Myositis ossificans

O2101 OPEN REDUCTION AND INTERNAL FIXATION WITH BOSWARTH SCREW FOR UNSTABLE CLAVICULAR FRACTURES

G. Macheras, K. Kateros, I. Sofianos, O. Koukou, S. Stougioti.

1st I.K.A. Hospital, Penteli, Greece and General Hospital of Levadia, Greece

Aim:We present our experience and the results of the treatment on 36 patients with fracture of the distal end of the clavicle (Grade II type 2) by open reduction of the fracture. Method: 25 men and 11 women were treated operatively for unstable (grade II. type 2) clavicular fracture from 1999 to 2002. The average age was 27.2 years (range, eighteen to thirty- five years). The operations were performed under general anaesthesia. By the proper procedure the clavicle and the base of the coracoid was exposed. A 3.5mm hole was drilled, and a screw is introduced through the clavicle into the coracoid. The torn ends of the coracociavicular ligaments are tagged with sutures. Six to nine weeks postoperatively the screw was removed. Results: all patients were reviewed radiologically and clinically after on average interval of 16 months. The healing of the fractures occurs about 8 weeks later. all patients were restored to the pre - injury level function with no pain or abnormal motion. Conclusions: Internal fixation with Boswarth screw and repair of the coracociavicular ligament is an effective operation for Grade II type 2 unstable clavicular fractures specially for young and athletic patients

O2102 CONSERVATIVE TREATMENT OF UNSTABLE FRACTURES OF THE MIDDLE THIRD OF THE CLAVICLE

V.M. Psychoyios, H. Dinopoulos, F. Villanueva-Lopez, E. Zambiakis, N. Sekouris.

Asclepeion Hospital, 5th Orthopaedic Department, Athens-Greece

Introduction: Primary surgical treatment has been recommended for unstable clavicular fractures if consequences of non-union or malunion have to be avoided. A prospective study was undertaken to evaluate the results of a conservative treatment of very unstable fractures of the middle third of the clavicle, with emphasis to very early mobilization. Material: Patients to be included in the study had to met the following criteria: 1) Fractures of the middle third of the clavicle, severely displaced or comminuted. 2) Closed injuries, 3) No neurovascular complications. 4) No pneumothorax or haemothorax and 5) No other injury in the ipsilateral upper extremity. Twenty-three patients with an average age of 24 years included in the study. Each patient evaluated with AP and 45-degree cephalad-tilted views. all patients treated with an arm sling and strongly instructed for early mobilization. all patients were evaluated in a weekly interval and assessed with the American Shoulder and Elbow Surgeon's shoulder evaluation form. Results: The average follow up was 21.4 months. all fractures were consolidated and all malunited; but no patient had residual symptoms or functional impairment of the limb. On patient developed mild hypestliesia in the ulnar nerve territory. Conclusion: The extremely encouraging results of our study, within the bounds of the above-mentioned follow up, indicate that conservative treatment with very early mobilization may be considered as a valid therapy. However it is a concern the functional result in a longer follow up as well as the cosmetic result.

O2103 COMPARATIVE OUTCOMES FOLLOWING PLATING OR TENSION BAND WIRING OF OLECRANON FRACTURES

N. Aslam. S. Nair, G. Ampat. K. Willett.

John Radcliffe Hospital, Hetulington, Oxford, United Kingdom

Aims: to evaluate the outcome following internal fixation of olecranon fractures using the techniques of tension band wiring and plating with a minimum follow up of two years. Methods:Design: retrospective evaluation and clinical review. Setting: regional trauma centre. Patients and participants: 48 consecutive patients with fractures of the olecranon were treated over a twenty month period (may 1993 to december 1994). 25 fractures were fixed using a tension band wiring technique and 23 underwent plating; the selection of method was based on agreed radiological fracture pattern criteria. Main outcome measurements: radiographie evaluation of the quality of reduction. Clinical outcome (broberg and morrey functional rating index). Results: clinical evaluation of 39 patients was carried out. In the tension band wiringgroup 17 (85 percent) patients had an excellent or good outcome and 11 (55 percent) patients underwent a second procedure for symptomatic metalwork. In the plating group 16 (84 percent) patients had an excellent or good outcome and 2 (11 percent) patients underwent a second procedure for symptomatic nietalwork.The latter group had more complex and associated fractures and included the only poor result. Conclusion: internal fixation of fractures of the olecranon results in good functional outcome. Fixation with a plate is effective and produces good outcome even though selected for the more complex olecranon fractures. Patients who have tension band wiring more often require a second procedure for removal of symptomatic metalwork.

