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Combined use of minimal screw synthesis and external articulated fixation is effective for the management of supra-intercondyloid humeral fractures in the elderly? A retrospective study
, Alessandro Isolab, Sebastiano Ortuc, Luca Boninib, Rossella Siriannib, Antonio Caponed, Mario Mancab
∗Corresponding author: Fabrizio Bienati. dott.bienati@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Fractures of the distal humerus are relatively rare and can be a source of disabling outcomes especially if not properly treated. Therefore, the objective of the treatment must be to obtain a stable synthesis that allows early mobilization, avoiding complications such as muscular hypotonotrophy, joint rigidity or delays in consolidation that may be due to prolonged immobilization of this joint. Although ORIF treatment of these fractures may intuitively appear to be the gold standard, there is still no consensus in the literature on which type of treatment is most suitable.
We report in this retrospective case series analysis our experience on 31 elder patients (more than 65 years old), affected by a supra-intercondyloid humerus fracture, treated using a minimal internal fixation with cannulated screws combined with the use of an external articulated elbow fixator. This methodology is less invasive but allows a stable synthesis and an early mobilization.
Clinical and radiographic examinations were performed for each patient at 1, 2, 3 and 6 months after surgery. At 6 months the residual joint excursion was evaluated and the data were collected. In addition, at 6 months, each patient underwent three different functional capacity assessment questionnaires: MAYO Elbow Performance score, The Disability of the ARM, Shoulder and Hand Score (QuickDASH) and Oxford Elbow Score.
The healing rate was 100% with no cases of non-union, despite the old age of our patients. The average range of motions obtained at 6 months from the surgery was 111° in flexion-extension and 157° in pronation-supination for the patient with an extra-articular fracture, 88° in flexion-extension and 153° in pronation-supination for the patients with a partial articular fracture and 85° in flexion-extension and 149° in pronation-supination for the patients with a complete articular fracture. Our results in the recovery of an arc of motion in flexion-extension are slightly less performing than the results obtained with an ORIF treatment. Indeed, according to literature the mean postoperative flexion arc in an ORIF treatment of distal humerus fractures in adults is 110°.
The functional results obtained were satisfactory, with an average score at 6 months from the surgery of 95/100 (Mayo score) for the patients with an extra-articular fracture, 83.3/100 for the patients with a partial articular fracture and 79/100 for the patients with a complete articular fracture.
The results obtained, in terms of range of motions, function, pain and healing and complications rate lead us to affirm that, in selected patients, this technique can represent a valid treatment and therefore a valid option that could be considered.
Keywords
Elbow
Upper limb fracture
Elderly fracture
Trauma
External fixation
1 Introduction
Fractures of the distal humerus represent a difficult challenge even for the experienced orthopaedic surgeon; in addition to the complexity of the anatomy of the distal third of the humerus, a problem for its reconstruction, there is also often the involvement of the joint.
These fractures are relatively rare, representing about 8% of humeral fractures and only 2% of all fractures1,2 with a distribution characterized by a bimodality both by age and sex. In fact, their peak of incidence occurs in males between 12 and 19 years of age and in females over 80 years of age.3,4 In addition, the traumatic mechanism is different, represented mainly in the young patients by high-energy trauma while in the elderly patients by low-energy trauma.
Although infrequent, they can be a source of disabling results, especially if not correctly treated. In elderly patients, who often live alone and autonomously, even partial loss of motor skills causes a loss of autonomy that often evolve into a need for care.
Therefore, the objective of the treatment must be to obtain a stable synthesis that allows early mobilization, avoiding complications such as muscular hypotonotrophy, joint rigidity or delays in consolidation that may be due to prolonged immobilization of this joint.
