Successful Treatment of Chronic Monteggia Fracture-dislocations in Children---A New Reference

BackgroundGreat difficulty and more failures were the descriptions of a chronic Monteggia fracture-dislocation. The treatment of chronic Monteggia lesion remains controversial and challenging for surgeons. This study aims to introduce our experience of a new reference in the treatment of chronic Monteggia fracture-dislocation in children and evaluate outcomes from clinical and radiographic findings.MethodsWe retrospectively reviewed 18 children who underwent surgical treatment because of chronic Monteggia lesion. Electronic medical records of clinical data, radiographic parameters, and operative details, were reviewed for study analysis. Parameters were compared at the time of pre-operation and the last follow-up. The relationship of lengthening and angulation of ulnar was calculated.ResultsMean interval time was 11.1 ± 15.7 months and follow-up time was 34.6 ± 23.7 months in this study. A congruent radiocapitellar reduction was observed in 15 (83.3%) patients, while 2 (11.1%) patients developed subluxation, and 1 (5.6%) patient had redislocation. The mean posterior bending angle was 12.88° (range, 3 to 25°), and the mean amount of elongation of the ulnar was 8.78 mm (range, 3.6 to 17.5 mm). The lengthening was significantly proportional to the magnitude of angulation of ulnar in good outcome patients (r = 0.637, p = 0.009), and the index was larger than the failed ones. Postoperatively, the Kim scores were obviously improved, from 59.17 ± 18.17 to 90 ± 6.64.ConclusionsWe highlight the ulnar osteotomy as the essential procedure during the reconstruction surgeries. Enough elongation and balanced angulation of the osteotomy is warranted to keep satisfactory outcomes. The ulnar should be lengthened to more than normal proportional ulnar length to stable the radial head reduction. Iliac crest autograft is recommended to avoid nonunion of ulnar osteotomy after enough lengthening.Level of evidenceLevel IV; Case Series; Treatment Study

Ulnar osteotomy is the only required procedure for chronic monteggia fracture in children.

Objective: To determine containment of radial head after ulnar osteotomy in chronic Monteggia fractures. Study Design: Retrospective study. Setting: Children Hospital and The Institute of Child Health, Lahore. Period: 2019 to January 2020. Material & Methods: Ten patients presented in outdoor patient department with a diagnosis of chronic Monteggia fracture. Four patients were labelled as missed Monteggia fractures, four with late presented Monteggia fractures and two with inadequately treated Monteggia fractures. Bado and Letts classifications were applied for patients. Mean age was 6 years and 8 months and ranged from 4 to 10 years. Mean time interval between injury and admission was 6.1 months. Open reduction of radial head and ulnar osteotomy was done through Boyed approach. Transcapitellar wire was inserted temporarily and then removed so it is not required permanently. The ulnar osteotomy was angulated opposite to the direction of radial head dislocation and fixed with plate and screws. Results: 10 patients were included in this study. The age range was between 4 and 10 years. The study period was six months and follow up was one year. Mean ulnar angulation at osteotomy site was 21.3° (16-25°). Mean ulnar lengthening at osteotomy site was 0.85 cm (0.5-1.8 cm).Improvement in flexion-extension was 20.3%, pronation was 5.1% and supination was 13.7%. Complications included were nounion in 1 case and cubitus valgus in 1 case. Conclusion: Containment of radial head is obtained by open reduction of radial head and with ulnar osteotomy in chronic Monteggia fractures. Annular ligament reconstruction and transcapitellar wire insertion are not required if proper angulation and fixation of ulnar osteotomy is performed. No age limit for this procedure but surgery should be performed before radial head deformation.

Treatment of Radius Curvus in a Young Dog with Association of Radial Physeal Stapling, Ulnar Ostectomy and Transarticular Dynamic External Fixator Techniques

