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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 126-130

Acute ulnar osteotomy versus gradual distraction by external fixator to correct missed monteggia type 1 fracture-dislocation; A comparative study


Department of Orthopedics, Unit of Limb Reconstruction and Pediatric Orthopedics, Tanta School of Medicine, Tanta University, Tanta, Egypt

Date of Submission23-Sep-2020
Date of Decision11-Dec-2020
Date of Acceptance14-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Abdelhakim Ezzat Marei
Department of Orthopedics, Unit of Limb Reconstruction and Pediatric Orthopedics, Tanta School of Medicine, Tanta University, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3719.305864

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  Abstract 


Background: Monteggia fracture-dislocations are complex injuries. These injuries, especially neglected ones, remain a challenge for orthopedic surgeons. The aim of this study is to compare the results of acute and gradual ulnar lengthening osteotomies in treating chronic Monteggia fractures in children. Patients and Methods: The study includes two groups of patients, treated at our institution in the period from April 2014 to September 2018. The first group (Group A) included nine patients who were treated by an overcorrective ulnar osteotomy with acute lengthening with bone grafting. The second group (B) includes 11 children who were treated by Ilizarov distraction osteogenesis for differential lengthening of forearm bones. There were 14 boys and 6 girls. The left elbow was involved in five patients and the right elbow 15 patients. All fractures were classified as Bado type I with anterior radial head dislocation. The average age at the time of surgery was 7 years and 4 months. Results: The mean interval from the injury to surgical interference was 8.6 months. There was a significant improvement of the elbow range of motion and Mayo elbow performance score. In group B, the mean external fixation time was 9.7 weeks (range from 9 to 15 weeks). The mean total treatment time was 12.3 weeks (ranged from 12 to 16 weeks). Superficial pin-tract infection occurred in all cases and was managed without further sequelae. Conclusions: Both approaches yielded equally good results. The open surgery approach entails a more invasive procedure, but more convenient to the patient and no arduous postoperative follow-up is needed. On the contrary, differential lengthening of forearm bones is a percutaneous procedure with the application of Ilizarov principles in a controlled biological manner; with no graft materials needed. Both techniques effectively reduced the radial head.

Keywords: Ilizarov, missed Monteggia fracture, reconstruction, ulnar osteotomy


How to cite this article:
Marei AE, El-Rosasy MA. Acute ulnar osteotomy versus gradual distraction by external fixator to correct missed monteggia type 1 fracture-dislocation; A comparative study. J Limb Lengthen Reconstr 2020;6:126-30

How to cite this URL:
Marei AE, El-Rosasy MA. Acute ulnar osteotomy versus gradual distraction by external fixator to correct missed monteggia type 1 fracture-dislocation; A comparative study. J Limb Lengthen Reconstr [serial online] 2020 [cited 2021 Apr 13];6:126-30. Available from: https://www.jlimblengthrecon.org/text.asp?2020/6/2/126/305864




  Introduction Top


Monteggia fracture-dislocations are complex injuries usually comprising fractures of the ulna associated with radiocapitellar dislocation and proximal radioulnar joint dissociation. These rare injuries constitute <1% of all forearm fractures in children. They occur mostly between 4 and 10 years of age.[1] These injuries, especially neglected ones, remain a challenge for orthopedic surgeons. Diagnosis is frequently missed in up to 33% of cases. After 4 weeks, the condition can be called “chronic Monteggia.” Neglected cases usually develop malunion of the ulnar fracture and soft-tissue contractures of the proximal radioulnar and radiocapitellar joints, making reduction difficult.[2] Missed Monteggia lesions can lead to valgus deformity of the elbow, chronic pain and disability, limitation of elbow flexion and forearm rotation, overgrowth of the radial head, and tardy ulnar neuritis.[3]

Missed or chronic Monteggia lesions are not uncommon. This may be attributed to the lack of experience or diagnostic skills. Successful treatment of those types of injuries is achieved by the restoration of a normal alignment of the ulna to obtain a concentric reduction of the radial head.[4]

Treatment of chronic Monteggia lesions remains challenging and numerous procedures were introduced, e.g., ulnar osteotomy, open reduction of the radial head dislocation with or without annular ligament reconstruction. Differential lengthening of the ulna through a proximal ulnar osteotomy, so that the radial head is gradually reduced without open surgery is another approach. The aim of this study is to compare the outcome of both techniques, investigate their merits and shortcomings, and when to use either.