If the fragmentation or loss of substance is excessive, as is often the case in the elderly patient because of bone fragility, Total Elbow Replacement (TER)5,6 is often preferable. However, recent studies state that this preference should be re-examined due to the high rate of complications beyond five years of follow-up with TER.7
Although the ORIF treatment with plate and screws may intuitively appear to be the gold standard in most of the cases,8,9 the debate in orthopaedic scientific arena on which type of treatment is more suitable is vivid.10
1.1 Objective
Trying to find a safe, valid and reproducible technique for the treatment of supra-intercondyloid humerus fractures in the elderly, starting from 2010, we have begun to treat some of these fractures, in patients over 65 years of age, through reduction and minimal synthesis combined with the use of an articulated elbow fixator. The objective of this study is to evaluate the functional and clinical results of this treatment after 6 months.
2 Methods
2.1 Participants
From July 2010 to September 2018 at the Orthopaedics and Traumatology Unit of the “Versilia” Hospital in Lido di Camaiore, 35 patients with clinical and radiographic diagnosis of fracture of the distal third of the elbow, 29 females and 6 males with an average age of 79.8 (min 65, max 95) were treated with minimum synthesis with cannulated screws and subsequent positioning of external articulated elbow fixator. As fixator, we used the ST.A.R. 90 F4 Citieffe®.
The criteria for inclusion were age over 65 years and indication to synthetic surgery for fracture of the distal third of the elbow. The exclusion criteria were the presence of a previous dysfunction in the traumatized district and the presence of Dementia.
The presence of Dementia is the main contraindication of this treatment due to the difficult acceptance from the patient of an external fixator.
According to these criteria we excluded from this study 4 patients, 3 for a cognitive impairment and one for the presence of a previous elbow fracture, non-operatively treated, with a residual impairment in the range of motion of the elbow.
During the follow-up we lost 4 patients, 3 woman and 1 men.
As result the partecipants in this study with a complete clinical and radiographic investigation were 31, 26 females and 5 males with an average age of 80.5 years (min 65, max 95).
3 Study design and setting
3.1 This study is a retrospective case series analysis
The fracture mechanism and the characteristics of the fracture were investigated. The fractures were classified and divided into subgroups by an experienced surgeon and a resident surgeon according to the AO classification.11 The surgeries were performed by different surgeons of the Trauma team of Versilia Hospital. The patients underwent the surgeries from 1 to 5 days from acceptance (average time 2,16 days). All the patients started the rehabilitation the day after the surgery.
Clinical and radiographic examinations were performed for each patient at 1, 2, 3 and 6 months after surgery. In the first and second months we pointed our attention to detect if there was pain or tenderness on palpation and examination. After the removal of the external fixator as clinical criteria used to define fracture union we used the previous two plus the ability to bear weight and the absence of pain or tenderness when bearing weight. During all the radiographic examinations we searched the presence of bridging of fracture site and the progressive obliteration of fracture line. At 6 months the residual joint excursion were evaluated and the data were collected. In addition, at 6 months, each patient underwent three different functional capacity assessment questionnaires: MAYO Elbow Performance score,12 The Disability of the ARM, Shoulder and Hand Score (QuickDASH)13,14 and Oxford Elbow Score.
The analysis of all the results obtained was performed in April 2019 by a single resident surgeon. Only patients with complete clinical and radiographic investigation at the established time were considered in this retrospective study.
3.1.1 Preoperative treatment
In all cases, in addition to classic radiographic imaging in anterior-posterior and lateral projections, in order to perform a more accurate preoperative planning, a computed tomography scan (CT) with acquisition of sagittal and frontal images and 3D reconstruction was performed.15 The help given from a 3D reconstruction was essential to perform surgery so we highly recommend CT scan for a more definite understanding of the fracture and then a more accurate management of all the fracture fragments.
