Does an Internal Joint Stabilizer and Standardized Protocol Prevent Recurrent Instability in Complex Persistent Elbow Instability?

Abstract

Background The treatment of complex persistent elbow instability after trauma is challenging. Previous studies on treatments have reported varied surgical techniques, which makes it difficult to establish a therapeutic algorithm. Furthermore, the surgical procedures may not sufficiently restore elbow stability, even with an additional device, and a noted high rate of arthritis progression.While a recently developed internal joint stabilizer effectively treats elbow instability, its clinical application for complex persistent elbow instability is limited and the standardized protocol is not well described. Additionally, we want to know whether the arthritis progression will cause a negative impact on the functional outcomes of complex persistent elbow instability. Questions/purposes (1) Does treatment of complex persistent elbow instability with a hinged internal joint stabilizer and a standardized protocol prevent recurrent instability and other complications? (2) What are the pre-to postoperative improvements in pain, disability, elbow performance, and ROM? (3) Is the development of posttraumatic arthritis associated with worse pain, disability, elbow performance, and ROM? Methods Between September 2014 and October 2019, we treated 22 patients for persistent dislocation or subluxation after initial treatment of traumatic elbow fracturedislocations. Of those, we considered patients who were at least 20 years of age, with an interval of 6 weeks or more between the injury (initial treatment) and the index reconstructive procedure, which had been performed at our institute, as potentially eligible. During that time, we used an internal joint stabilizer with a standardized protocol for posttraumatic complex persistent elbow instability. We performed total elbow replacements in patients older than 50 years who had advanced elbow arthritis. Based on that, 82% (18 of 22) of patients were eligible; 14% (3 of 22) were excluded because total elbow replacements was undertaken, and another 5% (1 of 22) were lost before the minimum study follow-up of 1 year (median 24 monthsThe study was funded by E-Da Hospital, Taiwan (EDAHP108035). Each author certifies that there are no outside funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Ethical approval for this study was obtained from (E-Da Hospital)

Using External Joint Stabilizer – Elbow (EJS-E) for treating elbow instability—biomechanical assessment and clinical outcomes

“…Osteoporosis is an impediment to internal fixation in elderly patients with elbow injury, especially when dealing with small fragments and comminution of the articular surface that may lead to persistent instability and require the adjunctive use of an external fixator [ 3 , 20 ]. Dislocation or subluxation for as little as 2 weeks causes changes to bone and soft-tissue properties, such that restoration of osseous stability and repair of the collateral ligaments may be inadequate to maintain elbow reduction [ 11 ]. Moreover, patients with a higher body mass index may be at risk for residual instability since the elbow experiences higher valgus loading when the shoulder is abducted in these patients [ 21 – 23 ].…”

“…The mean final arc of flexion–extension and pronation-supination was 113° and 148°, respectively. The average MEPS was 95 [ 11 ]. In the current study, clinical outcomes were similar to those of the other reported series.…”

“…Orbay and Mijares et al designed an internal joint stabilizer (IJS) for treating instability of the elbow using a temporary Steinmann pin bent and placed through the axis of the ulnohumeral joint and then attached to the proximal ulna [ 9 , 10 ]. This technique restores elbow stability and permits motion, showing promise for the treatment of patients with severe elbow instability [ 9 , 11 ]. Herein, we present a simple low-profile External Joint Stabilizer – Elbow (EJS-E) that represents a modified version of the IJS for the management of elbow instability.…”

“…This device is used temporarily to allow for ligament healing and is intended to be removed directly after 4 to 6 weeks without the need for a secondary surgical procedure. From a clinical outcomes point of view, using an IJS for treating complex elbow instability results in a satisfactory outcome [ 9 – 11 ]. However, EJS-E is a new technique that is not generally acknowledged.…”

Radial head arthroplasty vs. open reduction and internal fixation for the treatment of terrible triad injury of the elbow: A systematic review and meta‑analysis update

“…TTIE was first proposed by Hotchkiss in 1996( 2 ). The injury is often accompanied by valgus, rotation, axial and other stresses, as well as damage to the medial and lateral ligament complexes, which make the elbow joint markedly unstable even after reduction ( 3 ). Conservative treatment cannot restore the stability of the key structures of the elbow, resulting in traumatic instability of the elbow joint ( 4 ).…”