Abstract
Objectives
Describing our initial experience of performing box-loop ligament reconstruction in patients with chronically unreduced elbow dislocation.
Design
Retrospective review.
Setting
One tertiary referral centre.
Patients/participants
Six patients treated with box-loop ligament reconstruction from 2015 to 2018 were included in this study.
Intervention
Box-loop ligament reconstruction.
Main outcome measurement
Quick disabilities of the arm, shoulder and hand (Q-DASH) and Mayo elbow performance index (MEPI) score.
Results
All subjects exhibited substantial increase of range of flexion-extension motion of the affected elbow, from a mean of 24.2° initially to 119.2° postoperatively during the follow-up period (median = 14 months, range 12–31 months). The subjects recorded an average MEPI score of 82.5 points, and average Q-DASH score of 16.2 points. There were no complications that occurred.
Conclusions
This is the first case series of patients with chronically unreduced elbow dislocation treated with box-loop ligament reconstruction. Using this technique, all subjects had excellent outcome without any complication. Further studies with larger samples and better methodology are required to investigate the safety and efficacy of such technique.
Keywords: Elbow dislocation, Chronically unreduced, Box-loop
1. Introduction
The elbow is the second most frequently dislocated major joints in adults, following the shoulder.1,2 In fact, its incidence amounted to 20% of all articular dislocations.3 In developed countries, most patients with elbow dislocation often seek treatment soon after initial injury; thus, the dislocation rarely persists for a long time.4 However, chronically unreduced elbow dislocation, defined as dislocation which is left unreduced for more than 3 weeks,3 is commonly found in developing countries as some patients initially seek help from local bonesetters and have their dislocations massaged and manipulated, which further aggravates the problem and results in delayed presentation.3,5
The treatment of chronically unreduced dislocation of the elbow remains a challenging problem for orthopaedic surgeons, even for the experienced ones. Various treatment modalities are available for this condition; however, they have are not without drawbacks, which include stiffness, recurrent instability, and/or dysfunction related to violation of the extensor mechanism.5 In 2015, Finkbone and colleagues6 described a “box-loop” ligament reconstruction technique for medial and lateral elbow instability. In this technique, the donor tendon is passed through humerus and ulna and tied back on itself, thereby creating one continuous loop. The authors have found that the technique is effective in restoring the stability of the elbow, with satisfactory results (mean follow-up: 64 months). Moreover, the surgery is fast and simple, requiring only one graft during the operation.6 Nevertheless, to our knowledge, there are no published reports regarding the application of this technique in those with chronically unreduced elbow dislocation. We present our initial experience of treating five patients diagnosed with chronically unreduced dislocation of the elbows with box-loop ligament reconstruction.
2. Patients and methods
This was a retrospective study comprising of all patients diagnosed with chronically unreduced elbow dislocation, whether simple or complex, who underwent box-loop ligament reconstruction in our center. As firstly described by Finkbone6 the surgical technique used a “box-loop” design, whereby the donor tendon is passed through the humerus and ulna and tied back on itself, creating a continuous loop.
Postoperatively, the subjects were placed in a removable posterior splint for 3 weeks, and then followed by active range of motion exercises 2 to 5 times daily. The subjects were asked to revisit our outpatient clinic and to complete both Mayo elbow performance index (MEPI) and quick disabilities of the arm, shoulder and hand (Q-DASH) questionnaires. Depending on MEPI scores, results were rated as excellent (90–100), good (75–89), fair (60–74), or poor (<60). For those who were unable to visit our outpatient clinic, they were also asked to send pictures of their elbow in both full extension and flexion (from a perfect side view) to had their range of motion determined.
3. Results
The characteristics of the subjects are presented in Table 1. Four (80%) subjects were male, and their mean age was 28.6 years old. The flexion-extension motion of the affected elbow was awfully limited, with a mean arc of only 24.2°. The average onset of injury, measured from the time of surgery, was 13.5 months.
Table 1.