  Patients and Methods Top


This is a retrospective study of 20 cases of missed Monteggia fracture-dislocation treated in our department in the period from April 2012 to September 2016. Our series included 14 boys and 6 girls. The right elbow was involved in nine patients, and the left elbow was involved in the remaining 11 patients. All the injuries were classified as Bado type I.

The average age at the time of operative interference was 9 years (range 5 years to 13 years and 7 months). The average time interval between the traumatic incident and the surgery was 8.7 months (range 2–18 months). One child presented with posterior interosseous nerve palsy. All the patients had limitation of elbow flexion before surgery with a mean Mayo elbow performance score of 75.5.[5]

Nine patients (Group A) underwent overcorrective osteotomy of the ulna with acute lengthening, plate fixation, and iliac bone grafting. All those patients had open reduction of the dislocated radial head. A long arm cast was applied till osteotomy healing.

11 patients (Group B) underwent gradual correction of the deformed ulna by means of the circular external fixator. The ulna was lengthened with gradually increasing the posterior apex of the osteotomy. The dislocated radial head was gradually reduced to its original positioned without the need for open reduction. The frame was removed after the consolidation of the regeneration. The choice of either technique was done randomly after a detailed discussion with the parents about the merits, difficulties, and complications of each method.

Patients were followed clinically and radiographically. Physiotherapy was advised. The Mayo elbow performance score was used to assess the postoperative function at the final follow-up. Patients were categorized as excellent (>90), good (89–75), fair (74–60), and poor (<60). [Table 1] summarizes the preoperative data separately in both groups.
Table 1: Preoperative data

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Technique of overcorrective osteotomy

After the administration of general anesthesia, and under tourniquet, the proximal ulnar shaft was exposed through a longitudinal incision placed directly on the subcutaneous border. The incision was extended proximally above the olecranon by approximately 2 cm. The lateral skin flap was elevated to expose the Kocher interval (interval between the anconeus and the extensor carpi ulnaris) which was used to expose the radiocapitellar articulation. The ulnar osteotomy was done at the healed fracture site or approximately 2.5 cm from the coronoid process in cases with plastic deformation. The radiocapitellar joint was carefully debrided from any interposed tissue that could prevent the reduction of the radial head. The osteotomy was manipulated till a concentric radiocapitellar reduction was obtained. The position that could maintain joint reduction was at approximately 1 cm of lengthening with an apex dorsal and slightly ulnar. A small reconstruction plate was contoured with a dorsal-ulnar apex. The distraction of the osteotomy site was done by a lamina spreader. The plate was applied and radiocapitellar reduction was assessed in various positions using fluoroscopy. Iliac bone graft was harvested and added to the osteotomy site. Soft tissue was closed tightly over the joint without annular ligament reconstruction. If there are remnants of the annular ligament, they were re-approximated over the radial head or sutured to the ulnar periosteum by 2-0 or 3-0 nonabsorbable sutures. A freer elevator was used to reduce the annular ligament over the radial head. Wounds were closed and an above elbow splint was applied that was changed to a long arm cast on the 3rd day.

