Triceps-reflecting anconeus pedicle approach with double

Injury, Int. J. Care Injured xxx (2016) xxx–xxx

G ModelJINJ 6795 No. of Pages 7

Triceps-reflecting anconeus pedicle approach with doubleprecontoured locking plate fixation is efficient in the treatment oforthopaedic trauma association type C distal humerus fracture

Ying-Chao Chou*, Yung-Heng Hsu, Yi-Hsun Yu, Chi-Chuan WuDepartment of Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan

A R T I C L E I N F O

Article history:Accepted 27 June 2016

Keywords:Triceps-reflecting anconeus pedicleapproachOrthogonal precontoured locking platefixationAO type C distal humerus fracture

A B S T R A C T

Background: The purpose of this study was to determine if the triceps-reflecting anconeus pedicle (TRAP)approach combined with the precontoured locking plate can provide acceptable clinical outcomes in thetreatment of comminuted distal humerus fracture.Methods: Between August 2008 and June 2014, 48 patients with Orthopaedic Trauma Association type C(21 with C2, 27 with C3) distal humerus fractures underwent open reduction and internal fixation withorthogonal precontoured locking plate fixation using the TRAP approach. Occurrences of bony union,implant failure, posttraumatic arthrosis, and heterotopic ossification were detected with radiography.Clinical assessment included evaluation of range of motion and determination of the pain score, MayoElbow Performance Index (MEPI) score, and Disability of the Arm Shoulder and Hand (DASH) score.Results: The fractures healed within 3 months in 25 patients (53%) and within 6 months in 23 patients(47%). The 12-month assessment revealed improved elbow movement, with the mean arc of flexion-extension of 121� (range, 100�–140�), mean arc of supination-pronation of 163� (range, 150�–180�), andmean flexion contracture of 8� (range, 0�–30�). The mean MEPI score was 81 and the mean DASH scorewas 11.7.Conclusions: By retaining the intact olecranon by the TRAP approach, orthopedic surgeon can getadequate surgical exposure for fracture fixation and can use olecranon as a three-dimensional templateto restore the articular fragments. The promising results in this study obtain because that preciseidentification of the triceps muscle allowed the determination of a proper length-tension relationship fortriceps reattachment. The combination of triceps tendon repair and anconeous muscle repair ensured thestrength of the extensor mechanism. Therefore, the TRAP approach in combination with the usage of theprecontoured locking plate can be recommended as the optimal surgical approach for the treatment ofcomminuted distal humerus fracture.

ã 2016 Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

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Introduction

Fractures of the distal humerus constitute 1–7% of all fracturesand 30% of all elbow fractures. Up to 96% of distal humeral fracturesare of intercondylar type with articular involvement [1,2]. Over thelast 2 decades, many reports have suggested that operativetreatment provides satisfactory clinical and radiographic outcomes

* Corresponding author at: Department of Orthopedics, Chang Gung MemorialHospital, 5 Fu-Hsin St., 333, Taoyuan, Taiwan.

E-mail addresses: [email protected] (Y.-C. Chou),[email protected] (Y.-H. Hsu), [email protected] (Y.-H. Yu),[email protected] (C.-C. Wu).

http://dx.doi.org/10.1016/j.injury.2016.06.0360020-1383/ã 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Y.-C. Chou, et al., Triceps-reflecting afixation is efficient in the treatment of orthopaedic trauma association typj.injury.2016.06.036

[3,4]. Following the golden principle of joint fracture managementwith stable bony fixation to allow early mobilization, openreduction and double-plate internal fixation of both the radialand ulnar columns have become the treatment of choice fortreating comminuted distal humerus fractures [3–6]. For intra-articular comminuted fractures of the distal humerus, a number ofwell-described approaches have been introduced for providingadequate exposure of the distal humerus. These include olecranonosteotomy [7], triceps-reflecting anconeus pedicle (TRAP) [8],anconeus flap transolecranon osteotomy [9], triceps reflecting [10],triceps splitting [11], and the combination of triceps splitting andreflection approaches [12]. All these approaches involve eithermobilizing or detaching the extensor mechanism from the elbowto expose the joint. Olecranon osteotomy is still the most common

nconeus pedicle approach with double precontoured locking platee C distal humerus fracture, Injury (2016), http://dx.doi.org/10.1016/

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2 Y.-C. Chou et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx


approach owing to the extent of articular surface exposure[7,13,14].

