Garg Parag, Baid Prashant, Sinha Shivam, Ranjan Rajeev, Bandyopadhyay Utpal, Mitra S
Department of Orthopaedics, IPGMER, Kolkata, India.
Indian J Orthop. 2011 Sep;45(5):404-9. doi: 10.4103/0019-5413.83946.
The dislocated radial head in missed Monteggia fracture loses its concave articular surface and displays hypertrophic changes and flattened humeral capitellum configuration, thereby limiting the range of motion. We evaluated the results of open reduction in missed Monteggia fractures by various techniques.
Sixty-three missed Monteggia fractures were included in the analysis. We performed four combinations of operation: Group I: 22 patients treated with modified Hirayama ulnar osteotomy plus annular ligament reconstruction with free Palmaris longus grafting; Group II:18 patients treated with modified Hirayama ulnar osteotomy plus annular ligament reconstruction by the Bell Tawse's procedure; Group III-9: patients treated with only modified Hirayama's osteotomy; and Group IV: 14 patients treated with transverse osteotomy of ulna and annular ligament reconstruction by the Bell Tawse's procedure. During followup these cases were assessed for the following parameters: 1) range of motion and 2) mayo elbow performance index (MEPI). Results were noted on follow ups at 3, 6, 12 months and then on yearly basis. Sixty-three patients were followed up for an average duration of 5.6 years (range 3-8 years).
The mean range of motion was increased by 45°, 30°, 45°, 20° for Group I, II, III and IV respectively. The average increase in MEPI scores was also almost on the same lines. There was one case of frank dislocation in group III and six cases of subluxation, two each in Groups II, III, and IV. For Annular ligament reconstruction, amongst two procedures, Groups II and IV (Bell Tawse group), had a significant extension lag contributing to the lower increase in the range of motion as compared to the Palmaris longus reconstruction group (group I).
Hirayama's osteotomy is inherently more stable than the simple transverse osteotomy and it should be combined with annular ligament reconstruction. Palmaris longus graft for ligament reconstruction provides more stability as compare to Bell Towse's procedure.
孟氏骨折漏诊后桡骨头脱位会失去其凹形关节面，出现肥大性改变及肱骨小头形态变平，从而限制活动范围。我们评估了采用各种技术对漏诊的孟氏骨折进行切开复位的结果。
分析纳入63例漏诊的孟氏骨折。我们实施了四种手术组合：第一组：22例患者接受改良平山尺骨截骨术加游离掌长肌腱移植重建环状韧带；第二组：18例患者接受改良平山尺骨截骨术加贝尔 - 陶斯法重建环状韧带；第三组：9例患者仅接受改良平山截骨术；第四组：14例患者接受尺骨横截骨术加贝尔 - 陶斯法重建环状韧带。随访期间，对这些病例评估以下参数：1）活动范围；2）梅奥肘关节功能指数（MEPI）。在3、6、12个月随访时记录结果，之后每年记录一次。63例患者平均随访5.6年（范围3 - 8年）。
第一、二、三、四组的平均活动范围分别增加了45°、30°、45°、20°。MEPI评分的平均增加幅度也大致相同。第三组有1例完全脱位，第二、三、四组各有6例半脱位，每组2例。对于环状韧带重建，在两种手术方法中，第二组和第四组（贝尔 - 陶斯组）与掌长肌腱重建组（第一组）相比，存在明显的伸直滞后，导致活动范围增加幅度较小。
平山截骨术本质上比单纯的横截骨术更稳定，应与环状韧带重建相结合。与贝尔 - 陶斯手术相比，掌长肌腱移植重建韧带提供了更高的稳定性。
