Greiner Stefan, Voss Andreas, Soler Anna, Bhayana Himanshu
Department of Trauma Surgery, University Medical Centre, Regensburg, Germany.
Sporthopaedicum Regensburg, Regensburg, Germany.
Arch Orthop Trauma Surg. 2024 Dec 18;145(1):62. doi: 10.1007/s00402-024-05722-7.
Varus posteromedial rotatory instability (VPMRI) involves anteromedial coronoid fracture (AMCF), lateral ulnar collateral ligament (LUCL), and medial collateral ligament (MCL) injury. There is no general consensus regarding the surgical treatment, but most surgeons recommend internal fixation of the coronoid along with primary ligament repair. This methodology involves postoperative immobilization to allow ligament healing, occasionally associated with stiffness. Augmentation of one/or both collateral ligaments using a non-absorbable suture tape as an internal brace in VPMRI cases was the subject of the presented study. This method allows brace-free initiation of full elbow range of motion while protecting bony and soft tissue healing.
17 patients (13 males and four females) with VPMRI were treated in the center from 2017 to 2021 with internal brace augmentation of collateral ligament along with ORIF (Open reduction & internal fixation)/ reconstruction of the coronoid fragment. All patients were actively mobilized early after surgery. Patients who completed a minimum follow up of 24 months were included in the study. Clinical examination findings at follow-up assessment included ROM (range of motion) recording and instability testing, including special instability tests such as moving valgus stress test, lateral pivot shift test, Posterolateral rotatory drawer test, and gravity-assisted varus stress test. Disabilities of arm, shoulder and hand (DASH) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Visual Analogue Score (VAS), and SEV (Simple Elbow values) were assessed and noted at follow-up.
At 43 months of mean follow-up, none of the patients had significant postoperative contracture, and none had any clinically apparent signs of instability or suffered subluxation or re-dislocation. Postoperative radiographs showed complete fracture/graft healing with no signs of subluxation in all patients. The mean range of motion of the patients was 6.2 (1.0-11.3) to 139.1 (136.2-142.0), with a mean Oxford elbow score (OES) of 42.0 (39.9-44.7). The mean DASH (Disability of Arm, Shoulder & Hand) score was 11.4 (6.7-16.1), the mean MEPS (Mayo Elbow Performance Score) was 91.2 (86.3-96.0), the mean Visual Analogue Score (VAS) score was 0.6 (0.1-1.2), and the mean Simple Elbow value (SEV) was 85.4% (81.1-89.8%).
Internal brace augmentation with a non-absorbable suture tape in the setting of VPMRI is a safe and helpful adjunct to coronoid repair/reconstruction and primary ligament repair and allows early mobilization and recovery of elbow stability and range of motion.
内翻后内侧旋转不稳定（VPMRI）涉及前内侧冠突骨折（AMCF）、尺侧副韧带（LUCL）和内侧副韧带（MCL）损伤。关于手术治疗尚无普遍共识，但大多数外科医生建议对冠突进行内固定并同时进行韧带一期修复。这种方法需要术后制动以促进韧带愈合，偶尔会导致关节僵硬。本研究的主题是在VPMRI病例中使用不可吸收缝线带对一条或两条侧副韧带进行增强，作为一种内部支撑。这种方法可在保护骨和软组织愈合的同时，无需制动即可开始全肘关节活动范围的训练。
2017年至2021年期间，该中心对17例VPMRI患者进行了治疗，采用侧副韧带内部支撑增强术并同时进行冠突骨折切开复位内固定（ORIF）/重建。所有患者术后均早期积极进行活动。纳入研究的患者为至少随访24个月者。随访评估时的临床检查结果包括记录活动范围（ROM）和进行不稳定测试，包括特殊的不稳定测试，如移动性外翻应力试验、外侧轴移试验、后外侧旋转抽屉试验和重力辅助内翻应力试验。在随访时评估并记录上肢、肩部和手部功能障碍（DASH）评分、梅奥肘关节功能评分（MEPS）、牛津肘关节评分（OES）、视觉模拟评分（VAS）和简单肘关节值（SEV）。
平均随访43个月时，所有患者均无明显的术后挛缩，也没有任何临床明显的不稳定迹象，未发生半脱位或再脱位。术后X线片显示所有患者骨折/植骨均完全愈合，无半脱位迹象。患者的平均活动范围为6.2（1.0 - 11.3）至139.1（136.2 - 142.0），平均牛津肘关节评分（OES）为42.0（39.9 - 44.7）。平均DASH（上肢、肩部和手部功能障碍）评分为11.4（6.7 - 16.1），平均MEPS（梅奥肘关节功能评分）为91.2（86.3 - 96.0），平均视觉模拟评分（VAS）为0.6（0.1 - 1.2），平均简单肘关节值（SEV）为85.4%（81.1 - 89.8%）。
在VPMRI情况下，使用不可吸收缝线带进行内部支撑增强术是冠突修复/重建和韧带一期修复的一种安全且有用的辅助方法，可使肘关节早期活动并恢复稳定性和活动范围。
