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1602 M. Abdul Azeem et al.](https://image.slidesharecdn.com/piis1058274622002695-indocap-230703063217-f43e379e/85/Post-traumatic-radioulnar-synostosis-8-320.jpg)
Post-traumatic radioulnar synostosis
- 1. Post-traumatic radioulnar synostosis: a retrospective case series of 10 patients in Kuwait Mokhtar Abdul Azeem, MD, PhDa,b,c , Khalifa Alhojailan, MDd , Mohammad Awad, MDd , Aliaa F. Khaja, MBChB(Hons), KB-ORTHOc, * a Faculty of Medicine, Al-Azhar University Hospital, Cairo, Egypt b Faculty of Medicine, Kuwait University Hospital, Kuwait City, Kuwait c Orthopedic Trauma Department, Al-Razi Orthopedic Hospital, Kuwait City, Kuwait d Department of Orthopaedic Surgery, Al-Razi Orthopedic Hospital, Kuwait City, Kuwait Background: The development of radioulnar synostosis due to post-traumatic injuries of the elbow or forearm can lead to debilitating outcomes. Several treatment options are available to hinder the progression and prevent recurrence. We used a combination of these treatments in a series of patients and observed the outcomes. Methods: We conducted a retrospective study of 10 patients with post-traumatic radioulnar synostosis (9 men and 1 woman) who required surgical intervention in a tertiary orthopedic center. All of these patients were subjected to the same treatment combination (preoperative radiotherapy, tissue interposition after heterotopic ossification resection, and adjuvant indomethacin postoperatively). Improvement in range of motion (flexion, extension, and rotation) and the Mayo score was assessed and compared preoperatively and postoperatively via statistical analysis. Results: In comparison to the patients’ preoperative state, which ranged from poor to fair, all 10 patients reported excellent Mayo scores after intervention with the triple therapy combination, with a mean Mayo score of 36 10.2 points. Flexion, extension, and rota- tion improved by mean values of 55.2 38.7 , 50.2 34.0 , and 47.9 40.0 , respectively. There was 1 complication that has subsided on follow-up. Conclusion: The triple therapy combination was found to provide good functional and prophylactic results preventing recurrence. Level of evidence: Level IV; Case Series; Treatment Study Ó 2022 The Author(s). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/). Keywords: Radioulnar; synostosis; post-traumatic; elbow; hypertrophic ossification; stiffness Radioulnar synostosis is an undesired and uncommon complication of traumatic forearm and elbow fractures, with an occurrence rate that ranges from 1.2% to 6.2%.1,26 It is a type of heterotopic ossification (HO) in which the ulna and radius are connected, which leads to restriction of range of motion and overall disability if left untreated.1-3 It may occur in different parts of the forearm and elbow depending on several risk factors including, but not limited Institutional review board approval was not required for this study. Ethical approval was obtained from the Kuwait Ministry of Health (no. 2019/ 1176). *Reprint requests: Aliaa F. Khaja, MBChB(Hons), KB-ORTHO, Or- thopedic Trauma Department, Adult Deformity and Reconstruction Department, Al-Razi Orthopedic Hospital, PO Box 4235, Safat Code 1343, Kuwait. E-mail address: [email protected] (A.F. Khaja). J Shoulder Elbow Surg (2022) 31, 1595–1602 www.elsevier.com/locate/ymse 1058-2746/Ó 2022 The Author(s). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.jse.2022.01.151
- 2. to, extensive soft-tissue injury, head injury, fracture comminution, Monteggia-type fracture, and delay of sur- gical management.1,4,5 Patients with range-of-motion lim- itation benefit greatly from surgical resection, whereas those with a preserved arc of motion can be managed conservatively.6-8 A caveat to surgical resection, however, is the high recurrence rate of radioulnar synostosis; hence, surgeons have investigated multiple preventive measures as a means to avoid the need for revision surgical procedures in the future.9-12 Multiple treatment modalities have been reported in the literature to prevent recurrence of radioulnar synostosis after surgical resection. These include the use of adjuvant indomethacin, radiation therapy, and interposition flaps such as adipose tissue, anconeus, or tensor fascia lata.13-15 Some authors have even suggested the combination of all 3 modalities to achieve better results.16-18 The main aim of this study was to report