Technique of gradual correction by circular fixator

Under general anesthesia and no tourniquet was used, a preconstructed Ilizarov frame was applied to the forearm. The frame was formed of a proximal half ring and distal full ring connected by two hinges. The axis of the hinges was located at the level of ulnar osteotomy in the coronal plane to allow dorsal angulation of the lengthened ulnar osteotomy site. The frame was fixed proximally by two 4-mm half pins inserted into the proximal ulna in a posterior to anterior direction and attached to the proximal half ring. The distal fixation consists of two 4-mm half pins inserted into the ulnar diaphysis and attached to the full ring. To maintain the distal radio-ulnar relationship, one half pin was inserted into the radius diaphysis, with the forearm in full supination, and this pin was attached to the distal full ring. [Figure 1] shows the final assembly of the fixator. A percutaneous osteotomy, using multiple drill holes and osteotome, was then performed in the proximal ulnar metaphysis 1 cm distal to the coronoid process. The ulnar osteotomy was axially distracted after 7 days at a rate of 1 mm per day until the radius head is seen pulled down well-below the capitellum. Then, angular distraction was performed to produce posterior angulation of the proximal ulna pushing the radius head gradually to the position in line with capitellum. The frame was tightened and left in place until radiological consolidation of the ulnar osteotomy [Figure 2]. The radial half pin was first removed to allow pro-supination movements. After full consolidation, the frame was removed and above elbow cast was applied in pronation and 100° flexion for 4 weeks to avoid stress fractures at pin-sites. After which physiotherapy and rehabilitation were conducted.
Figure 1: Final assembly of the circular fixator prior to ulnar osteotomy

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Figure 2: Final consolidation of the bone regenerate at the site of ulnar lengthening. Notice the angulation at the osteotomy site and the concentric reduction of the radiocapitellar joint

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Statistical analysis

The comparisons between the two groups were analyzed using the Mann–Whitney test for continuous variables and Fisher's exact test for categorical variables. P < 0.05 was set as the cutoff for the level of significance. SPSS 17.0 SPSS Inc., 233 South Wacker Drive, Chicago, USA IL 60606-6412 was used for statistical analysis.


  Results Top


The mean follow-up of the patients was 17 months (range 12–24 months). The mean time for the union in cases treated by overcorrective ulnar osteotomy was 2.7 months [Figure 3]. For cases managed by circular fixator, the mean time needed for full consolidation of the regenerate was 3.8 months. Pin-tract infection was reported in all patients treated by circular fixators and managed conservatively with local care and systemic antibiotics. On the last follow-up, the range of movement in all cases showed significant improvement compared to the preoperative range. The Mayo score improved significantly in both groups. The mean Mayo score in group A was 94.4 and that for group B was 95 at the final follow-up. There was a nonsignificant difference between Mayo elbow performance score between the two groups (P = 0.97). [Table 2] summarizes the postoperative data at the final follow-up in both groups.
Figure 3: (a and b) preoperative radiographs of a case of neglected Bado type 1 Monteggia fracture dislocation. (c and d) Postoperative radiographs of the same case 3 months after acute over-corrective osteotomy and bone grafting, showing concentric reduction of the radiocapitellar join

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Table 2: Postoperative date at the final follow-up

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One child treated presented, preoperatively, with a missed Monteggia fracture-dislocation and posterior interosseous nerve palsy. We performed external neurolysis at the time of overcorrective osteotomy. Electromyography at 3 months after neurolysis showed no recovery potentials. Hence, tendon transfer was conducted. The patient did not have a palmaris longus, so the flexor digitorum superficialis of the fourth digit was transferred to the extensor pollicis longus, and the flexor carpi radialis was transferred to the extensor digitorum communis. [Figure 4] shows the final range of motion of this case.
Figure 4: Final range of motion of a case suffering from posterior interosseus nerve palsy. The patient was treated by acute over-corrective ulnar osteotomy and lengthening. Three months later the patient underwent tendon transfer. (a and b) supination, pronation range, (c)fingers and thumb extension after tendon transfer

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  Discussion Top


Missed or chronic Monteggia lesions are not uncommon. This may be attributed to the lack of experience or diagnostic skills. Successful treatment of those types of injuries is achieved by the restoration of a normal alignment of the ulna to obtain a concentric reduction of the radial head.[4] In neglected or chronic Monteggia lesions, the annular ligament is usually avulsed or entrapped preventing concentric reduction.[6]

After aligning the ulnar fracture in acute cases, the radial head usually reduces with a palpable clunk. This should be monitored fluoroscopically. Feeling a rubbery resistance may suggest soft-tissue interposition that can be the periosteum or annular ligament.[7]

