Olecranon osteotomy vs.triceps-sparing for open reduction and internal fixation in treatment of distal humerus intercondylar fracture:a systematic review and meta-analysis

Background:The open reduction and internal fixation(ORIF)was a standard treatment approach for fracture at distal humerus intercondylar,whereas the optimal way before ORIF remains inconclusive.We,therefore,performed a systematic review and meta-analysis to assess the efficacy and safety of olecranon osteotomy vs.triceps-sparing approach for patients with distal humerus intercondylar fracture.Methods:The electronic searches were systematically performed in PubMed,EmBase,Cochrane library,and Chinese National Knowledge Infrastructure from initial inception till December 2019.The primary endpoint was the incidence of excellent/good elbow function,and the secondary endpoints included Mayo elbow performance score,duration of operation,blood loss,and complications.Results:Nine studies involving a total of 637 patients were selected for meta-analysis.There were no significant differences between olecranon osteotomy and triceps-sparing approach for the incidence of excellent/good elbow function(odds ratio[OR]:1.37;95%confidence interval[CI]:0.69-2.75;P=0.371),Mayo elbow performance score(weight mean difference[WMD]:0.17;95%CI:-2.56 to 2.89;P=0.904),duration of operation(WMD:4.04;95%CI:-28.60 to 36.69;P=0.808),blood loss(WMD:33.61;95%CI:-18.35 to 85.58;P=0.205),and complications(OR:1.93;95%CI:0.49-7.60;P=0.349).Sensitivity analyses found olecranon osteotomy might be associated with higher incidence of excellent/good elbow function,longer duration of operation,greater blood loss,and higher incidence of complications as compared with triceps-sparing approach.Conclusions:This study found olecranon osteotomy did not yield additional benefit on the incidence of excellent/good elbow function,while the duration of operation,blood loss,and complications in patients treated with olecranon osteotomy might be inferior than triceps-sparing approach.

Inserting the Ulnar Prosthesis into Radius as a Novel Salvage Surgery for Revision Total Elbow Arthroplasty with Massive Bone Defect

Background： Infection and aseptic loosening are common complications of total elbow arthroplasty （TEA） and often require revision surgery. However, bone defects, along with other complications, bring an extra difficulty to the second surgery, especially for patients with a massive bone defect in the proximal ulna. Several methods including allograft or autograft have been introduced into practice, but none sufficiently solves these problems. Methods： We conducted a new surgical method for patients with a massive ulnar bone defect needing revision TEA. During revision arthroplasty, the ulnar prosthesis was inserted into the radius as a salvage procedure. Four consecutive patients received revision arthroplasty with this method between 2013 and 2016. Patients＇ data were collected to evaluate the clinical outcome. Results： All patients had a Grade Ill ulnar bone defect. At the last follow-up session, all patients reported a painless, functional elbow joint. Three patients suffered from a periprosthetic infection that was completely cured using the two-stage method. No major complications, including infection, aseptic loosening, or wound problems were found. One patient had a transient ulnar neuritis, and another had a transient radial neuritis. Both patients had full recovery at the last follow-up session. Conclusions： Inserting an ulnar prosthesis into the radius is a novel procedure for patients with a massive bone defect due to infection or aseptic loosening. It is a safe, quick, and effective treatment with a promising short-term outcome. This method should be provided as a salvage procedure for patients with a nonreconstructable ulnar bone defect.

Anterior Subcutaneous Transposition of the Ulnar Nerve Affects Elbow Range of Motion： A Mean 13.5 Years of Follow-up

Background：Surgical decompression of the ulnar nerve is effective for cubital tunnel syndrome.However,deep approaches may result in iatrogenic elbow stiffness.This long-term study was to evaluate the range of motion （ROM） of the elbow and functional outcomes after anterior subcutaneous transposition.Methods：A total of 115 patients （78 male and 37 female;mean age：46.6 years） who underwent anterior subcutaneous transposition of the ulnar nerve between 2001 and 2005 were evaluated retrospectively;mean follow-up was 13.5 years.Elbow ROM was measured as flexion arc,flexion,and extension preoperatively and at the final follow-up,and compared via a mixed analysis of variance adjusting for age.Neuropathy was assessed preoperatively using a modified McGowan neuropathy grade and postoperatively using modified Wilson-Krout criteria.An ordinal logistic regression analysis used postoperative modified Wilson-Krout criteria as the outcome and preoperative factors as predictors.Results：Preoperative McGowan grades were Grade 1 in 14 patients （12.2%）,Grade 2A in 28 （24.3%）,Grade 2B in 53 （46.1%）,and Grade 3 in 20 （17.4%） patients.Postoperatively,66 patients （57.4%） had excellent results,26 （22.6%） had good results,16 （13.9%） had fair results,and 7 （6.1%） had poor results at the final follow-up,as per the Wilson-Krout criteria.There were no complications.Pre-and postoperative elbow ROM was significantly decreased in patients with previous trauma or surgery of the elbow compared with those without （P 〈 0.05）.Anterior subcutaneous transposition of the ulnar nerve did not significantly affect elbow ROM regardless of previous trauma or surgical history nor preoperative ROM （P 〉 0.05）,after adjusting for age.Patients with prolonged symptoms prior to surgery and worse neuropathy tended to have less satisfactory functional outcomes （P 〈 0.05）,after adjusting for covariates.Conclusions：Anterior subcutaneous transposition of the ulnar nerve is an effective and reliable treatment of cubital tunnel syndrome with satisfactory outcomes and minimal effect on elbow ROM.