Background: Radius curvus is a clinical manifestation of the premature closure of the distal ulnar physis and the most common physeal disease in dogs, representing 63% of all physeal injuries. There are few reports indicating the technique of stapling for treatment of radius curvus in squeletically immature dogs. The aim of this study is to report a case of radius curvus in a young dog successfully treated with a combination of 3 surgical tecniques: 1- Stapling the medial and cranial portions of the distal radial physis; 2- Oblique osteotomy of the proximal ulna and ostectomy of the distal ulna, and 3- Dynamic external skeletal fixation in the elbow joint.Case: A 5-month-old female dog was referred to the University Veterinary Hospital with a history of left thoracic limb deformity for 2 weeks. There was a history of possible traumatic event on the front limb, in addition to providing nutritional supplements daily. In the radiographic evaluation the changes were identified in the left thoracic limb: shortening of the ulna, procurvatum and medial angulation of the distal radius, increased joint space and articular incongruity of the elbow joint. The dog was subjected to surgical treatment by the combination of three main surgical techniques. For the stapling of the distal radial physis the surgical approach on the cranial-medial surface of the distal radius was made. Two surgical staples were positioned in the distal radial physis. Thereafter a caudal approach was made to the distal region of the ulnar diaphysis for the distal ostectomy of the ulna. A bone segment of 1 cm in length of the distal ulnar diaphysis was removed. Another caudal approach was made to the proximal region of the ulnar diaphysis and a proximal oblique osteotomy of the ulna was performed. For the dynamic external skeletal fixation in the elbow joint two Steinmann pins were inserted. The first pin was proximal to the supracondilar foramen of the humerus and the second pin was caudal to the trochlear notch of the ulna, both parallel to the joint surface. To create a dynamic system, the pin tips were connected with elastic rubber bands on the medial and lateral sides of the elbow joint. Clinical and radiographic revaluation were made at 15, 30 and 60 days after surgery. Total correction of the limb deviation was achieved at 60 days postoperative. Two years after the surgical procedure, the owner was contacted and reported that the dog was very well and with no change in the operated limb.Discussion: The most common cause of premature closure of the distal ulnar physis is trauma. Due to the proper conical shape of the distal ulnar physis, there is more predisposition to the compression of the germinative cells in traumatic events, leading to radius curvus disease. Another cause of the radius curvus is the nutritional disbalances. In the reported case the patient had both predisponent factors, although unilateral limb involvement suggested trauma with primary causative agent. The treatment included the interruption of the supplementation of the diet associated with surgical techniques. The stapling of the distal radial physis is usually indicated for mild angular valgus deviation. In the current case the technique was applied with success regardless of the higher grade of radial deviation. Generally, the ulnar ostectomy is preferred to the osteotomy, since it reduces the rate of ulnar osteosynthesis, ensuring that the restrictive effect of the ulna upon the radial growth does not restart. In the reported case the ulnar ostectomy was associated with ulnar osteotomy to achieve a more effective result. Furthermore, the proximal ulnar osteotomy is usually indicated when elbow subluxation is present. In the current case the joint congruence was improved with the use of the dynamic external skeletal fixator.

Influence of Ulnar Bow Sign on Surgical Treatment of Missed Bado Type I Monteggia Fracture in Children

PurposeThe present study aimed to explore the influence of ulnar bow on the surgical treatment of Bado type I missed Monteggia fracture in children.MethodsThis study is a retrospective review of 24 patients between November 2010 and March 2019. All patients were treated with open reduction of the radial head and ulnar opening wedge osteotomy without annular ligament reconstruction. The mean interval between injury onset and surgery was five months (range: 2–12 months). The average age of participants at the time of surgery was 6.4 years (range: 3–10 years). We evaluated the maximum ulnar bow (MUB) and MUB position (P-MUB) via radiography. The patients were divided into middle group (group A: 14 cases, MUB located at 40% to 60% of the distal ulna) and distal group (group B: 10 cases, MUB located at 20% to 40% from the distal end of the ulna) based on P-MUB. The mean period of follow-up was 37 months (range: 6–102 months).ResultsAt the last follow-up, all the children showed stable reduction of the radial head, and the flexion function of elbow joint improved after operation (P<0.05). Group A presented a larger the ratio of maximum ulnar bow(R-MUB) and angle of ulnar osteotomy(OA) than group B (P<0.05). There was statistically significant difference between group A and Group B in the P-MUB (P < 0.05). The osteotomy angle was positively correlated with the R-MUB (R2 =0.497,P=0.013), The osteotomy angle was positively correlated with the P-MUB (R2=0.731,P=0.000), The R-MUB is proportional to the P-MUB (R2 =0.597,P=0.002). The regression equation of P-MUB and osteotomy angle: Angle=7.064+33.227* P-MUB (R2=0.459, P =0.000).ConclusionWhen the ulnar bow is positioned at the middle ulna, a stable reduction of radial head need to be achieved through a larger angle in the ulnar osteotomy. If the position of maximum ulnar bow (P-MUB) is closer to the middle of the ulna or the ratio of maximum ulnar bow (R-MUB) is larger, the osteotomy angle is larger.