Characteristics of the subjects.
| Case | Sex | Age | Side | Initial F/E Arc | Onset of injury | Accompanying diagnosis | Concomitant surgery | Source of tendon autograft |
|---|---|---|---|---|---|---|---|---|
| 1 | Male | 22 | Left | 20–30° | 12 months | Fracture of olecranon process, malunion of intercondylar humerus | Interposition arthroplasty | Palmaris longus |
| 2 | Male | 28 | Right | 20–40° | 2 months | Fracture of coronoid process | None | Semitendinosus |
| Left | 30–60° | 11 months | Fracture of proximal shaft of ulna, coronoid process, and radial head | ORIF plate and screw, radial head replacement | Semitendinosus | |||
| 3 | Female | 42 | Right | 10–45° | 48 months | Fracture of olecranon process, radial head | Radial head excision | Semitendinosus |
| 4 | Male | 32 | Left | 0–40° | 4 months | None | None | Palmaris longus |
| 5 | Male | 19 | Left | 20–30° | 4 months | Fracture of olecranon process, coronoid process | None | Palmaris longus |
The first patient of our series suffered from concomitant fracture of olecranon process and malunion of intercondylar humerus. He was splinted by a traditional bonesetter in full extension for 3 months, and then gradually exercised his elbow, although quite limited and painful. Intraoperatively, the joint surface was found to be severely arthritic with extensive erosion of articular cartilage and early formation of marginal osteophytes. After complete release of surrounding fibrotic tissue, the elbow joint was highly unstable; however, the ulnohumeral axis was preserved and the articulating motion was concentric. Therefore, we decided to perform boxloop ligament reconstruction to provide elbow stability, in addition to interpositional arthroplasty using fascia lata in attempt to provide smooth gliding motion of the joint.
The second patient fell from the stairs, landed heavily on both his elbows. Refusing any medical treatment, the patient initially visited a bonesetter who splinted both of the patient's elbow in slight flexion. Two months later, the patient decided to visit orthopaedic subspecialty clinic at our centre, obtained radiographs (Fig. 1), and found that he dislocated both of his elbows. In addition to chronic dislocation, his right elbow also sustained from coronoid process fracture. On the left side, the patient fractured the proximal ulnar shaft, coronoid process, and radial head. Initially, the patient underwent open reduction and box-loop ligament reconstruction for his right elbow. At the same time for his left elbow, the proximal shaft of the ulna was fixated with a plate. Moreover, since the radial head was severely comminuted, it was excised and replaced temporarily with carefully-molded bone cement. Nine months later, the right elbow regained function satisfyingly (Fig. 2); however, the patient complained left elbow instability. The plate and temporary replacement for radial head were removed, and the elbow was reconstructed using box-loop technique.
Fig. 1.
Serial radiographs of Case 2. Preoperative X-ray and CT images of right elbow (A, B) showing chronic elbow dislocation with coronoid process fracture. The patient then underwent open reduction and box-loop ligamentous reconstruction; a semitendinosus tendon graft was used (C). The patient also sustained from fracture of proximal ulnar shaft, coronoid process, and radial head along with chronically unreduced dislocation of the left elbow (D, E). We performed open reduction, plating, and temporary radial head replacement on the left elbow (F). A year later, union was achieved, and the plate and temporary radial head were removed; then, the elbow was reconstructed by using semitendinosus tendon graft.
Fig. 2.
Clinical results of Case 2. During the last follow-up, the patient demonstrated flexion-extension arc of 40°–150° and 30°–140° in the right and left elbow, respectively. The patient could lift a 1.5 kg chair one-handedly with both of his hands.
The third patient suffered from chronic dislocation of right elbow along with fracture of olecranon process, corodoid process, and radial head. She was involved in a motor vehicle accident 48 months beforehand. Being reluctant to seek help from medical department, she visited a bonesetter and had her elbow splinted in extension for two months. Gradually, she was able to move her joint. However, at the time she visited our center, she had a limited range of elbow motion, with pain in the ends of flexion and extension. Intraoperatively, we found severe comminution of the radial head, with moderately-sized cartilage defect on several areas of articulating surface, mainly the capitellum. Meanwhile, the articular cartilage on both the olecranon and trochlea was still preserved. She underwent open reduction, excision of radial head fragment, and box-loop ligament reconstruction.
The fourth patient suffered from a simple elbow dislocation, without any concomitant fracture, four months before admission. He was treated with open reduction and box-loop reconstruction.
The fifth patient of the series presented with left elbow dislocation, accompanied by fracture of olecranon and coronoid process. He was involved in a motor vehicle accident four months before admission. Intraoperatively, the ulnohumeral joint was severely unstable, and we performed with boxloop ligament reconstruction.
From a total of six elbows in the series, three elbows were reconstructed using palmaris longus, and the other three were reconstructed using semitendinosus tendon autograft.