Early motion is critically important after open reduction andinternal fixation (ORIF) of the intra-articular distal humerusfractures because of the risk of early elbow joint capsule scarring.For management of the elbow joint, immobilization for more than3 weeks has been linked to poor outcomes [2,15]. Many studiessuggested the superiority of secure fixation with precontouredlocking plate fixation for the humerus fracture site in the treatmentof comminuted distal humeral fractures [16,17]. However, there isless information on the fixation methods for the olecranonosteotomy site that would correspond to the locking plate fixationfor the humeral site [18].

Considering the risk of complications associated with using thetension-band wire construct for olecranon osteotomy fixation[19,20], we have switched our standard surgical exposure methodfrom olecranon osteotomy to the TRAP approach when treatingdistal humerus fractures in our daily practices. We hypothesizedthat the TRAP approach can provide adequate surgical exposure ofthe distal humerus and allow early elbow joint movement withoutsignificant tendon-to-bone healing problems in the extensormechanism, thereby fulfilling the requirement of early mobiliza-tion of the elbow joint. The purpose of this study was to review ourexperience with using precontoured locking plates in the TRAPapproach for the treatment of Orthopaedic Trauma Association(OTA) type C distal humerus fractures.

Patients and methods

Between August 2008 and September 2014, 77 consecutiveadult patients (>15 years old) with OTA type C distal humerusfractures underwent ORIF performed by the first author at ourinstitution. This study included patients treated using the TRAPapproach with precontoured locking plate fixation of the distalhumerus fracture. Patients with less than 2 years of follow-up,simultaneous fractures of the same upper extremity, head injurywith poor compliance of early rehabilitation course were excluded.Forty-eight patients met the inclusion/exclusion criteria during thestudy period, including 19 women and 27 men with a mean age of41 years (range, 18–74 years) at the time of fracture. Twenty-eightpatients had experienced motorcycle accidents, 11 had fallen froma high elevation at work, and 9 had experienced bicycle accidents.Twenty-six patients suffered from comminuted distal humerusfractures on their dominant sites and 22 patients on their non-dominant sites (29 right, 19 left). Based on the OTA fractureclassification, all 48 patients were diagnosed with type C distalhumerus fracture, including 21 patients with C2 and 27 with C3distal humerus fractures. The review of patients’ clinical recordsand radiographs for this retrospective study was approved by theinstitutional review board.

At the initial patient presentation, distal humerus fracture wasdiagnosed with standard anterior-posterior and lateral plainradiography of the elbow joint. 3-D CT was also performed forall 48 patients for detailed intra-articular fracture assessment. Forall patients, the injured arm was placed in a long arm splint, anddefinitive surgery was electively performed after adequatesubsiding of elbow joint swelling. The average time betweeninjury and surgery was 3.6 days (range, 0–9 days).

Surgical technique

Patients were placed under general anesthesia, and cefazolin(1 g) was administered as antibiotic prophylaxis. The patient wasplaced in a lateral decubitus position with the index upperextremity hanging free over a bolster.


Triceps-reflecting anconeus pedicle approach

A longitudinal posterior surgical incision was made and theulnar nerve was identified and protected with artery slings. Thetriceps tendon was identified beginning laterally with theanconeus muscle following a modified Kocher approach, and themedial part of the triceps tendon was separated as described byByran-Morrey [10]. The triceps was fully reflected off the distalhumerus by carefully releasing the Sharpey’s fibers from theinsertion at the tip of the olecranon with a scalpel. Next, the entiretriceps and anconeus pedicle were retracted proximally, and theelbow joint was positioned in full flexion to permit adequateexposure of the distal humerus. All patients underwent fracturefixation using the standard AO/ASIF technique [21] with orthogo-nal plating using a precontoured locking plate (Synthes Ltd., Paoli,PA) (Fig. 1A–D). By retaining the intact olecranon, we can useolecranon, coronoid, and radial head as a three-dimensionaltemplate to restore the articular fragments (Fig. 2A, B).

