Elbow dislocation is a common dislocation among the major joints in adults with usually simple and satisfying treatment (
1). In contrast, old elbow dislocation is rare with difficult treatment. Old elbow dislocation is more common in developing countries ( 4, 5). In these countries, it is difficult to use new technology such as the hinge external fixator because of the prohibitive costs. On the other hand in the developed countries, this neglected dislocation is rare. Consequently, there is a dearth of data on the results of its treatment with early ROM using a hinge external fixator ( 1). The best approach to old unreduced elbow fracture and fracture dislocation is, therefore, still unclear.
Almost all authors prefer to use the posterior approach for open reduction, while Potini et al. (
6) prefer medial over the top, Mahaisavariya et al. ( 4) opt for triceps splitting, and Coulibaly et al. ( 5) and Jupiter ( 2) favor the paratriceps approach. We used either paratriceps or trans-olecranon approach with the same encouraging results. We did not make any change to our postoperative protocol because of olecranon osteotomy, and nor did we face any additional complications related to osteotomy. What is more, we enjoyed a better view of the joint structures. Reconstruction of the joint was also simpler in this approach. We would not suggest the application of olecranon osteotomy in all cases; nevertheless, we never tend to hesitate to utilize this approach in difficult cases.
Triceps contraction is a problem, especially in long-term neglected dislocations (
4, 5). Triceps lengthening is mandatory in such cases. The most common type of lengthening is the V-Y plasty of the triceps. We were forced to lengthen the triceps in 3 of our patients with 8, 12, and 12 months’ delay in treatment, respectively. We performed a fractional lengthening of the triceps in the musculotendinous portion and manipulation with good results. The number of cases is too small to formulate a suggestion, but it could be considered as an option.
There are some controversies about the importance of the repair or reconstruction of the collateral ligaments with the application of the hinge external fixator and resumption of the elbow motion very soon after surgery (
2, 4- 6). Our study supports the opinion that repair or reconstruction of the collateral ligaments is not mandatory for a concentric reduction and stable joint at the final follow-up in this treatment technique.
Our English literature review of studies with at least 5 patients with old dislocation and fracture-dislocation treated with hinge external fixation and early ROM yielded 4 papers. Ruch and Triepel (
3) reported 8 patients treated with the external fixator: 5 of them in old elbow fracture-dislocation. They had an average of 84-degree elbow ROM with an average flexion contraction of 33 degrees, and all the patients showed concentric reduction at the final follow-up. Ring et al. ( 7) reviewed 13 patients with old unreduced elbow fracture-dislocation: all the patients recovered elbow stability with an average Mayo Elbow Performance Index score of 84 and average elbow motion of 99 degrees. Potini et al. ( 6) retrospectively reviewed 7 patients with old elbow fracture-dislocation with at least one month’s delay in treatment. At least 5 of their patients had fractures interfering with elbow stability. The average elbow ROM reached 120 degrees with stable joint in their patients. The authors confronted major complications in 4 of their patients. None of these papers could be compared with our study, which is mainly focused on chronic dislocations. Jupiter and Ring ( 2) published the largest case-series with old elbow dislocation treated via open reduction and hinge external fixators in 5 patients with old elbow dislocation without associated fracture who required no lengthening of the triceps or other soft tissues. The investigators also used a passive gear incorporated into the hinge external fixator and drew upon gradual active mobilization as their postoperative treatment. Their study population had an average age of 49 years, and all the patients had medical attention after their injury. The delay in treatment was an average of 11 weeks. The authors found stable concentric reduction in all of their patients at the last follow-up. The average arc of elbow motion was 123 degrees with 136-degree flexion and 13-degree flexion contraction. The average of the Mayo Elbow Performance Index score was 89. The results of elbow ROM and Mayo score were superior in Jupiter and Ring’s study. However, there are some differences between their study and ours. The delay to surgical treatment is significantly longer in our series, obliging us to do fractional lengthening in 2 of our 8 patients. Another point of great significance is the efficacy of physical therapy after treatment. Most of our patients came from provinces far from the capital city, which precluded us from providing them with physical therapy under our own supervision. We merely trained them and their family regarding active-assisted early ROM. Our results, therefore, may have been affected by these factors. Be that as it may, all of our patients gained a stable painless elbow with functional ROM.
First and foremost among the limitations of the present study is its low sample volume. Nonetheless, it is still one of the largest studies in the field of treatment of elbow dislocation and fracture-dislocation with the application of the hinge external fixator. Furthermore, to the best of our knowledge, it is also the largest case-series of old elbow dislocation treated with this technique (
1, 2). Reporting old dislocation together with old fracture-dislocation is another weak point of our study, but it is deserving of note that it is not uncommon in other studies ( 4- 6). To our mind, these two categories share the same principles of treatment. We also sought the objective of evaluating the role of olecranon osteotomy in the treatment with hinge elbow fixation. Finally, we assessed the results of pure old dislocations separately for comparison with other studies. We excluded one of our patients from statistical evaluation (Patient 6). As was mentioned before, we are of the opinion that the complication of this patient, who lost his elbow motion, was due to primary articular surface damage and, as such, cannot be considered a problem related to the treatment. Although we could not compare patients with and without olecranon osteotomy, we have been able to introduce this option for difficult cases. The present study is retrospective in its design; however, in our view in such a rare condition, this can offer us a better concept of treatment options.