3.1.2 Surgical technique
In all cases patients were supine during surgery, the injured limb was resting on the radio transparent support of the operating bed, operators on injured side and C-arm at patient's feet. The entire humerus and elbow should be visualized in two planes with the image intensifier. The arm can be rotated to get AP and lateral views. We highly recommend to check if is possible to obtain an optimal visualization of the elbow under fluoroscopy before starting the surgery because is essential for the success of this treatment. Reductive manoeuvre is similar to the manoeuvre used to reduce the children's supracondylar fractures16: we start with a traction of the elbow in a partially extended position, between 20 and 30°, to avoid the possibility of tethering neurovascular structures over an anteriorly displaced proximal fragment. For fractures with significant displacement, hold traction as long as necessary to allow soft tissue realignment while the operator applies pressure with his fingers in medial or lateral direction depending on the prevailing displacement, in order to reduce the fracture. The assistant provides counter traction against patient's axilla allowing traction to be applied. It is possible also to work with the movement of the forearm to correct the varus and valgus angular alignment, but it requires the elbow to be in straight position. We prefer the first method.
As a priority, in case of a fractured trochlea, it is stabilized with a cannulated screw. Then we proceed by flexing the elbow while applying anterior pressure to the olecranon with the surgeon's thumb and pronating the forearm if the displace is prevalent in the posterior medial sense or supinating if the displace is in the posterior lateral sense. This manoeuvre, however, cannot be standardized; it may be that a good reduction can be found in both pronation and supination in the forearm. It will therefore be up to the operator to identify the position that allows the best reduction before stabilization.
If it is not possible to manoeuvre the fracture by manipulation alone, it is also possible to use a Kirschner wire using the Joystick technique to allow the fractured fragment to find its position. Once the reduction has been achieved, the Kirschner threads are introduced on the lateral and medial columns on which the cannulated screws are subsequently placed, which must reach the opposing cortical. Additional screws can then be positioned for possible stabilization of free fragments. In our experience, we have noticed that in most fractures type 1.3. A minimum of 2 cannulated screws was sufficient to achieve adequate stability prior to positioning the external fixator –see Fig. 1-, while as the complexity of the fracture increased, more screws were required, from a minimum of 3 to a maximum of 7 (average 4.8) in the group of 6 patients with type 1.3 fractures. C –see Fig. 2-. In this group, it was necessary to perform a mini surgical access in order to help the reduction and among the screws used, in addition to the classical cannulated screws, variable pitch cannulated milled head screws were used for the synthesis of the humeral condyles.
The second step is the search for the perfect centre of rotation at elbow level, the cornerstone of the articulated external fixer assembly. It can be identified by making a lateral projection of the elbow joint and is represented by the centre of the circumference corresponding to the lateral projection of the humeral spool and the circumference of the lateral projection of the humeral condyle. Once identified, the guide wire is positioned, the insertion of which should also be checked in anteroposterior projection to ensure that it runs parallel to the articular rhyme.
At this point we had to position 3 Schanz screws at humeral level, anterolaterally. We paid attention to avoid Schanz screw placement distal to the middle third of the humerus to be sure not to accidently injure the radial nerve. Then, with the forearm in neutral position, we had to insert 3 Schanz screws into the lateral or posterolateral part of the proximal or middle third of the ulna. After the insertion of all the Schanz screws we checked pronation and supination to make sure the screw does not affect the radius.17
Now we turned the micrometric screw of the external fixator we distracted the joint. As a final step, we ensured that there are no obstructions in the movements of flexion and extension of the joint.
3.1.3 Aftercare
Neurovascular observations were made frequently. Hand pumping exercises were started as soon as possible to reduce lymphedema and to improve venous return in the limb. In addition, flexion and extension assisted exercises of the elbow should be initiated as soon as possible, as the elbow is prone to stiffness. Exercises were performed starting from the day next to the surgery, during morning and afternoon, under the control of a physiotherapist.
The mean time before the Schanz screw and Fixator removal was 8.4 weeks (range 8–12).
No load-bearing or strengthening exercises were allowed until early fracture healing was established by x-ray and clinical examination and the Fixator was removed.