O2104 MOBILISATION OF STIFF ELBOW WITH EXTERNAL FIXATOR

Gopalkrishna Verma. A. Mehta, R. Prabhoo, E.G. Kanaji, B.B. Joshi.

Jess Research and Development Centre, Mumbai (India)

Aims: To treat posttraumatic stiffness of elbow by distraction arthrodiastasis and mobilisation. Standard operative procedures were combined for 4 patients with bony blocks due to myositis ossificans. Methods: We reviewed 8 patients. 5:M. 3:F aged 20-42 years. 3 x 2.5mm k-wires were passed in lower-third humerus from lateral to medial side and 3 x 2.5mm k-wires in proximal ulna. Distractors were applied on anterior and posterior aspect of elbow and hinge-joint at the level of elbow-joint. Elbow was gradually distracted to achieve arthrodiastatic state of joint. Maintaining arthrodiastatic state now elbow deformity is gradually corrected by distracting anterior distractors. Than distractors and hinge are locked for tissue reaction to subside over 2-3 weeks followed by dynamic mobilization. Movement gradually improves over 2-3weeks (sometimes prolonged in severe cases). Than fixator is removed and appropriate dynamic splint is applied to maintain correction while allowing mobility. In 4 cases bone block was removed surgically and followed by distraction arthrodiastatic procedure. No steroid in any form was used in any stage of treatment. Results: Average follow-up: 2years (maximum 4years). all elbows were stable and extension increased by 30° and flexion increased by 50°. One case had minor pin-tract infection, responded to basic treatment. No neurovascular deficit was not seen post procedure in any patients. Conclusion: This technique may be considered before arthrolysis is undertaken for stiff elbow.

O2105 ARTHROLYSIS FOR THE POST TRAUMATIC STIFF ELBOW

A.Adair, J.R.M. Elliott.

Musgrave Park Hospital, Belfast, Northern Ireland

Aims: To establish the results of elbow arthrolysis for the post-traumatic stiff elbow. Methods: A retrospective review of 20 patients undergoing open arthrolysis of the elbow under brachial plexus block followed by continuous passive motion between 1994 and 2002. Results: Eighteen patients were reviewed independently at an average follow up of 35 months (6-84 months). The range of motion improved in all patients from a mean pre-operative arc of flexion of 59.7° (5°-85°) to a mean post-operative arc of flexion of 99.3° (55°-120°). However, the range of motion achieved intra-operatively was rarely maintained at review. The greatest improvement was seen in those with the most severe restriction in movement pre-operatively. A functional range of movement (30°-130°) was achieved in 14 patients (77.7%). According to the Mayo Elbow Performance Score, measuring functional outcome, 17 patients (94%) had a good or excellent result. Arthrolysis had the added benefit of relieving chronic post-traumatic elbow pain in 10 patients (56%). We recorded no significant complications and no evidence of contracture recurrence. Conclusions: The results of conservative treatment for elbow stiffness are often disappointing. Although open elbow arthrolysis can be technically challenging a functional range of motion is readily achievable. It has been shown to be a safe procedure with a high level of patient satisfaction.

O2106 RADIAL HEAD REPLACEMENT AND LIGAMENT RECONSTRUCTION FOR COMPLEX ELBOW FRACTURES (RADIAL HEAD AND CORONOID FRACTURE WITH DISLOCATION)

G. Pattison, M. Bould, N. Blewitt.

Frenchay Hospital, Bristol, BS16 ILE, UK

Background: Posterior dislocation of the elbow with fractures of the radial head and coronoid process is a rare injury which, when treated conservatively, has a high redislocation rate and poor results (7/11 in the largest published series). Methods: Six patients with this injury were treated with triple reconstruction, involving exploration of the joint via a lateral approach with insertion of a radial head prosthesis. The coronoid fracture and anterior capsule was repaired (using an in-to-out technique) and the lateral collateral ligament was reattached, using Mitek Super Anchors. all patients were evaluated prospectively. Results: The average age was 52 years (37-75y). At one year follow up all elbows remained in joint and all were pain free or causing slight pain only. The average range of ulno-humeral movement was 55 degrees (range 38-68) and the average forearm rotation was 67 degrees (range 18-104). Functional assessment showed an average Liverpool score of 23/36 (range 17-29) and average Broberg and Morrey score of 74/100 (range 68-84). Conclusions: Triple reconstruction recognises and remedies the three elements of this devastating injury. all of these must be addressed in order to fulfill the short-term goal of restoring and maintaining stability. Our patients have a stable, pain free, though stiff, elbow in contrast to the poor results reported from previous conservative and operative treatments.