on cases that underwent surgery with a combination of prophylactic tri- ple therapy to confirm that the results are consistently excellent and in keeping with the experiences shared by other centers. Materials and methods Data extraction We performed a retrospective evaluation of a total of 10 patients with a diagnosis of post-traumatic HO of the elbow in Kuwait’s only tertiary orthopedic center, Al-Razi Hospital. The following data were recorded: patient demographic characteristics, presence of HO risk factors (ie, head injury), fracture type (ie, open vs. closed), mechanism of injury, neurologic examination findings, time from injury to intervention, need for secondary surgery (if applicable), location of HO according to the Viola and Hastings classification system,8 treatment modalities used, complications, and follow-up (Table I). The Mayo score was recorded preoper- atively and postoperatively for each patient. All patients under- went a standard elbow rehabilitation protocol. Therapeutic intervention All patients received the same triple therapy combination. A single radiation dose of 800 cGy was administered on the day of the intervention prior to the surgical procedure. Surgical resection was performed to closely restore the anatomy of the radius and ulna, followed by the insertion of an anconeus interposition flap. Adjuvant indomethacin was given postoperatively at a dosage of 25 mg orally 3 times daily for a period of 2 weeks. Surgical procedure The surgical procedure was performed with the patient under general anesthesia in the supine position. A tourniquet was used, and the arm was positioned against the chest and stabilized by an assistant. The surgical planes were dependent on the anatomic location of the synostosis. For diaphyseal radioulnar synostosis, the interval between the flexor carpi ulnaris and extensor carpi ulnaris muscles was used to expose the ulna via a volar Henry approach. For proximally positioned radioulnar synostosis, a posterior approach was performed using a lateral window (Kocher or Kaplan interval) and a medial window (trans–flexor carpi ulnaris) to access both sides. This was particularly helpful to address extensive HO (type IIIC) and to perform ulnar nerve exploration. An arthroscopic-assisted approach was used in 1 case; an arthroscopic release was performed for the anterior capsule, medial compartment, and lateral compartment using the anterior and anterolateral portals. This resulted in an incomplete resection of the HO; thus, a Kocher interval was used to complete the resection. The anconeus interposition flap was then mobilized distally to proximally. The fascia of the flap was attached to the margin of the triceps. The distal portion of the flap was inserted between the proximal part of the radius and ulna and then tied to the proximal part of the radius via drill holes. The range of motion of the forearm was examined with gentle manipulation. This helped to ensure that the maximum range of motion of the forearm was achievable. The tourniquet was then released. Hemostasis was secured preceding deep and superficial closure with a single suction drain embedded in the deepest layer. All surgical pro- cedures were performed by the same surgeon (M.A.A.). The surgical approaches used were individualized per the location of the radioulnar synostosis for optimal results. An example of preoperative and postoperative surgical resection and fixation performed in a study participant is shown in Figure 1. Statistical analysis Data were stratified per individual patient case. Continuous vari- ables were analyzed with Wilcoxon and Mann-Whitney U tests. Categorical data were stratified via the c2 test. Statistical analysis was performed using RStudio software, version 3.6.2 (Boston, MA, USA). Results Patient demographic characteristics Overall, 10 patients were surgically treated in this study, comprising 9 men and 1 woman. The mean age of the patients was 35.5 years (range, 21-58 years). All patients were followed up for 24-36 months postoperatively. Preoperative presentation None of the patients experienced any head injury prior to presentation. The fracture type was predominantly closed (7 of 10), with only 3 patients having open fractures. Regarding neurologic injuries, only 1 patient presented with radial nerve palsy whereas the rest had intact neuro- logic examination findings. Regarding the mechanism of 1596 M. Abdul Azeem et al.
