THE ALGORITHM OF TREATMENT OF PATIENTS WITH HUMERORADIAL JOINT INJURY.
Clinical Medicosurgical Center,
Omsk State Medical University, Omsk, Russia
Humeroradial joint injuries account for approximately 4 % of all fractures, more than 50 % of all fractures of the proximal forearm, and more than 30 % of fractures with combinations of ulnar bone fractures with injuries to LCL-complex and the annular ligament [1-3]. The epidemiology of fractures of the head and the neck of the radial bone and eminentia capitate varies within the range from 25 to 39 per 100,000 adult persons per year, with approximately even gender and mean age (40 years) distribution [1, 3]. About 10 % of such injuries are accompanied by dislocations, instability of the forearm and other fractures [3]. About a half of cases is fractures of the femoral neck. The incidence increases with the age, with decreasing rate of complicated fractures [1, 3].
The indications for surgical treatment of a stable isolated fracture are quite disputable, because there are some well-known long term results of conservative treatment. There are some problems in treatment of non-stable fractures, i.e. estimation of indications and choice of a technique for internal fixation or primary endoprosthetics, diagnostics, or a method for reconstruction of the ligamentous apparatus, choice between primary total resection or removal of a fragment of the femoral head, a problem of choice of design of a prosthetic implant in case of primary radial head replacement [4]. As a rule, the main aim of surgical treatment of unstable fractures is reconstruction of stability in the ulnar joint, prevention of dislocation or subdislocation in the ulnar joint and provision of a possibility for early functional load to the ulnar joint [5].
The objective of the study – to improve the results of treatment of patients with injuries to the humeroradial joint area.
The task of the study included the development of the individual model of radial head endoprosthesis (the utility patent for the radial head endoprosthesis No.40147) and the treatment algorithm of the injuries in the region of the humeroradial joint for practical traumatology and orthopedics).
MATERIALS AND METHODS
In our study we analyzed the results of treatment of 107 patients with the injuries in the region of the humeroradial joint. The patients received the surgical treatment in the department of traumatology and orthopedics No.1, Clinical Medicosurgical Center, in 2007-2014. The group distribution of the patients with injuries to the proximal department of the radial bone was conducted with the classification by Mason-Johnston. The patients with the fractures of eminentia capitate were distributed in concordance with the classification by Bryan-Morray. Moreover, our study reviews the results of the treatment of the patients with primary resection of the radial head and subsequent replacement.
All patients received the surgical intervention. The fixation of the head and the neck of the radial bone was conducted for 16 patients from the group of Mason-Johnston II, for 36 patients from the group of Mason-Johnston 3 and for 6 patients from the group of Mason-Johnston 4. Also the fixation was performed for all 18 patients with fractures of eminentia capitate. Primary replacement of the radial head was conducted for 13 patients in the group of Mason-Johnston 2, for 3 patients in the group of Mason-Johnston 4 and for 8 patients with primary resection of the radial head.
The individual group (7 persons) included the patients with the comminuted fractures of the radial head (Mason-Johnston 3 and 4) in the combination with the fractures of the proximal ulnar bone, who received the primary individual endoprosthetics of the radial head (besides ulnar bone fixation) for restoration of stability in the ulnar joint.
The clinical analysis of the long term results of the surgical treatment was conducted after 12 months from the moment of surgery. The estimation of the outcomes was conducted with the own estimation list. The list was used for registration of the passport data, diagnosis, the date of the injury, the date of surgery, the way of surgical treatment, the long term results of the surgical treatment according to Mayo (Mayo Elbow Performance Index), as well as for the data of rotation movements in the humeroradial bone.
For registration of the results we used the descriptive statistics and its non-parametrical values. The median was used as a mean value (P 50). The quartiles P 25 and P 75 were selected for the borders of the statistical standard. The minimal and maximal values were indicated. For comparison of the groups we used the non-parametrical criteria. The comparison of 2 groups was realized with Mann-Whitney test, 3 groups and more – with Kruskal-Wallis test. The calculations and construction of the charts were realized with Statistica 10.0. The p value of 0.05 was considered as statistically significant.
The study was approved by the ethical committee of Omsk State Medical Academy. It was conducted with adherence to ICH GCP E6 and the requirements of Helsinki Declare, and in concordance with GOST R 52379-2005.The informed consent for preparation of personal data was received from each patient.
RESULTS AND DISCUSSION
In our study we observed the long term results of surgical treatment of 27 men and 80 women (age of 17-72).
Depending on the types of the injuries, the patients were distributed into the following groups: fractures of the head and the neck of the radial bone of type 2 according to Mason-Johnston – 16 (men – 5, women – 11), type 3 according to Mason-Johnston – 49 (men – 11, women – 38), type 4 according to Mason-Johnston – 9 (men – 1, women – 8). In the group with fractures of eminentia capitate the distribution of the patients was as follows: Bryan-Morray 1 – 6 (men – 2, women – 4), Bryan-Morray 2 – 8 (men – 3, women – 5), Bryan-Morray 3 – 4 (men – 1, women – 3). The group with primary resection of the radial head included 8 patients (3 men, 5 women).