O2107 EARLY MOBILISATION FOR MINIMALLY DISPLACED RADIAL HEAD FRACTURES: A PROSPECTIVE, RANDOMISED STUDY OFTWO PROTOCOLS

Nanda Rajesh. R.Y.L. Liow, A. Cregan, R.J. Montgomery.

Middlesbrough General Hospital, Ayresome Green Lane, Middlesbrough, Cleveland. TSS SAZ

Aims: To compare two protocols of early mobilisation for minimally displaced radial head fractures through a single-blinded, prospective randomised trial. Methods: Sixty patients were randomly allocated to either immediate active mobilisation or 5-day delay before active mobilisation was commenced. Patients were reviewed at 7 days, 4 weeks and 3 months after injuries. A blinded observer assessed each patient. Results: All fractures united by the third month. At the end of 7days. the mobilisation group had less pain (VAS 6 vs 7.6,'p=0.002): greater flexion (mean 112° vs 98°. p=0.(K)04): greater strength in supination (p

02108 LONG-TERM RESULTS OF LIGAMENTOUS RECONSTRUCTION FOR POSTEROLATERAL ROTATORY INSTABILITY OFTHE ELBOW

J. Sanchez-Sotelo. B.F. Morrey, S.W. O'Driscoll.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA

Aims: Posterolateral rotatory instability of the elbow is believed to express dysfunction of the lateral collateral ligament complex. The purpose of this study was to determine the long-term results of lateral ligamentous reconstruction in patients with posterolateral rotatory instability of the elbow. Methods: From 1986 to 1999. forty-five consecutive elbows with posterolateral rotatory instability were treated by direct repair of the lateral ligament complex (twelve cases) or augmented reconstruction with a tendon autograft (thirty-three cases). One patient was lost to follow-up one year postoperatively. The remaining forty-four patients were followed for an average of six (range, two to fifteen) years. Results: Surgery initially restored elbow stability in ail but five cases, two of which became stable after a second procedure. At most recent follow-up, three of the forty-five patients had persistent instability. The most recent mean Mayo Elbow Performance Score was eighty-five points (range, sixty to 100 points). According to the rating system of Nestor et al., the result was excellent in nineteen, good in thirteen, fair in seven and poor in five cases. Thirty-eight patients (86 per cent) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a postraumatic etiology (p=0.03). subjective complains of instability at presentation (p=0.006), and augmented reconstruction using a tendon graft (p=0.04). Conclusions: Lateral ligamentous reconstruction is an effective long-term procedure for posterolateral rotatory instability. Reconstruction using a tendon graft seems to provide better results than ligament repair. The results of ligamentous reconstruction do not seem to deteriorate with time.

02109 INDICATION, TIMING AND COMPLICATIONS OF PLATE REMOVAL AFTER FOREARM FRACTURES: RESULTS OF A METANALYSIS INCLUDING 635 caseS

B. Evers, R. Habelt. H. Gerngrofl.

Dept. of Surgery, Military Hospital, UIm, Germany

Aims: Removal of metal implants after complete fracture healing is controversial. Potential negative aspects of indwelling implants such as stress shielding, metal release, allergies, limitations for later surgical procedures contrast with high cost. Furthermore, knowledge about indication, timing and complications remains very limited. Purpose of this study was to analyse published reports on indication, timing and complications of forearm plate removal. Methods: 14 studies (1984 to 2002), including 635 cases of forearm plate removal, were analysed for indication, timing and complications. Results: While 69.1 % of the patients were asymptomatic. 30.9% com-plained of tenderness, barometric pain, implant prominence and bone infections. The average total frequency of complications was 24.0 ( 11.8-40)%: Iatrogenic nerve injuries occurred in 11.5 (2.0-29.1)%, followed by refractures in 7.7 (2.0-26.1)%, wound infections in 6.8 (4.8-11.5)% and hypertrophie scars in up to 9.1%. However, e.g. the increased forearm refracture rate turned out to be clearly associated with the use of 4.5mm DC plates, plate removal after less than 12 months, poor anatomic reduction and open fractures. Conclusions: Considering the identified risk factors, forearm plate removal can be performed with a low complication rate. Since the present analysis is based on a few heterogeneous retrospective studies, major prospective clinical studies are required to acquire representative data to finally answer the question whether to remove the implant or not. However, leaving metal implants in young patients is necessarily associated with disadvantageous biomechanical properties, inevitable metal release and may interfere with later bone surgical procedures.

Copyright British Editorial Society of Bone & Joint Surgery 2004
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