ligamentous stabilizers of the elbow, a hinged external fixator allows for immediate concentric joint motion while the soft tissues are protected and allowed to heal in the optimal position for motion.21 A number of investigators reported satisfactory results and relatively low complications treating chronic
Data are shown as degrees.
3 80 50
70
118
120
0
35 155
118 0
80 20
80
30 30
50 7
Complications and Failures
Two patients had failures related to persistent elbow instability. One patient began to report pain and instability with terminal extension and developed progressive loss of motion after 2 years. The patient ultimately developed worsening elbow pain resulting from posttraumatic arthritis and received a total elbow arthroplasty (TEA). The second patient required early removal of the external fixator at 4 weeks owing to pin track and soft tissue infection. Despite initial reconstruction of both the MCL and LCL, the patient had persistent elbow instability and subluxation after removal of the external fixator. A temporary elbow-spanning bridge plate was used to hold the ulnohumeral joint reduced. The plate was removed 4 weeks later and the patient began therapy. Range of motion was 0 to 130 at 16-month follow-up.
30
40 6
10
Patient
90
3
1
90
5 80
130
0
130
0
0 60 90 5
30
60 4
30
0
40 30
135
5
130
15
2 70 80 3
55
0 0 25
130
27
103
45
3
2 45
50
70
80
100
145 15
25 125 25
0
60
25 0
70 2
50
20 1
20
20
160
Final Pronation Final Arc Final Extension Preoperative Supination Preoperative Pronation Preoperative Arc Preoperative Extension Preoperative Flexion
Preoperative Range of Motion
TABLE 3.
Patient
TABLE 2.
Functional and Radiographic Treatment Outcomes
Final Flexion
Final Follow-Up Range of Motion
Final Supination
Final Radiographic Arthrosis (Broberg and Morrey20)
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elbow fracture-dislocations using hinged external fixators.5,12e16 Our results confirm that patients can eventually achieve improved, functional ROM of the elbow. However, contrary to other studies, many of our patients encountered complications over the course of treatment that resulted in numerous additional surgical procedures or treatment failure. Four patients had complications during treatment and 3 required a minimum of 4 additional procedures each. Previous reports documented that a concentric reduction can be maintained even without direct repair or reconstruction of the collateral ligaments owing to restoration of the elbow’s bony stability. Advocates of using a hinged external fixator believe that continuous, protected elbow motion allows the ligaments to heal or scar back to the epicondyles without restricting motion.13,22,23 As opposed to an acute injury, we think that restoring the ligamentous structures in chronic elbow fracture-dislocations is important to maintain a concentric reduction after removal of the hinge fixator. In our experience, despite the chronic nature of the injury we were able to perform direct repair of the collateral ligaments in many instances. It is possible that by dissecting the soft tissue from the humerus and leaving the ligaments attached to the ulna, more local tissue was preserved for repair. There is concern that open repair of ligaments in a chronic dislocation results in more fibrosis around the joint and unacceptable loss of motion.13,24,25 In our series, although many patients were not able to achieve full elbow extension after treatment, all of them ultimately achieved functional elbow motion that allowed them to perform essential daily tasks.26 The primary complication in our series was infection, occurred in 4 patients. One patient had cellulitis that resolved with antibiotics but the remaining 3 patients developed notable deep infections that required multiple operative debridements and adjunct treatments. The reason for these infections was likely multifactorial, because the combination of a thin soft tissue envelope at the elbow and the hinged external fixator device placed these patients at higher risk. Ring et al27 reported that patients treated with hinged external fixators for acute or subacute elbow instability had more adverse events compared with cross-pinning of the elbow. Other studies mentioned complications related to hinge external fixators about the elbow, including osteomyelitis, osteolysis, and purulent discharge.10,28 Cheung et al29 examined 100 patients who had placement of external fixators about the elbow and noted a 25% overall complication incidence. Most of these were related to erythema and drainage around the fixator pins, J Hand Surg Am.