Triceps reattachment after fixation of the distal humeralfracture is a principally important step. Four vertical drill holeswere made in the olecranon tip at the Sharpey’s fiber attachmentsite. The elbow of the patient in the lateral decubitus position withthe index arm resting over the bolster was flexed to 90�, and 4threads of non-absorbable suture (no. 5 Ethibond) were positionedat the attachment site of the triceps and placed through the drillholes to reattach the triceps back to the olecranon. The tourniquetwas temporary released during the triceps reattachment proce-dure in order to get proper length-tension relationship on theextensor mechanism. The fascial sleeve, including the edges of thetriceps periosteum and anconeus pedicle, was then closed with arunning suture over the periosteum of the proximal ulna (Fig. 2C,D).

Postoperative management

The operative elbow was initially immobilized in 90� of flexionfor 2 days. The rehabilitation course started with restricted passiverange-of-motion exercises with a protective range of motion brace.Patients were encouraged to alternate splint application anglebetween 10� and 90� every 1–2 h for 2 weeks. Active assistedflexion and passive extension were then started and continued for6 weeks, followed by active range-of-motion exercise.

Assessment

Patients were examined at our orthopedic outpatient unit 1week and 1, 3, 6, 12, and 24 months after the surgery by a singlephysician who had not been involved in any of the surgeries.Anteroposterior and lateral plain radiographic examinations wereperformed during each follow-up visit to evaluate bone union.Radiographic assessment also included identification of implantloosening or failure, heterotopic ossification, and posttraumaticarthrosis. Fracture site union was defined as appearance ofbridging callus or vanishing of the fracture line on 3 of the 4cortices seen on the anteroposterior and lateral radiographs.Posttraumatic elbow arthritis was classified according to thesystem of Brobery and Morrey and heterotopic ossificationaccording to the system of Hasting and Graham [22,23]. Clinicalassessment included evaluation of pain and range of motionrecovery of the index elbow, including flexion-extension, supina-tion-pronation, and extension lag. Elbow motion was assessed inthe standing position without shoulder abduction (Fig. 3A, B), withthe exception of extension lag, which was detected in the proneposition with the index arm abducted at 90� and the forearmhanging vertically over the side of the table. The examiningphysician used one hand to hold the patient’s arm and asked the




Fig. 1. Preoperative (A) anterioposterior and (B) lateral 3D-CT scan of the right elbow of a 57-year-old female with an AO C3 fracture of the distal humerus. Postoperative (C)anterioposterior and (D) lateral radiographs showing anatomic reduction and fixation with the precontoured orthogonal locking plate on the distal humerus fracture site.

Y.-C. Chou et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx 3


patient to maximally extend his/her elbow. The physician thenused another hand to lift the patient’s forearm to detect further lagin the elbow (Fig. 3C, D). The Mayo Elbow Performance Index


(MEPI) was used as an objective measure of clinical outcome [24].Patients also completed 2 limb-specific Patient-reported OutcomeMeasures (PROMs) of the Disability of the Arm, Shoulder and Hand




Fig. 3. Six-month follow-up (A) and (B) photographs showing 0� extension and 140� flexion of the right elbow. Six-month follow-up (C) and (D) photographs showingpreparation and detection of extensor lag on right elbow while the patient in prone position.

Fig. 2. Intraoperative (A) photograph showing adequate exposure of the intact olecranon and comminuted distal humeral fragments by retracting the triceps muscle throughthe TRAP approach. Intraoperative (B) photograph showing adequate reduction of the humeral fragments by playing the intact olecranon as a template and adequate fixationof distal humerus by locking plates in orthogonal configuration. Intraoperative (C) photograph showing 4 bands of Ethibond placed through the drill holes for reattachment ofthe triceps back to the olecranon. Intraoperative (D) photograph showing running sutures over the anconeus pedicle flap.



Please cite this article in press as: Y.-C. Chou, et al., Triceps-reflecting anconeus pedicle approach with double precontoured locking platefixation is efficient in the treatment of orthopaedic trauma association type C distal humerus fracture, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.06.036





(DASH) questionnaire [25]. MEPI takes into consideration pain,motion, stability, and daily function. DASH is a 30-item question-naire that detects upper-extremity disability. The maximum scoreof 100 indicates the worst possible disability, whereas zeroindicates no disability.

Results

All the 48 patients completed a regular follow-up course thatlasted for at least 24 months. The mean follow-up time was 44.2months (range, 24–88).