- 3. Table I Detailed characteristics of patients including demographic information, clinical presentation, management, and follow-up Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 Age, yr 21 58 34 25 31 41 33 32 27 52 Sex Male Male Male Male Male Male Male Male Male Female Head injury No No No No No No No No No No Fracture type Open Closed Closed Closed Closed Closed Open Closed Open Closed Neurologic examination Radial nerve palsy Intact Intact Intact Intact Intact Intact Intact Intact Intact Mechanism of injury Motor vehicle accident Fall from height Fall on left elbow Fall from height Fall from height Fall from height Fall from height Fall on right elbow Motor vehicle accident Fall on right elbow Injuries Upper limb open, left midshaft humeral fracture, radial nerve palsy, nondisplaced right tibial plateau fracture Right terrible triad injury with dislocation Left distal humeral comminuted intercondylar fracture Left elbow terrible triad injury with dislocation Right elbow terrible triad injury Right elbow dislocation, nondisplaced radial head fracture, left distal radius fracture Right elbow terrible triad injury, distal one-third of ulna and comminuted open distal radius fracture with disruption of distal radial ulnar joint Right radial head fracture Left ulnar open comminuted fracture, radial head fracture Right elbow terrible triad injury Management of injury Henry approach, ORIF of dorsal ulna (DCP for ulna, LCDCP for radius) Posterior approach; ORIF of radial head; repair of MCL, LCL, and coronoid with pullout suture; hinged external fixation owing to continued instability (extensive soft- tissue violation) Boyd approach, olecranon osteotomy, 2 locked plates Kocher approach, ORIF of ulna using LCDCP, ORIF of terrible triad injury with pullout suture for coronoid, fixation of radial head Kocher approach, fixation of radial head by screws, fixation of coronoid fracture by pullout suture, repair of LCL by pullout suture to lateral epicondyle Kaplan approach, ORIF using proximal radial plate LCP, AES 4 stages* Nonoperative management D ebridement, external fixation, skin traction Reduction of radial head by LC, repair of MCL plus pullout suture in anterior capsule Time from injury to intervention, d 15 15 9 12 5 0 0 d 14 5 Secondary surgical procedures None External fixation removal and manipulation under GA None Compartment syndrome on POD 1, fasciotomy performed; wound closure performed on POD 5 Direct posterior approach, lateral window, anconeus flap harvest, removal of HO from anterior and posterior lateral sides HO resection, anconeus flap interposition, radial head plate removal Removal of plate and screws, except for 2 screws at head; exploration of ulnar nerve (which was compressed under medial epicondyle); release until intermuscular septum proximally Arthroscopic and open removal of HO Arthroscopic: release of anterior capsule and medial and lateral compartments through anterior and anterolateral portal; large osteophyte could Kocher approach to remove radioulnar synostosis and anterior osteophyte, application of bone wax Intraoperative ROM showed extension of 170 , flexion of 70 , and full Removal of HO through lateral and medial incision, exploration of ulnar nerve (continued on next page) Post-traumatic radioulnar synostosis: case series 1597
- 4. Table I Detailed characteristics of patients including demographic information, clinical presentation, management, and follow-up (continued) Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 not be removed by arthroscopy Open: posterior approach, medial window, exploration of ulnar nerve (intact) supination/ pronation Dorsomedial approach, bone excision on anterior and posteromedial sides, application of bone wax, anconeus flap procedure Location of HO: Viola and Hastings classification Type II Type IIIC Type IIIC Type IIIC Type IIIC Type IIIC Type IIIC Type IIIC Type IIIC Type IIIC Radiation dose and duration Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Single dose, 800 cGy Resection and interposition HO excision, hardware removal, anconeus interposition flap Posterior approach, removal of metal in radial neck, HO resection, exploration of ulnar nerve, anconeus interposition flap Posterior incision, HO resection, anconeus interposition flap, bone wax Removal of HO, repair of LCL, removal of 2 screws from radial head, anconeus interposition flap HO excision, hardware removal, anconeus interposition flap HO resection, anconeus flap interposition, radial head plate removal Medial widow through flexor pronator, partial release from common flexor, excision of HO in this area, removal of large bone blocking flexion on anteromedial side plus removal of posteromedial HO, lateral window of posterior approach used to remove HO posteriorly and anteriorly plus radioulnar joint HO excision, anconeus interposition flap HO excision, hardware removal, anconeus interposition flap HO excision, hardware removal, anconeus interposition flap Indomethacin dose and duration 25 mg TDS for 2 weeks 25 mg TDS for 2 weeks 25 mg TDS for 2 weeks 25 mg TDS for 2 weeks 25 mg TDS for 30 d 25 mg TDS for 2 weeks 25 mg TDS for 2 weeks 25 mg TDS for 2 weeks 25 mg TDS for 2 weeks 25 mg TDS for 2 weeks Postoperative physiotherapy Started on POD 2: CPM then active and active assisted for 3 Started on POD 10: active and active assisted for 3 weeks, passive Started POD 3: CPM then active and active assisted for 3 weeks, Started on POD 2: CPM then active and active assisted for 3 Started on POD 21 (delayed because patient was on a backslab. and Started on POD 2: CPM then active and active assisted for 3 Started on POD 1 (delayed because patient was on a backslab. and had Started on POD 3: CPM then active and active assisted for 3 Started on POD 2: continued for 74 d Started on POD 1: continued for 75 d (2 d on inpatient basis 1598 M. Abdul Azeem et al.