The interval between the anconeus and the extensor carpi ulnaris (Kocher interval) provides an adequate exposure of the radiocapitellar articulation.[8] Another approach that is more extensile was introduced by Boyd.[9] Keeping the forearm pronated during the exposure helps protect the posterior interosseous nerve. Anterior, Henry's approach to the radiocapitellar articulation was also described as a method of reduction, with better exposure of the nerve, that also facilitates neurolysis, when needed. Synostosis was reported in some series with Boyd's and Kocher's approach. However, both approaches facilitate annular ligament reconstruction.[10]

Numerous procedures were introduced to treat chronic Monteggia injuries, e.g., ulnar osteotomy, open reduction of the radial head dislocation with or without annular ligament reconstruction, radial osteotomy, and radial head excision at the end of the growth.[11]

Chronic lesions may be complicated by progressive valgus deformity of the elbow, restricted motion, especially forearm rotation and elbow flexion, overgrowth and early physeal closure of the radial head, and late ulnar nerve palsies.[12] Early diagnosis and treatment are fundamental to reduce these sequelae. However, there are still some complications reported after surgical treatment of such cases, including elbow stiffness or instability, nonunion or malunion of the osteotomies, growth disturbance or avascular necrosis of the radial head, nerve injury, infection, and degenerative arthritis.[13]

Although reconstruction and joint relocation provide the best results,[14] Hirayama et al. recommended avoiding joint reduction in neglected cases with deformation of the radial head or capitellum. A normal concave radial head articular surface and normal shape and contour of capitellum are important prerequisites for reduction.[15] Reduction after more than 3 years was also reported to increase the incidence of complications.[16]

Restoration of the alignment of the ulnar shaft is the most crucial step to achieve a concentric reduction. Many authors recommend concurrent reconstruction of the annular ligament in conjugation with ulnar osteotomy.[17] But in our series, we did not find this important. Reconstruction of the annular ligament remains controversial. Annular ligament reconstruction may, however, increase the incidence of elbow stiffness, heterotopic ossification, radio-ulnar synostosis, or avascular necrosis of the radial head.[18] Plate fixation provides a sufficient stability for the lengthened and angulated ulna. Bone grafting of the osteotomy site was done in the overcorrective osteotomy group. This has been supported in a number of series.[13]

Lammens et al., first described the principles of gradual ulnar lengthening and angulation using Ilizarov external fixator to reconstruct the elbow.[19] This was followed by several case reports with satisfactory outcomes.[20] To the best of our knowledge, there are no studies comparing between acute ulnar overcorrective osteotomy and gradual correction by distraction osteogenesis.

The incidence of radial nerve injury with Monteggia lesions is approximately 10%–20%, making it the most common complication. Nerve recovery is the role in most cases, usually by the 3rd month. Neurolysis through a separate anterolateral approach was required in some series to restore nerve function.[21]

Regarding our study, the small sample sizes in both groups remain, however, an important limitation.


  Conclusions Top


The open surgery is preferred in cases necessitating exposure of the radial head, e.g., heterotopic ossification requiring open excision and posterior interosseous nerve palsy which needs nerve exploration. The differential lengthening approach is best suited for chronically dislocated radius head with excessive proximal migration. The choice of either technique is based on the preoperative requirements of each case and detailed discussion with the parents or caregivers regarding the merits and difficulties of each method and the expected outcomes.

Ethical approval

The authors declare that all investigations were conducted in conformity with ethical standards. Informed consent for participation in the study was obtained from the parents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Babb A, Carlson WO. Monteggia fractures: Beware! S D J Med 2005;58:283-5.  Back to cited text no. 1
    
2.
David-West KS, Wilson NI, Sherlock DA, Bennet GC. Missed monteggia injuries. Injury 2005;36:1206-9.  Back to cited text no. 2
    
3.
Kim HT, Conjares JN, Suh JT, Yoo CI. Chronic radial head dislocation in children, Part 1: Pathologic changes preventing stable reduction and surgical correction. J Pediatr Orthop 2002;22:583-90.  Back to cited text no. 3
    
4.
Rahbek O, Deutch SR, Kold S, Søjbjerg JO, Møller-Madsen B. Long-term outcome after ulnar osteotomy for missed Monteggia fracture dislocation in children. J Child Orthop 2011;5:449-57.  Back to cited text no. 4
    