Radiographic results

The distal humeral fractures were healed on the postoperative3-month follow-up visit in 25 patients (52%) and on thepostoperative 6-month follow-up visit in the remaining 23patients (48%). Three patients (6.3%) had a 2-mm articular gapresulting from bone absorption. Two patient (4%) had a lockingscrew slightly penetrating into the articular surface, but this wasnot accompanied by any symptoms. Heterotopic ossificationaround the anterior aspect of the coronoid process or bilateralepicondyles without significant disturbance of elbow jointmovement occurred in 11 patients (23%). Four patients (8.3%)elected for removal of the implants because of subcutaneousprominence of the hardware and 2 (4.2%) because of emotionalembarrassment associated with the implant retention. All theseremoval procedures were performed using a triceps sparingapproach without re-detachment of the triceps insertion. Themean operation time was 15 months (range, 13–19) after theindex operation. The overall implant removal rate was 12.5%(6/48).

Clinical results

On the postoperative 6-month assessment, the mean arcs offlexion-extension and supination-pronation were 108� (range,90�–140�) and 158� (range, 150�–180�), respectively. The meanflexion contracture was 19� (range, 0�–40�). The range of motion inthe injured elbow further improved on the 12-month assessment,with the mean arc of flexion-extension of 121� (range, 100�–140�),mean arc of supination-pronation of 163� (range, 150�–180�), andmean flexion contracture of 8� (range, 0�–30�). The range of motionthen leveled out, with no significant differences between theresults of the postoperative 12-month and 24-month follow-ups.On the 24-month follow-ups, the mean MEPI was 81 (range,75–100), with 14, 26, 6, and 2 scores falling into excellent, good,fair, and poor categories, respectively. The mean DASH score was11.7 (range, 0–45). Twenty-six patients (54%) were able to fullyperform their pre-operative activities and work duties. Fifteenpatients (32%) decreased their workloads but retained their jobs.Seven patients (15%) lost their previous jobs but did not experiencesignificant changes in their recreational activities.

Complications

Six patients (13%) experienced mild soreness of the posterolat-eral aspect of the elbow joint around the anconeus muscle for 3months after the surgery, which gradually disappeared by month6. Four patients (8.3%) suffered from temporary numbness on ulnarnerve territory after the plating surgery but significant subsidenceof the symptom within 6 weeks after the surgery. Two patients(4.2%) suffered from repeat wound infections and finally advancedosteoarthrosis on the elbow joint. These two patients lastlyunderwent shifting to total elbow replacement on postoperatively13 and 15 months after the plating surgery. None of the patients


had triceps rupture on the last follow-up. Four patents (8.3%) hadsignificant extension lags of 5� and 10� at the last follow-up.

Discussion

Two major concerns should be taken into account by orthopedicsurgeons when treating patients with intra-articular comminutedor osteoporotic distal humerus fractures. The first one is choosingan adequate implant that provides stable fixation allowing earlyunrestricted range-of-motion exercise of the elbow joint [1–6]. Thesecond one is selecting the optimal surgical approach not onlyallowing adequate exposure for fracture fixation but also promot-ing early joint movement [7,13,26]. In this present study, weprovided most of our patients good to excellent results without thenecessity of routine implant removal procedures by selecting theprecontoured locking plate in orthogonal fixation figuration. Theacceptable clinical results in our study also proved that earlymobilization can be applied for our patients even though theyunderwent the TRAP approach with taking down and suturing backof the extensor mechanism during the operation.

Three factors could explain the successful outcome observed inthe present study. First, the tourniquet was temporary releasedduring the triceps reattachment procedure in order to get properlength-tension relationship for triceps reattachment with theelbow in the 90� position. Second, the combination of tricepstendon repair with four-thread Ethibond vertical osseous sutureand anconeous muscle repair with fascial sleeve running sutureprovided sufficient extensor mechanism strength to allow earlyrehabilitation without significant complications related to tricepsmuscle restoration. Third, all our patients were recommended tostart their elbow exercise in the supine or standing position withthe shoulder abducted. Therefore, the effect of antigravity wasavoided during the elbow extension exercise.

