Background 

The treatment of complex persistent elbow instability after trauma is challenging. Previous studies on treatments have reported varied surgical techniques, which makes it difficult to establish a therapeutic algorithm. Furthermore, the surgical procedures may not sufficiently restore elbow stability, even with an additional device, and a noted high rate of arthritis progression.While a recently developed internal joint stabilizer effectively treats elbow instability, its clinical application for complex persistent elbow instability is limited and the standardized protocol is not well described. Additionally, we want to know whether the arthritis progression will cause a negative impact on the functional outcomes of complex persistent elbow instability.

Questions/purposes 

(1) Does treatment of complex persistent elbow instability with a hinged internal joint stabilizer and a standardized protocol prevent recurrent instability and other complications? (2) What are the pre- to postoperative improvements in pain, disability, elbow performance, and ROM? (3) Is the development of post-traumatic arthritis associated with worse pain, disability, elbow performance, and ROM?

Methods 

Between September 2014 and October 2019, we treated 22 patients for persistent dislocation or subluxation after initial treatment of traumatic elbow fracture-dislocations. Of those, we considered patients who were at least 20 years of age, with an interval of 6 weeks or more between the injury (initial treatment) and the index reconstructive procedure, which had been performed at our institute, as potentially eligible. During that time, we used an internal joint stabilizer with a standardized protocol for posttraumatic complex persistent elbow instability. We performed total elbow replacements in patients older than 50 years who had advanced elbow arthritis. Based on that, 82% (18 of 22) of patients were eligible; 14% (3 of 22) were excluded because total elbow replacements was undertaken, and another 5% (1 of 22) were lost before the minimum study follow-up of 1 year (median 24 months [range 12 to 63]), leaving 64% (14 of 22) for analysis in this retrospective study. We treated 14 patients (14 elbows) with posttraumatic complex persistent elbow instability with an internal joint stabilizer and a standardized protocol that comprised debridement arthroplasty with ulnar neurolysis, restoration of bony and ligamentous (reattachment) structures, application of an internal joint stabilizer, and early rehabilitation. There were eight men and six women in this study, with a median (range) age of 44 years (21 to 68). The initial elbow fracture-dislocation injury pattern was a terrible triad injury in seven patients, a posterolateral rotatory injury in four patients, and a posterior Monteggia fracture in three patients. Preoperative and follow-up radiographs were reviewed for evidence of recurrent instability and arthritis. Complications such as wound infection, seroma, neurovascular injury, and hardware complications were ascertained through chart review. Preoperative and postoperative VAS score for pain, DASH, and Mayo Elbow Performance Scores (MEPS) were collected and compared. Furthermore, extension-flexion and supination-pronation arcs were collected by chart review. We divided the patients into two groups according to whether or not they developed posttraumatic arthritis. We then presented the differences between pain, disability, elbow performance, and ROM. The hinged internal joint stabilizer was removed using another open procedure under general anesthesia 6 to 8 weeks after surgery.

Results 

There were no recurrent instability during and after device removal. Seven patients developed complications, including wound infection, seroma, neurovascular injury, hardware complications, and heterotopic ossification. Two patients had complications related to internal joint stabilizers and three had complications linked to radial head prostheses. Median (range) preoperative to postoperative changes included decreased pain (VAS 5 [2 to 9] to 0 [0 to 3], difference of medians -5; p < 0.001), decreased disability (DASH 41 [16 to 66] to 7 [0 to 46], difference of medians -34; p < 0.001), improved function (MEPS 60 [25 to 70] to 95 [65 to 100], difference of medians 35; p < 0.001), improved extension-flexion arc (40° [10° to 70°] to 113° [75° to 140°], difference of medians 73°; p < 0.001), and supination-pronation arc (78° [30° to 165°] to 148° [70° to 175°], difference of medians 70°; p < 0.001). Between patients with and without development of post-traumatic arthritis, there were no differences in postoperative pain (VAS 0 [0 to 3] to 0 [0 to 1], difference of medians 0; p = 0.17), disability (DASH 7 [0 to 46] to 7 [0 to 18], difference of medians 0; p = 0.40), function (MEPS 80 [65 to 100] to 95 [75 to 100], difference of medians 15; p = 0.79), extension-flexion arc (105° [75° to 140°] to 115° [80° to 125°], difference of medians 10°; p = 0.40), and supination-pronation arc (155° [125° to 175°] to 135° [70° to 160°], difference of medians -20°; p < 0.18).

Conclusion 

In this small, retrospective study, we found that an internal joint stabilizer with a standardized treatment protocol could maintain concentric reduction while allowing early functional motion, and that it could improve clinical outcomes for patients with complex persistent elbow instability. However, patients must be counseled that the complications related to the radial head prostheses may occur, and that the benefits of early motion must compensate for an additional removal procedure and the risk of seroma formation.

Level of Evidence 

Level IV, therapeutic study.