5.
Morrey BF, An KN. Functional evaluation of the elbow. In: Morrey BF, editor. The Elbow and its Disorders. 3rd ed. Philadelphia: WB Saunders; 2000. p. 82.  Back to cited text no. 5
    
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Tan JW, Mu MZ, Liao GJ, Li JM. Pathology of the annular ligament in paediatric Monteggia fractures. Injury 2008;39:451-5.  Back to cited text no. 6
    
7.
Tompkins DG. The anterior Monteggia fracture: Observations on etiology and treatment. J Bone Joint Surg Am 1971;53:1109-14.  Back to cited text no. 7
    
8.
Park H, Park KW, Park KB, Kim HW, Eom NK, Lee DH. Impact of open reduction on surgical strategies for missed monteggia fracture in children. Yonsei Med J 2017;58:829-36.  Back to cited text no. 8
    
9.
Boyd HB. Surgical exposure of the ulna and proximal one third of the radius through one incision. Surg Gynecol Obstet 1940;71:86-8.  Back to cited text no. 9
    
10.
Wang MN, Chang WN. Chronic posttraumatic anterior dislocation of the radial head in children: thirteen cases treated by open reduction, ulnar osteotomy, and annular ligament reconstruction through a Boyd incision. J Orthop Trauma 2006;20:1-5.  Back to cited text no. 10
    
11.
Di Gennaro GL, Martinelli A, Bettuzzi C, Antonioli D, Rotini R. Outcomes after surgical treatment of missed Monteggia fractures in children. Musculoskelet Surg 2015;99 Suppl 1:S75-82.  Back to cited text no. 11
    
12.
Holst-Nielson F, Jensen V. Tardy posterior interosseus nerve palsy as a result of an unreduced radial head dislocation in Monteggia fractures: A report of two cases. J Hand Surg Am 1984;9:572-5.  Back to cited text no. 12
    
13.
Hasler CC, Von Laer L, Hell AK. Open reduction, ulnar osteotomy and external fixation for chronic anterior dislocation of the head of the radius. J Bone Joint Surg Br 2005;87:88-94.  Back to cited text no. 13
    
14.
Fowles JV, Sliman N, Kassah MT. The Monteggia lesion in children. Fracture of the ulna and dislocation of the radial head. J Bone Joint Surg Am 1983;65:1276-82.  Back to cited text no. 14
    
15.
Hirayama T, Takemitsu Y, Yagihara K, Mikita A. Operation for chronic dislocation of the radial head in children. Reduction by osteotomy of the ulna. J Bone Joint Surg Br 1987;69:639-42.  Back to cited text no. 15
    
16.
Nakamura K, Hirachi K, Uchiyama S, Takahara M, Minami A, Imaeda T, et al. Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children. J Bone Joint Surg Am 2009;91:1394-404.  Back to cited text no. 16
    
17.
Hui JH, Sulaiman AR, Lee HC, Lam KS, Lee EH. Open reduction and annular ligament reconstruction with fascia of the forearm in chronic monteggia lesions in children. J Pediatr Orthop 2005;25:501-6.  Back to cited text no. 17
    
18.
Oner FC, Diepstraten AF. Treatment of chronic post-traumatic dislocation of the radial head in children. J Bone Joint Surg Br 1993;75:577-81.  Back to cited text no. 18
    
19.
Lammens J, Mukherjee A, Van Eygen P, Fabry G. Forearm realignment with elbow reconstruction using the Ilizarov fixator. A case report. J Bone Joint Surg Br 1991;73:412-4.  Back to cited text no. 19
    
20.
Exner GU. Missed chronic anterior Monteggia lesion. Closed reduction by gradual lengthening and angulation of the ulna. J Bone Joint Surg Br 2001;83:547-50.  Back to cited text no. 20
    
21.
Spinner M, Freundlich BD, Teicher J. Posterior interosseous nerve palsy as a complication of Monteggia fracture in children. Clin Orthop Relat Res 1968;58:141-5.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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