Olecranon osteotomy is the most frequently used surgical routeto expose the distal humerus for AO type C fractures [7,13,14]. Forthe fixation of olecranon osteotomy site, it is quite hard to find afixation method unless a locking plate that provides necessarystability and durability corresponding to the precontoured lockingplate for the fixation of distal humeral fracture site. Although the K-wire/tension band fixation of the olecranon site allows early range-of-motion exercise of the elbow joint, thereby promoting bonehealing [27], previous clinical reports have identified delayedhealing and/or fracture nonunion in approximately 10% of patientsand prominent hardware in approximately 25% [19,20,28]. Somestudies showed promising results of semitubular plating orcancellous screw fixation for olecranon osteotomy fixation [29].However, unpredictable long-term implant loosening and persis-tent skin irritation associated with the use of non-locking implantson olecranon sites led us towards using the TRAP approach toexpose the distal humerus fracture site during the treatment ofcomminuted intra-articular distal humerus fractures. The presentclinical data demonstrate promising results and the absence ofsignificant complications in the extensor mechanism even with anearly rehabilitation course that satisfies the early mobilizationrequirement for treating intra-articular distal humerus fracturesusing precontoured locking plates.

Retaining the intact olecranon by the TRAP approach, orthope-dic surgeon can use olecranon, coronoid, and radial head as a three-dimensional template to restore the articular fragments [8,9,11].On the other hand, with releasing Sharpey’s fibers from the tricepsinsertion at the tip of the olecranon by the TRAP procedure, someorthopedic surgeons worry about the extensor weakness by tricepsmuscle damage itself and unpredictable outcome by the erratictendon-to-bone healing potential [8,9,11,12]. But from our results,the clinical outcomes of mean range of motion recovery andfunctional scores showed no significant impairment in the TRAP






group compared with that in the olecranon osteotomy group. Itmay come from the less olecranon complications and adequatetriceps reattachment for achieving accurate triceps tension andsufficient suture strength on the muscle for early rehabilitation[8–13].

The use of precontoured locking plates is currently favored forthe management of intra-articular fracture, with a simultaneousrecommendation of aggressive early mobilization of the indexjoint to avoid stiffness [30,31]. Precontoured locking plate fixationat the distal humerus was introduced two decades ago [32], andsome biomechanical studies demonstrated advantages of suchimplants, including promising stability in fracture fixation andease of application [14,26,33]. Although some reports suggestedthat there are no significant differences in preliminary tointermediate clinical results between conventional non-lockingand locking plate fixation for distal humerus fractures [26,33,34],other studies revealed more long-term complications related toimplant loosening when the conventional non-locking platefixation was used; loosening of distal screws after lateral columnplating fixation of the distal humerus was especially common [35].Accordingly, fixation with precontoured locking plates wasrecommended because of less frequent need for surgical revisionfor symptomatic or prophylactic implant removal.

The restrictive national health insurance plan, which providescoverage to all the citizens of our country, does not fully cover theusage of a locking plate for fracture fixation. Therefore, a patientwho selects the locking plate fixation incurs additional costs.Consequently, financial concerns make it difficult to recommendmost of our patients selecting locking plate fixation of both thedistal humerus fracture site and the olecranon osteotomy site.Furthermore, patients who elect to pay for locking plate fixation ofthe fracture site usually expect long-term retention of the implantwithout the need for further surgical procedures for implantremoval. This is truly hard to ask these patients to accept additionalsurgery just for removing the implant on the olecranon osteotomysite. In this regard, the TRAP approach offers nearly the samesurgical exposure as olecranon osteotomy without the need forimplant removal or risk of implant-related complications of theextensor mechanism restoration. This constitutes an importantadvantage of the TRAP approach for the treatment of distalhumerus fracture.

This study has limitations. Due to the early recognition ofpotential complications coming from restrictive implant selectionpolicy between the humerus fracture site and the olecranonosteotomy site, we shifted our surgical approach from olecranonosteotomy to TRAP early after we started using locking plates fortreating distal humerus fractures. This limited the number of casesin our clinical practices with olecranon osteotomy for locking platefixation of distal humerus fractures. Because of the retrospectivenature of this study and financial limitations described above, wecould not compare TRAP and olecranon osteotomy with anyimplant on the olecranon osteotomy site.

Conclusions

Fixation of comminuted distal humerus fracture with theprecontoured locking plate is recommended based on less frequentcomplications associated with implant loosening. The TRAPapproach can be advocated as an optimal surgical approach forcomplex intercondylar distal humerus fractures because of fewimplant-related complications in the extensor mechanism and thepossibility of early rehabilitation. In order to identify the advantageand disadvantage of the TRAP approach, future studies andresearches can be designed on comparisons between the TRAPand the olecranon osteotomy approach with the some fixationimplants for treating comminuted distal humerus fractures.


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Triceps-reflecting anconeus pedicle approach with double