中文翻译：

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内部关节稳定器和标准化协议是否可以防止复杂的持续性肘部不稳定性中的复发性不稳定性？

背景 

创伤后复杂的持续性肘关节不稳定的治疗具有挑战性。先前的治疗研究报告了不同的手术技术，这使得建立治疗算法变得困难。此外，即使使用额外的装置，外科手术也可能无法充分恢复肘部稳定性，并且关节炎进展率很高。虽然最近开发的内部关节稳定器可以有效治疗肘部不稳定，但其在复杂的持续性肘部不稳定中的临床应用受到限制，并且标准化协议没有得到很好的描述。此外，我们想知道关节炎的进展是否会对复杂的持续性肘关节不稳定的功能结果产生负面影响。

问题/目的 

(1) 使用铰接内关节稳定器和标准化方案治疗复杂的持续性肘关节不稳定是否可以预防复发性不稳定和其他并发症？(2) 疼痛、残疾、肘部功能和活动度方面术前术后有何改善？(3) 创伤后关节炎的发展是否与疼痛、残疾、肘部功能和活动度恶化有关？

方法 

2014年9月至2019年10月期间，我们治疗了22名在初次治疗外伤性肘部骨折脱位后出现持续性脱位或半脱位的患者。其中，我们认为年龄至少 20 岁、受伤（初始治疗）与在我们研究所进行的索引重建手术之间间隔 6 周或更长时间的患者可能符合资格。在那段时间里，我们使用了内部关节稳定器和标准化方案来治疗创伤后复杂的持续性肘部不稳定性。我们对 50 岁以上患有晚期肘关节炎的患者进行了全肘关节置换术。基于此，82%（22 名患者中的 18 名）符合资格；14%（22 人中的 3 人）因进行了全肘关节置换术而被排除，另外 5%（22 人中的 1 人）在最短研究随访 1 年（中位 24 个月 [范围 12 至 63]）之前丢失，留下64%（22 人中的 14 人）用于本回顾性研究中的分析。我们使用内部关节稳定器和标准化方案治疗了 14 名患有创伤后复杂持续性肘部不稳定的患者（14 个肘部），该方案包括清创关节置换术和尺神经松解术、骨和韧带（重新附着）结构的恢复、内部关节稳定器的应用以及早期关节置换术。复原。这项研究中有 8 名男性和 6 名女性，中位年龄（范围）为 44 岁（21 至 68 岁）。最初的肘部骨折脱位损伤类型为七名患者的可怕三联伤，四名患者的后外侧旋转损伤，以及三名患者的后孟氏骨折。检查术前和随访的X光片以寻找复发性不稳定性和关节炎的证据。通过图表审查确定了伤口感染、血清肿、神经血管损伤和硬件并发症等并发症。收集并比较术前和术后疼痛 VAS 评分、DASH 和 Mayo 肘部性能评分 (MEPS)。此外，通过图表审查收集了伸展-屈曲和旋后-旋前弧。我们根据患者是否患有创伤后关节炎将患者分为两组。然后我们介绍了疼痛、残疾、肘部功能和活动度之间的差异。术后 6 至 8 周，在全身麻醉下通过另一次开放手术移除铰接的内部关节稳定器。

结果 

在装置移除期间和之后没有反复出现不稳定。七名患者出现并发症，包括伤口感染、血清肿、神经血管损伤、硬件并发症和异位骨化。两名患者出现与内部关节稳定器相关的并发症，三名患者出现与桡骨头假体相关的并发症。术前至术后变化的中位数（范围）包括疼痛减轻（VAS 5 [2 至 9] 至 0 [0 至 3]，中位数差值 -5；p < 0.001）、残疾减少（DASH 41 [16 至 66] 至 7） [0 至 46]，中位数差 -34；p < 0.001），功能改善（MEPS 60 [25 至 70] 至 95 [65 至 100]，中位数差 35；p < 0.001），改善伸展-屈曲弧（40° [10° 至 70°] 至 113° [75° 至 140°]，中位差 73°；p < 0.001），以及旋后旋前弧（78° [30° 至 165°] 至 148°） [70° 至 175°]，中位数差 70°；p < 0.001）。在发生和未发生创伤后关节炎的患者之间，术后疼痛（VAS 0 [0 至 3] 至 0 [0 至 1]，中位数差异 0；p = 0.17）、残疾（DASH 7 [ 0 到 46] 到 7 [0 到 18]，中位数差 0；p = 0.40），函数（MEPS 80 [65 到 100] 到 95 [75 到 100]，中位数差 15；p = 0.79），扩展-屈曲弧（105° [75° 至 140°] 至 115° [80° 至 125°]，中线差 10°；p = 0.40），以及旋后旋前弧（155° [125° 至 175°]至 135° [70° 至 160°]，中值差 -20°；p < 0.18）。

结论 

在这项小型回顾性研究中，我们发现采用标准化治疗方案的内部关节稳定器可以保持同心复位，同时允许早期功能运动，并且可以改善复杂的持续性肘关节不稳定患者的临床结果。然而，必须告知患者可能会发生与桡骨头假体相关的并发症，并且早期活动的好处必须补偿额外的切除手术和血清形成的风险。

证据水平 

IV级，治疗研究。