- 5. injury, injury due to a fall from a height was most common (5 of 10), followed by a fall onto the elbow (3 of 10) and a motor vehicle accident (2 of 10). The most common injury pattern was a terrible triad injury of the elbow (5 of 10 patients), in addition to other concomitant injuries due to polytrauma, such as fractures of the humerus (distal, mid- shaft, and intercondylar), distal radius, tibial plateau, ulna, and radial head. The mean time from injury to surgical intervention on initial presentation was 8.3 days (range, 0-15 days). Of the 10 patients, only 1 was treated non- operatively. A full description of each injury pattern is presented in Table I. The HO location was predominantly type IIIC (9 of 10), whereas 1 patient had a type II location. The HO types and subtypes are depicted in Table II. Treatment All patients were given adjuvant indomethacin at a dosage of 25 mg orally 3 times daily for a mean of 14.2 days (range, 3-30 days), in addition to a single radiation dose of 800 cGy. All patients underwent a standard elbow reha- bilitation protocol postoperatively. Outcomes and complications All patients showed postoperative improvement in flexion, extension, and rotation of the forearm. Flexion showed the greatest mean improvement (55.2 38.7 ), followed by extension (50.2 34.0 ) and rotation (47.9 40.0 ). Subjective patient-reported outcomes measured by the Mayo score indicated significant improvement in all 10 patients, with a mean of 36 10.2 points (Fig. 2). We observed 1 complication: Ulnar nerve palsy developed in 1 patient after open reduction–internal fixation but had sub- sided at 3 months of follow-up. No surgical-site infections occurred in any case. There were no cases of compartment syndrome. Details describing each patient are presented in Table I, and data on range of motion and the Mayo score are given in Table III. Discussion Radioulnar synostosis due to post-traumatic injuries of the forearm and elbow may pose a challenge. Although some patients may be effectively treated via surgical resection, the high probability of recurrence places patients at risk of more extensive surgical procedures in the future.9-12 A consensus on the gold-standard treatment modality has yet to be reached, although an exhaustive list of options has been reported in the literature. These options include, but are not limited to, the reverse Sauv e-Kapandji proced- ure19,20 ; tissue expander capsule interposition21 ; posterior interosseous antegrade-flow pedicled flap22 ; triple therapy weeks, passive for 3 weeks, weights after 9 weeks for 3 weeks, weights after 9 weeks passive for 3 weeks, weights for 3 weeks weeks, passive for 3 weeks, weights after 9 weeks (25 sessions) had wound infection after hematoma): continued for 30 d weeks, passive for 3 weeks, weights after 9 weeks (18 sessions) wound infection after hematoma): continued for 30 d weeks, passive for 3 weeks, weights for 3 weeks and 73 d on outpatient basis; followed up weekly) Subjective result Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Complications None Ulnar nerve palsy after ORIF, now subsided None None None None None None None None * In stage 1, d e bridement was performed, followed by external fixation using 2 Schanz screws (4 mm) in the humerus, 2 Schanz screws (4 mm) in the proximal ulna, 2 Schanz screws (4 mm) and subcutaneous K-wires in the distal radius, and 2 Schanz screws (3 mm) in the MCP. In stage 2, d e bridement was performed, followed by exploration of the ulnar and median nerve (intact), MCL repair, and insertion of Ethibond pullout suture (Ethicon, Somerville, NJ, USA) for the coronoid fracture. In stage 3, a lateral Kocher approach was performed, followed by radial head fixation with 4 mini screws and a radial head plate in the safe zone, as well as LCL and common extensor repair. A volar Henry approach was then performed for the distal radius, followed by insertion of an LCP volar plate, external fixation, and a K-wire for the DRUJ. Finally, a direct approach was performed for the ulna. In stage 4, external fixator removal and cast application were performed. MCP, Metacarpal phalngeal; DRUJ, Distal radioulnar joint; ORIF, Open reduction internal fixation; DCP, Dynamic compression plate; LCDCP, Low contact dynamic compression plate; MCL, medial collateral ligament; LCL, Lateral collateral ligament; LCP, Lateral compression plate; AES, Above elbow slab; LC, Lateral condyle; GA, General Anesthesia; POD, Post operative day; HO, heterotopic ossification; ROM, Range of Motion; TDS, 3 times a day; CPM, continuous passive motion. Post-traumatic radioulnar synostosis: case series 1599