4 Results
The most common injury found in patients treated by us was a 1.3. A2 fracture (11 patients), and the A2.3 was the most frequent subtype (9 of 11 patients, 29% of patients treated). A minimum of two cannulated screws and external fixator (9 patients with fracture A2.3 and 2 patients with fracture A3.1) and a maximum of 7 cannulated screws and external fixator (in 2 patients with fracture C3.3) were used for the treatment of these fractures -see Fig. 3-. The mean retention time of the articulated external fixator was 8.4 weeks (min 8, max 12) –see Figs. 4 and 5 -, with a healing rate of 100% at 12 weeks and no cases of non-union. The fixator screws were removed without any anaesthesia in all our patients.
The mean ROM obtained at the removal of the external fixator was 97° in flexion-extension (mean flexion 118°, mean extension 21°) and 72° in pronation and 80° in supination. These values increased slightly at the 6 months control, resulting in an average ROM of 102° in flexion extension (average flexion 122°, average extension 20°) and 72° in pronation and 83° in supination. In three cases it was necessary to remove some screws, for their mobilization (pat. 21, 27 and 31 Table 1).
| N° | Patient | Age | Gender | Side | AO classification | Flex | Ext | Flex 6 m. | Ext 6 m. | Sup. | Pron. | Sup 6 m. | Pron 6 m. | Quick DASH | OES to 100 | Oxford Elbow score | Treatment |
| 1 | L.L | 81.2 | F | R | 13 A2.2 | 110 | 20 | 140 | 20 | 85 | 75 | 85 | 75 | 6.8 | 95.8 | 46 | 4 cannulated screws + h.e.f. |
| 2 | P.L | 94.1 | F | L | 13 A2.2 | 105 | 25 | 115 | 20 | 80 | 75 | 80 | 75 | 9.1 | 95.8 | 46 | 4 cannulated screws + h.e.f. |
| 3 | D.M | 77.9 | M | L | 13 A2.3 | 100 | 15 | 120 | 15 | 80 | 75 | 80 | 75 | 18.2 | 87.5 | 42 | 2 cannulated screws + h.e.f. |
| 4 | N.M | 84.0 | F | R | 13 A2.3 | 105 | 20 | 125 | 20 | 80 | 75 | 80 | 75 | 15.9 | 95.8 | 46 | 2 cannulated screws + h.e.f. |
| 5 | A.I | 81.4 | F | R | 13 A2.3 | 120 | 15 | 140 | 15 | 85 | 70 | 85 | 70 | 18.2 | 87.5 | 42 | 2 cannulated screws + h.e.f. |
| 6 | R.L | 77.3 | F | R | 13 A2.3 | 115 | 20 | 125 | 20 | 80 | 75 | 80 | 75 | 9.1 | 95.8 | 46 | 2 cannulated screws + h.e.f. |
| 7 | J.MR | 80.9 | F | R | 13 A2.3 | 120 | 10 | 130 | 10 | 85 | 75 | 85 | 75 | 6.8 | 95.8 | 46 | 2 cannulated screws + h.e.f. |
| 8 | R.L | 80.8 | F | R | 13 A2.3 | 110 | 15 | 135 | 15 | 80 | 75 | 80 | 75 | 2.3 | 100.0 | 48 | 2 cannulated screws + h.e.f. |
| 9 | M.V | 70.6 | F | R | 13 A2.3 | 105 | 10 | 130 | 10 | 85 | 75 | 85 | 75 | 6.8 | 91.7 | 44 | 3 cannulated screws + h.e.f. |
| 10 | A.ML | 74.2 | F | R | 13 A2.3 | 95 | 25 | 115 | 20 | 80 | 75 | 85 | 75 | 38.6 | 54.2 | 26 | 2 cannulated screws + h.e.f. |
| 11 | BM.EE | 71.0 | F | L | 13 A2.3 | 100 | 20 | 120 | 20 | 75 | 75 | 80 | 75 | 4.5 | 95.8 | 46 | 2 cannulated screws + h.e.f. |