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although the authors noted that the only patients who developed deep infections were those who had undergone complex elbow reconstructions. Multiple studies have shown that the risk of pin track infections increases the longer a fixator is in place.30e32 Most external fixator pins become colonized with bacteria by the time of removal, which makes pin site care critical to prevent complication.33 Relaxing skin incisions around pin sites may also have a role in decreasing colonization of the pin tracks.34 Although our goal was 6 to 8 weeks in the fixator, the logistics of follow-up and scheduling removal of the fixator sometimes resulted in the fixator being in place for up to 10 weeks. In our series, many infectious complications were related to external fixator pins despite instructions for pin care and regular clinical follow-up. Unfortunately, investigators have failed to identify a superior method to prevent external pin site infections.34e36 The risks of complex elbow reconstructive surgery include infection and skin breakdown owing to the thin soft tissue envelope. The posterior skin incision at the elbow allows the surgeon to perform multiple procedures with a single incision,18 which can be useful in the open treatment of a chronic elbow dislocation. This approach is commonly used in TEA but is associated with a 26% incidence of wound complication.37e39 Early ROM for patients treated with a hinged external fixator can also put this posterior surgical incision at risk. This tissue is over the apex of a joint with great ROM, where the tension and motion it sustains inhibit healing and increase risk of wound dehiscence.40 Six of 7 patients in our series underwent surgery via a posterior skin incision; 1 patient required an additional procedure related to surgical wound breakdown. Similar to other authors,5 we elected to perform the posterior approach in most patients to visualize both sides of the elbow joint and ensure sufficient soft tissue release and balancing. Although the posterior approach has a higher risk of wound complications, we think that developing fullthickness flaps and staying within one surgical plane minimizes the risk. In addition, the posterior approach allows for the possibility of future reconstructive procedures or conversion to TEA to be performed through the same incision. Our study had several limitations, one of which is its retrospective nature. The rare injury pattern and strict inclusion criteria of the study contributed to the small sample size and limited the applicability of our findings. However, with the lack of available literature, we believe that even with our small sample size there is useful information for clinicians who might r
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encounter this multifaceted problem. Another limitation is that the study reflected one surgeon’s experience. This may have affected treatment outcomes and failure in some circumstances. In patient 5, we decided not to perform a radial head replacement because of the intra-operative finding of capitellar wear and concern for postoperative pain. However, in retrospect, a prosthetic radial head might have conferred additional stability. Finally, our average follow-up was 41 months (range, 17e106 mo) but several patients had less than 2-year follow-up. In time, some of these patients may develop other complications or require additional salvage procedures with longer follow-up. In our opinion, there are a few general principles to consider when performing elbow surgery for a chronic elbow dislocation. As with any elbow fracturedislocation, restoration of the bony anatomy is important to regain reduction and stability of the ulnohumeral joint. In chronic injuries, reconstructing or repairing ligaments becomes important to contribute additional stability to the joint. To obtain adequate soft tissue release and visualize the elbow joint, the posterior skin incision may be the most useful. To minimize wound complications, thick skin flaps are raised without dissecting through multiple subcutaneous tissue planes. In our series, many complications were related to infections stemming from the external fixator pins. Although no good preventative measures are known, vigilant pin site care and follow-up may be most beneficial in preventing complications. Ultimately, patients can achieve meaningful improvements in ROM and function but should be counseled regarding the high risk of complications, potential treatment failure, and need for additional procedures.