- 6. with indomethacin, radiotherapy, and HO resection13-15,23 ; dual therapy with indomethacin and HO resection,24 and intramedullary nailing.25 Regardless of what preoperative management is performed, surgical intervention remains the most effective option to restore functional range of motion in patients with limited pronation and supination.21 The timing of surgical intervention has also been a chal- lenging topic because it depends not only on waiting for the synostosis to fully mature on radiographic imaging but also on preventing contracture development if surgical delay is prolonged.21,27,28 As a result, good timing would involve waiting for at least 6-12 months but no longer than 3 years.21,26 Multiple risk factors have been documented as the causes behind the development of radioulnar synostosis.29 More commonly, patients presenting with extensive soft- tissue injury, head injury, fracture comminution, or Monteggia-type fracture, among others, are at risk of radioulnar synostosis development.1,4,5 Less common risk factors include biceps tendon repair,2 congenital develop- ment,19 percutaneous fixation of distal radial and ulnar styloid fractures,20 and intramedullary nailing.25 In all the patients in our study, radioulnar synostosis developed due to the most common causedfractures. In this study, we used a combination of adjuvant indo- methacin, radiotherapy, and HO resection, followed by the insertion of an anconeus interposition flap, in all 10 pa- tients. Our results showed favorable outcomes with respect to range of motion, with mean improvements in flexion, extension, and rotation of 55.2 38.7 , 50.2 34.0 , and 47.9 40.0 , respectively. Assessment of the subjective Mayo score also showed improvement, by a mean of 36 10.2 points. Significance could not be assessed owing to the study’s small sample size, but subjective assessments and objective changes in range of motion were concluded to be favorable in all patients. Limitations Regarding study limitations, the lack of a control group hinders the ability to establish the efficacy of triple therapy compared with single-therapy modalities. Another limita- tion is that the surgical procedures were performed by a single surgeon. Thus, the technique difficulty level could not be assess as it is was not standard for this type of surgical intervention. Additionally, because of the scarcity of such cases, we appreciate that the sample size is too small to provide more accurate results. Figure 1 Clinical example of a 40-year-old male patient presenting with post-traumatic radioulnar synostosis. Table II Viola and Hastings classification system for het- erotopic ossification of forearm Type Location I Proximal radioulnar joint II Proximal radioulnar joint with extension to bicipital tuberosity III Between radius and ulna distal to proximal radioulnar joint There are 3 subtypes: A (anterior involvement), B (posterior involvement), and C (intra-articular involvement). 1600 M. Abdul Azeem et al.
- 7. Conclusion Treating post-traumatic radioulnar synostosis with a combination of adjuvant indomethacin, radiotherapy, and tissue interposition with an anconeus flap after HO resection resulted in favorable functional outcomes and prevented recurrence. Disclaimers: Funding: No funding was disclosed by the authors. Conflicts of interest: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments Table III Range of movement (flexion, extension, and rotation) and Mayo score of each patient before and after surgery Flexion, Extension, Rotation, Mayo score Preop Postop Improvement (arc) Preop Postop Improvement (arc) Preop Postop Improvement (arc) Preop Postop Improvement Patient 1 135 135 0 135 135 0 0 140 140 65 100 35 2 105 110 5 105 110 5 100 130 30 70 100 30 3 50 130 80 50 130 80 135 135 0 50 100 50 4 80 112 32 80 112 32 0 44 44 65 90 25 5 20 120 100 20 55 35 10 55 45 60 90 30 6 65 115 50 65 115 50 60 110 50 55 95 40 7 20 90 70 20 90 70 0 30 30 45 85 40 8 30 140 110 30 140 110 80 80 45 100 55 9 35 85 50 35 85 50 55 55 55 80 25 10 50 50 120 70 65 70 5 70 100 30 Mean 59.0 115.2 55.2 59.0 109.2 50.2 46.3 84.9 47.9 58.0 94.0 36.0 SD 38.0 18.8 38.7 38.0 26.0 34.0 52.2 40.7 40.0 9.5 7.4 10.2 Minimum 20 85 0 20 55 0 0 30 0 45 80 25 Maximum 135 140 110 135 140 110 135 140 140 70 100 55 Preop, preoperative; Postop, postoperative; SD, standard deviation. Figure 2 Graph showing range of motion (in degrees) and subjective patient-reported outcomes measured by Mayo score preoperatively and postoperatively. Post-traumatic radioulnar synostosis: case series 1601
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