The group with the fractures of type 2 according to Mason-Johnston showed mainly excellent long term results of osteosynthesis (95-100 points according to MEPI). The results were estimated as good in two cases (MEPI = 85) and satisfactory in one case. The group of the patients with the fractures of type 3 according to Mason-Johnston showed 15 excellent outcomes (MEPI ≥ 90), 14 good outcomes (MEPI = 75-89) and 5 unfavorable outcomes (MEPI < 60). The group of the patients with the fractures of type 4 according to mason-Johnson did not show any excellent results of osteosynthesis, but the good outcomes were noted in 2 cases, satisfactory one – in 1 case, unfavorable ones – in 3 cases (Fig. 1).
Figure 1
Comparison of long term results of fixation (MEPI, points) in the groups of the patients with fractures of head and neck of the radial bone of Mason-JohnstonII-IV type (p = 0.00…)
The figure 2 shows the excellent (MEPI = 95-100) long term outcomes in 9 patients with the fractures of type 3 according to Mason-Johnston, good (MEPI = 85) outcomes in 3 patients, the unfavorable (MEPI = 45) result in on case with aseptic instability of the prosthesis stem. In the group of primary endoprosthetics for the patients with fractures of type 4 according to Mason-Johnston the excellent (1 patient) and good (2 patients) results were noted (Fig. 2).
Figure 2
Comparison of long term results of primary endoprosthetics (MEPI, points) in the groups of the patients with fractures of head and neck of the radial bone of Mason-JohnstonIII-IV type(p = 0.00…)
The patients with fractures of eminentia capitate (Bryan-Morray types 1 and 2) showed mainly excellent and good long term results of osteosynthesis. In 2 patients with fractures of eminentia capitate (Bryan-Morray type 2) the long term results of the surgical treatment were estimated as unfavorable. The outcome of osteosynthesis was aseptic necrosis of eminentia capitate in 3 patients (MEPI < 55). It required the recurrent surgery for decreasing the intensity of pain syndrome – removal of the implants, resection of eminentia capitate; the good result was achieved only in one case (MEPI = 75) (Fig. 3).
Figure 3
Comparison of long term results of osteosynthesis (MEPI, points) in the groups of the patients with fractures of capitellum of Bryan-MorrayI-III type (p = 0.00…)
All results were estimated as unsatisfactory in the patients with primary resection of the radial head after visiting the clinic for clarification of the indications for endoprosthetics. One year after radial head replacement the excellent long term results were received in 5 patients, good ones – in 3 (Fig. 4).
Figure 4
Comparison of long term results (MEPI, points) of primary resection and subsequent endoprosthetics of the radial head (p = 0.00…)
Primary radial head replacement with use of the individual model showed the similar results in all 7 cases as compared with single-block prosthesis (Fig. 5). The excellent (4 patients with MEPI = 90-100) and good (3 patients with MEPI = 80-85) long term results of the surgical treatment were achieved (Fig. 5).
Figure 5
Comparison of long term results (MEPI, points) of endoprosthetics of the radial head with use of the model of individual endoprosthetics and monoblock endoprosthesis (p = 0.00…)
The analysis of the long term results of osteosynthesis in the group of Mason-Johnston types 3 and 4 showed the excellent and good results of the surgical treatment in those cases when the radial head was presented as not more than 3 big fragments without significant impression of articular surface. The unsatisfactory results were identified in the attempt of fixation of comminuted impression fractures of the radial head. However 7 of 8 cases of the failed attempts were excellent (2 patients) and good (5 patients).
The unsatisfactory outcome of endoprosthetics in one of 8 patients was associated with the incorrect choice of a method for fixing the endoprosthesis. Primary endoprosthetics of the radial head in unstable fractures of Mason-Johnston types 3-4, as well as use of the model of the individual endoprosthesis of the radial head, show mainly the excellent and good results of the surgical treatment. In the early postsurgical period we observed the radiological signs of aseptic loosening of the prosthetic stem (cementless fixation). The subsequent recurrent endoprosthetics with cement fixation of the prosthetic stem showed the good long term results of the surgical treatment (MEPI = 85).
The analysis of the long term results of the surgical treatment of injuries to the humeroradial joint allowed developing the algorithm for individual treatment with the following steps (Fig. 6).
Figure 6. The algoritm of individual treatment of injuries to the humeroradial joint
CONCLUSION
1. The excellent and good results of the surgical treatment of fractures of the head and the neck of the radius of Mason-Johnston type 2 were achieved with the technique of stable osteosynthesis.
2. The surgical treatment of fractures of the head and the neck of the radius of Mason-Johnston type 3 and 4 should consider the qualitative and the quantitative values of the fracture: excellent and good long term results of the surgical treatment with choice of osteosynthesis are expected only in the case when the radial head is presented with not more than 3 big fragments with absent impression of articular surface; for comminuted and impression fractures the method of choice should be primary endoprosthetics.
3. Treatment of patients with unstable fractures of the head and the neck of the radius of Mason-Johnston type 3-4 in combination with fractures of the proximal ulnar bone is associated with excellent and good long term results of the surgical treatment which are achieved with the model of the individual endoprosthesis of the radial head, and these results are comparable with use of single-block prosthetic devices. However the rate of survival of this model as the final endoprosthesis requires further observation.
4. Primary resection of the radial head shows mainly bad long term outcomes of the surgical treatment and should not be considered as a method of choice.
5. Fixation of fractures of eminentia capitate of Bryan-Morray types 1 and 2 shows mainly good and excellent long term results. The attempts of fixation of the fractures of Bryan-Morray type 3 show the unsatisfactory results and possibly require the primary endoprosthetics of eminentia capitate./