| 12 | P.R | 79.1 | F | L | 13 A3.1 | 105 | 15 | 125 | 15 | 80 | 75 | 85 | 75 | 6.8 | 95.8 | 46 | 2 cannulated screws + h.e.f. |
| 13 | G.D | 76.7 | M | L | 13 A3.1 | 125 | 25 | 140 | 25 | 85 | 75 | 85 | 75 | 2.3 | 79.2 | 38 | 2 cannulated screws + h.e.f. |
| 14 | B.A | 92.1 | F | R | 13 A3.2 | 120 | 20 | 135 | 20 | 85 | 70 | 85 | 70 | 6.8 | 87.5 | 42 | 3 cannulated screws + h.e.f. |
| 15 | B.N | 85.3 | F | R | 13 A3.2 | 105 | 15 | 125 | 15 | 80 | 75 | 80 | 75 | 2.3 | 95.8 | 46 | 3 cannulated screws + h.e.f. |
| 16 | M.L | 69.1 | F | L | 13 B1.3 | 95 | 25 | 110 | 25 | 80 | 75 | 80 | 75 | 6.8 | 89.6 | 43 | 3 cannulated screws + h.e.f. |
| 17 | B.F | 86.8 | F | L | 13 B2.1 | 90 | 25 | 105 | 20 | 75 | 70 | 80 | 70 | 34.1 | 68.8 | 33 | 3 cannulated screws + h.e.f. |
| 18 | B.T | 90.2 | F | L | 13 B2.1 | 95 | 25 | 110 | 25 | 80 | 75 | 80 | 75 | 9.1 | 95.8 | 46 | 3 cannulated screws + h.e.f. |
| 19 | S.L | 79.3 | F | R | 13C1.1 | 90 | 30 | 110 | 30 | 80 | 70 | 80 | 75 | 25 | 75.0 | 36 | 3 cannulated screws + h.e.f. |
| 20 | N.G | 77.8 | M | R | 13C1.1 | 95 | 25 | 115 | 25 | 80 | 70 | 80 | 70 | 18.2 | 68.8 | 33 | 3 cannulated screws + h.e.f. |
| 21 | B.U | 75.6 | F | R | 13C1.3 | 90 | 30 | 105 | 25 | 80 | 70 | 80 | 70 | 22.7 | 75.0 | 36 | 3 cannulated screws + h.e.f. |
| 22 | B.C | 76.9 | M | L | 13C1.3 | 95 | 20 | 105 | 20 | 75 | 65 | 75 | 65 | 2.3 | 95.8 | 46 | 3 cannulated screws + h.e.f. |
| 23 | M.M | 88.8 | F | R | 13C1.3 | 90 | 25 | 100 | 25 | 75 | 70 | 75 | 70 | 22.7 | 68.8 | 33 | 3 cannulated screws + h.e.f. |
| 24 | CDF.A | 84.6 | F | R | 13C2.1 | 95 | 25 | 110 | 20 | 80 | 70 | 80 | 70 | 15.9 | 79.2 | 38 | 3 cannulated screws + h.e.f. |
| 25 | P.E | 81.5 | F | R | 13C2.3 | 105 | 15 | 105 | 15 | 75 | 65 | 75 | 65 | 22.7 | 87.5 | 42 | 3 cannulated screws + h.e.f. |
| 26 | M.R | 95.8 | F | R | 13C3.1 | 95 | 25 | 115 | 25 | 80 | 70 | 85 | 70 | 15.9 | 83.3 | 40 | 4 cannulated screws + h.e.f. |
| 27 | B.A | 91.9 | F | R | 13C3.1 | 90 | 25 | 115 | 25 | 80 | 70 | 80 | 70 | 20.5 | 75.0 | 36 | 5 cannulated screws + h.e.f. |
| 28 | DB.L | 67.0 | M | L | 13C3.2 | 100 | 15 | 120 | 15 | 80 | 65 | 80 | 70 | 18.2 | 68.8 | 33 | 3 cannulated screws + h.e.f. |
| 29 | G.V | 91.2 | F | R | 13C3.2 | 85 | 35 | 95 | 30 | 70 | 70 | 75 | 70 | 20.5 | 68.8 | 33 | 3 cannulated screws + h.e.f. |
| 30 | B.P | 68.7 | F | L | 13C3.3 | 95 | 20 | 110 | 20 | 75 | 65 | 80 | 65 | 25 | 68.8 | 33 | 7 cannulated screws + h.e.f. |
| 31 | M.A | 65.0 | F | L | 13C3.3 | 100 | 15 | 100 | 15 | 80 | 70 | 80 | 70 | 43.2 | 68.8 | 33 | 7 cannulated screws + h.e.f. |
In one case we noticed a radial nerve palsy lasted for 5 months. This palsy appeared after the removal of one screw, that it was removed after 4 months due to its excessive length (pat 31).