The patients were followed up for a median of 14 months. There was substantial increase of range of flexion-extension motion of the affected elbows, from a mean of 24.2° initially to 119.2° postoperatively. The subjects recorded an average MEPI score of 82.5 points, and average Q-DASH score of 16.2 points (Table 2).
Table 2.
Study outcome.
| Case | Initial F/E Arc | Final F/E Arc | MEPI | Q-DASH | Follow-up |
|---|---|---|---|---|---|
| 1 | 20–30° (10°) | 45°–145° (100°) | 75 | 27 | 12 months |
| 2 | 20–40° (20°) | 40°–150° (110°) | 80 | 14 | 31 months |
| 30–60° (30°) | 30°–140° (110°) | 80 | 20 | 21 months | |
| 3 | 10–45° (35°) | 5°–140° (135°) | 90 | 11 | 12 months |
| 4 | 0–40° (30°) | 0°–140° (140°) | 90 | 9 | 15 months |
| 5 | 20–30° (10°) | 30°–150° (120°) | 80 | 16 | 13 months |
4. Discussion
The main goal of treatment for chronically unreduced elbow dislocation is to restore a stable, concentric joint and regain a satisfactory arc of motion. Due to the apparently conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, the treatment of chronic elbow dislocation remains a challenge for trauma surgeons. The standard treatment of these dislocations consists of open reduction, v-y-muscleplasty of the triceps and temporary arthrodesis and/or cast immobilisation. However, prolonged postoperative immobilisation may result in elbow stiffness, which significantly limits the upper extremity range of motion.1
The box-loop technique, initially described by Finkbone and colleagues,6 is a less invasive method which reconstructs the entire collateral ligament complex, using only one circumferential tendon graft rather than reconstructing the ligaments individually. Moreover, such technique allows early motion of the joint without any need for periods of immobilisation. Two studies have performed this technique in chronic elbow instability, and it is found to be a safe and effective technique.6,7 In this series, we describe our experience in treating patients with chronically unreduced elbow dislocation using box-loop ligament reconstruction. To our knowledge, this is the first report of patients with such conditions undergoing box-loop reconstruction.
In this study, four (80%) subjects underwent gross destabilisation of their elbow. These subjects not only sustained from ligament injury that dislocated the complex joint structure but also complex fracture affecting intercondylar humerus, olecranon process, coronoid process, radial head, proximal ulna, or combination of some. For these elbows, the necessity to recreate the stability while performing functional range of motion is a difficult task to achieve. We thought that both temporary fixation and hinged external fixation could not provide true joint stability and function in the long term, since theoretically it mainly depends on fibrotic tissue formation around the joint. Thus, from our considerations, ligament reconstruction was probably the best option to provide a stable concentric joint while regaining a satisfactory arc of motion. In an in vitro study, Hackl et al.8 found that box-loop reconstruction provided elbow joint stability similar to that of lateral collateral ligament reconstruction technique. Moreover, they found that this technique had an excellent biomechanical profile with respect to graft stiffness. In a recent prospective study of 27 subjects with complex elbow stability, Vicenti et al.7 found that the subjects had increased range of movement, and the whole joint stability was not compromised. These findings were in line with our study, in which all subjects had significant improvement of range-extension motion of the affected elbows during the follow-up period (median = 14 months, 12–31 months). Moreover, no subjects developed complications.
In this study, we used palmaris longus for three elbows. For ligamentous reconstruction, a palmaris longus is commonly used. Other autografts used include the gracilis, semitendinosus, patella, Achilles, plantaris, toe extensor, and extensor carpi radialis longus tendons.9 In the other three elbows, we used semitendinosus grafts. The reason behind choosing these tendons over palmaris longus tendons was the subjects had small palmaris longus tendons, which make them unideal as autografts.
Our study is limited by the small number of subjects. However, our findings confirm the data reported by Finkbone et al.6 and Vicenti et al.,7 which found satisfactory short-term outcomes of box-loop reconstruction. Further studies with larger samples and longer follow-up are required to better investigate the efficacy and safety of this technique.
5. Conclusion
The box-loop technique provides a quick and simple option to treat chronically unreduced elbow dislocation. This technique also allows early joint motion and return to function while providing adequate stability, with functional outcome from our study reported to be excellent. Further studies with larger samples and longer follow-up regarding the use of this technique in patients with chronically unreduced elbow dislocations are required to better investigate the efficacy and safety of such procedure.
Conflicts of interest
None declared.
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