9. Naidoo KS. Unreduced posterior dislocations of the elbow. J Bone Joint Surg Br. 1982;64(5):603e606. 10. Cobb TK, Morrey BF. Use of distraction arthroplasty in unstable fracture dislocations of the elbow. Clin Orthop Relat Res. 1995;(312):201e210. 11. Madey SM, Bottlang M, Steyers CM, et al. Hinged external fixation of the elbow: optimal axis alignment to minimize motion resistance. J Orthop Trauma. 2000;14(1):41e47. 12. Ivo R, Mader K, Dargel J, Pennig D. Treatment of chronically unreduced complex dislocations of the elbow. Strategies Trauma Limb Reconstr. 2009;4(2):49e55. 13. Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am. 2002;84(9): 1630e1635. 14. Degreef I, De Smet L. Chronic elbow dislocation: a rare complication of tennis elbow surgery: successful treatment by open reduction and external fixator. Chir Main. 2007;26(3):150e153. 15. Lo CY, Chang YP. Neglected elbow dislocation in a young man: treatment by open reduction and elbow fixator. J Shoulder Elbow Surg. 2004;13(1):101e104. 16. Ohno Y, Shimizu K, Ohnishi K. Surgically treated chronic unreduced medial dislocation of the elbow in a 70-year-old man: a case report. J Shoulder Elbow Surg. 2005;14(5):549e553. 17. Dowdy PA, Bain GI, King GJ, Patterson SD. The midline posterior elbow incision: an anatomical appraisal. J Bone Joint Surg Br. 1995;77(5):696e699. 18. Patterson SD, Bain GI, Mehta JA. Surgical approaches to the elbow. Clin Orthop Relat Res. 2000;(370):19e33. 19. Hotchkiss R. Elbow Contracture. In: Green DP HR, Pederson WC, eds. Green’s Operative Hand Surgery. Vol. 1. 4th ed. Philadelphia, PA: Churchill Livingstone; 1999:667e682. 20. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am. 1986;68(5):669e674. 21. Tan V, Daluiski A, Capo J, et al. Hinged elbow external fixators: indications and uses. J Am Acad Orthop Surg. 2005;13(8):503e514. 22. Pennig D, Gausepohl T, Mader K. Transarticular fixation with the capacity for motion in fracture dislocations of the elbow. Injury. 2000;31(suppl 1):35e44. 23. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint: a prospective randomized study. J Bone Joint Surg Am. 1987;69(4):605e608. 24. Arafiles RP. Neglected posterior dislocation of the elbow: a reconstruction operation. J Bone Joint Surg Br. 1987;69(2):199e202. 25. Fowles JV, Kassab MT, Douik M. Untreated posterior dislocation of the elbow in children. J Bone Joint Surg Am. 1984;66(6):921e926. 26. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6): 872e877. 27. Ring D, Bruinsma WE, Jupiter JB. Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability. Clin Orthop Relat Res. 2014;472(7):2044e2048. 28. Nielsen D, Nowinski RJ, Bamberger HB. Indications, alternatives, and complications of external fixation about the elbow. Hand Clin. 2002;18(1):87e97. 29. Cheung EV, O’Driscoll SW, Morrey BF. Complications of hinged external fixators of the elbow. J Shoulder Elbow Surg. 2008;17(3): 447e453. 30. Hutson JJ Jr, Zych GA. Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators. J Orthop Trauma. 1998;12(3):214e218. 31. Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract infection with contemporary external fixation: how much of a problem? J Orthop Trauma. 2003;17(7):503e507. 32. Antoci V, Ono CM, Antoci V Jr, Raney EM. Pin-tract infection during limb lengthening using external fixation. Am J Orthop (Belle Mead NJ). 2008;37(9):E150eE154. 33. Mahan J, Seligson D, Henry SL, et al. Factors in pin tract infections. Orthopedics. 1991;14(3):305e308.
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38. McKee MD, Veillette CJ, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reductioneinternal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009;18(1):3e12. 39. Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am. 2004;86(5): 940e947. 40. Patel KM, Higgins JP. Posterior elbow wounds: soft tissue coverage options and techniques. Orthop Clin North Am. 2013;44(3): 409e417.
34. Bibbo C, Brueggeman J. Prevention and management of complications arising from external fixation pin sites. J Foot Ankle Surg. 2010;49(1):87e92. 35. Lethaby A, Temple J, Santy-Tomlinson J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev. 2013;12:CD004551. 36. Jennison T, McNally M, Pandit H. Prevention of infection in external fixator pin sites. Acta Biomater. 2014;10(2):595e603. 37. Ali A, Shahane S, Stanley D. Total elbow arthroplasty for distal humeral fractures: indications, surgical approach, technical tips, and outcome. J Shoulder Elbow Surg. 2010;19(2 suppl):53e58.
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