No patient had a loss of the reduction obtained in the operating room, residual instability or major complications (septic arthritis, implant failure, postoperative deformity and functional impotence). From the moment of discharge, each patient underwent a weekly check-up, during which the dressing renewal was performed. In 2 patients there was a superficial Pin infection, which was treated with oral antibiotic therapy (beta-lactam for 10 days) and brought no consequences.
Within 6 months of the date of surgery, functional clinical evaluation tests were performed (Mayo Score, Quick Dash Score, Oxford Elbow Score). For the Mayo Score the average score was 87.5, for the Quick Dash Score 15.3 and for the Oxford Elbow Score 85.7.
Dividing patients into three groups according to the AO fracture classification, the results were 95 for the Mayo Score, 12.4 for the Quick Dash Score and 88.9 for the Oxford Elbow Score in patients with fracture 1.3. A, 83.3 for the Mayo Score, 16.7 for the Quick Dash Score and 84.4 for the Oxford Elbow Score in patients with fractures 1.3. B and 79 for the Mayo Score, 19.1 for the Quick Dash Score and 76.3 for the Oxford Elbow Score in patients with fractures 1.3. C.
We analysed these differences using ANOVA as statistical test and we found that patients with extra-articular fracture had better functional results then patients with partial articular fracture who themselves had better functional results then patients with a complete articular fractures. These differences were statistically significant with a P < 0,05 for all the three functional tests analysed.
The average range of motion in flexion-extension at 6 month from operation was 111° for the first group, 88,3° for the second and 85° for the third. For the pronation supination was 157° for the first group, 153.3° for the second and 148,9° for the third.
The average time of these surgeries were 80,65 min (min. 35 – max 200).
5 Discussion
Articulated external fixation is certainly not a new method, having been introduced in the late 70s of the last century, but it still represents a valid technique. In recent years in fact, in addition to its prevailing role in reconstructive surgery, it had also found space in trauma surgery.18,19 Although ORIF treatment seems to be the gold standard treatment,10,8 in the elderly patient there are often clinical conditions both at local and systemic level which are not in favour of extensive surgical access, long protracting surgery or prone patient positioning. Despite the conditions of these patients a non-operative treatment is not usually recommended except of exceptional cases due to the really poor outcomes as demonstrate in multiple studies.20,21,22
In these patients, the execution of a minimal synthesis that could restore the triangle of stability,23 protected by an articulated external fixation, able to provide a controlled movement and neutralizing the forces that could break down the surgical reduction can therefore represent a valid alternative to the most common techniques, also taking advantage of the possibility of starting functional recovery in the immediate postoperative period.
During the surgery, in the positioning of the elbow fixator, the key point is the search for the perfect centre of rotation at elbow level. In fact, in a study conducted on cadaveric models, it has been demonstrated that misalignments, even of small magnitude (5 mm of translation or 5° of angulation), correspond to an important increase in resistance to movement24(15), with consequent mobilization of the screws, persistent rigidity or instability.
The healing rate was 100% with no cases of non-union, despite the old age of our patients.