Mid- to Long-Term Outcome after Arthroscopy and Proximal Abducting Ulnar Osteotomy Versus Arthroscopy Alone in Dogs with Medial Compartment Disease: Thirty Cases

Objective The aim of this study was to determine owner-assessed mid- to long-term outcome for dogs with medial compartment disease treated arthroscopically with fragment removal with or without proximal abducting ulnar osteotomy (PAUL). Study Design This was a retrospective clinical study. Materials and Methods Records from 30 dogs with medial compartment disease treated with arthroscopy with or without PAUL were retrospectively reviewed over a 5-year period. Proximal abducting ulnar osteotomy cases were matched to arthroscopy-alone controls based on bodyweight and modified Outerbridge score. Outcome was assessed via owner questionnaire using the Canine Brief Pain Inventory (CBPI), frequency of non-steroidal anti-inflammatory drug (NSAID) administration and owner-assessed overall improvement. Results Canine Brief Pain Inventory score for dogs in the PAUL group was not significantly different from the control group (p = 0.54). Non-steroidal anti-inflammatory drug administration was similar between groups (p = 0.61) and there was no significant difference between modified Outerbridge score and outcome (p = 0.57) over a median of 43 months post-surgically (range: 7–66 months). Canine Brief Pain Inventory and NSAID use were affected by the age of the dog with dogs greater than 3 years of age at the time of surgery having a higher CBPI score and increased NSAID use regardless of the surgery that was performed. Overall, owner-assessed improvement was not different between groups (p = 0.72). Clinical Significance Proximal abducting ulnar osteotomy showed no owner-assessed benefit over arthroscopic medial coronoid fragment removal for dogs with medial compartment disease and modified Outerbridge score of 3 or greater. A prospective, blinded, controlled clinical trial is warranted to determine the appropriate clinical application of the PAUL procedure.

Distal Metaphyseal Osteotomy Allows for Greater Ulnar Shortening Compared to Diaphyseal Osteotomy for Ulnar Impaction Syndrome: A Biomechanical Study

Purpose To compare the biomechanical characteristics between diaphyseal and metaphyseal ulnar-shortening osteotomy with respect to (1) maximal shortening achieved at each osteotomy site and (2) force required to achieve shortening at each site. Methods Nine fresh frozen cadaveric upper extremities were affixed through the proximal ulna to a wooden surgical board. A metaphyseal 20-mm bone wedge was resected from the distal ulna and sequential shortening was performed. A load cell was attached to a distal post that was clamped to the surgical board and used to measure the force required for each sequential 5-mm of shortening until maximal shortening was achieved. The resected bone was reinserted, and plate fixation was used to restore normal anatomy. A 20-mm diaphyseal osteotomy was performed, and force measurements were recorded in the same manner with (1) interosseous membrane intact, (2) central band released, and (3) extensive interosseous membrane and muscular attachments released. Results Metaphyseal osteotomy allowed greater maximal shortening than diaphyseal osteotomy with the interosseous membrane intact and with central band release but similar shortening when extensive interosseous membrane and muscle release was performed. Force at maximal shortening was similar between metaphyseal and diaphyseal osteotomy. Sequential soft tissue release at the diaphysis allowed for increased shortening with slightly decreased shortening force with sequential release. Conclusion Metaphyseal ulnar osteotomy allows greater maximal shortening but requires similar force compared with diaphyseal osteotomy. Sequential release of the interosseous membrane permits increased shortening at the diaphysis but requires extensive soft tissue release. Clinical Relevance Both sites of osteotomy can achieve sufficient shortening to decompress the ulnocarpal joint for most cases of ulnar impaction syndrome. The greater shortening from metaphyseal ulnar osteotomy may be reserved for severe cases of shortening, especially after distal radius malunion or in the setting of distal radius growth arrest in the pediatric population. Level of Evidence This is a Level V, basic science study.