The average range of motions obtained at 6 months from the surgery was 111° in flexion-extension and 157° in pronation-supination for the patient with an extra-articular fracture, 88° in flexion-extension and 153° in pronation-supination for the patients with a partial articular fracture and 85° in flexion-extension and 149° in pronation-supination for the patients with a complete articular fracture. Our results in the recovery of an arc of motion in flexion-extension are slightly less performing than the results obtained with an ORIF treatment. Indeed, according to literature the mean postoperative flexion arc in an ORIF treatment of distal humerus fractures in adults is 110°25
For the functional analysis we decided to use the Mayo Score, the Quick Dash Score and the Oxford Elbow score to allow an appropriate cross-study comparison with further or past studies.26
The functional results obtained were satisfactory, with an average score at 6 months from the surgery of 95/100 (Mayo score) for the patients with an extra-articular fracture, 83.3/100 for the patients with a partial articular fracture and 79/100 for the patients with a complete articular fracture.
Also with the Quick Dash Score and the Oxford Elbow score we noticed this trend, with better functional results in patients with extra-articular fractures.
What we obtained in terms of Mayo score results are slightly lower to the results obtained with open reduction and fixation according to the studies that we found in literature like the one conducted by Athanaselis et al., in 2022 (79 points versus 83.3 in patients with 1.3C fractures),27 by Flinkkila et al., in 2014 (79 points versus 88 in patients with 1.3C fractures),28 by Atalar et al., in 2009 (79 points versus 86 in patients with 1.3C fractures)29 or by Sanchez-Sotelo et al., in 2007 (79 points versus 83 in patients with 1.3C fractures).30
However we have to say that in all these studies the mean age of the patients was under 65 years old and we think that the older age of our patients could have affected the results in a bad way. Unfortunately we didn't find any article in literature to support our theory that older patients could have worst results during the rehabilitation subsequent to a complex elbow fracture.
The biggest complication was the radial palsy occurred after the removal of one screw that it was too long. We didn't noticed that error on the x-ray checks until the removal of the external-fixator. Despite one patient among 31 represents a high rate of complications (3%), this was an easily evitable error and we assume all the responsibility for this wrong measurement during the first operation. In two patients (6,5%) we had a minor complication as a superficial skin infection of one Pin, treated with oral antibiotic therapy (beta-lactam for 10 days) that brought no consequences.
In terms of complications, the results obtained in our study outstand the results obtained with an ORIF treatment of a distal elbow fracture where, according to a systematic review and meta-analysis published on 2021 on the Journal of Shoulder and Elbow Surgery by Yetter T.R., the overall complication rate was 53%, and the overall reoperation rate was 21%.25
6 Conclusion
The results obtained in this study in terms of healing and reoperation rate, ROM and clinical functionality seem to support the validity of this therapeutic choice in the elderly. The low rate of major and minor complication are two further points in favour of this methodology. However, the limit of this method is the skill of the surgeon, since only a precise and correct application of the method can lead to satisfactory results.
Our hope is that in future further studies could confirm that is a safe and reproducible technique and therefore a valid option that could be considered in the treatment of these arduous fractures in selected patients.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Informed consent
A Verbal consent in presence of at least two doctors for data collection and for pictures utilization was taken at the first access in the hospital.
Ethical committee approval
This retrospective study was approved by the Ethical Committee of Azienda USL Toscana Nord Ovest - Comitato Etico Area Vasta Nord Ovest (CEAVNO)- Sezione Autonoma del Comitato Etico Regionale per la Sperimentazione Clinica.
Authors contribution
•Fabrizio Bienati: Conceptualization, Methodology, Investigation, Writing - Original Draft, Visualization, Review & Editing•Alessandro Isola: Conceptualization•Sebastiano Ortu: Data Curation•Luca Bonini: Formal analysis•Rossella Sirianni: Data Curation•Antonio Capone: Supervision•Mario Manca: Conceptualization, Writing - Review & Editing, Supervision
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