Treatment of long-standing dislocation of the radial head in neglected monteggia fractures

The Monteggia injury is defined as radial head dislocation with a fracture of the ulnar shaft. This combination should be sought routinely in patients with ulnar fractures, even when the displacement is small. The emergent management is simple, as reducing the ulnar fracture is usually sufficient to stabilise the radial head. Internal fixation of the ulna deserves to be widely used to fully stabilise the radial head. Irreducibility of the radial head at the acute stage may indicate an interposition, which requires open surgery on the joint. Radial head dislocation may occur even with minimal displacement of the ulnar fragment. Chronic Monteggia fractures are more challenging to treat and their outcomes are more variable. The radial head becomes irreducible after 2 to 3 weeks. When a simple surgical approach fails to ensure stable reduction, the most widely used method at present is open reduction of the radial head and proximal osteotomy of the ulnar shaft. Stability must be obtained intra-operatively. Without treatment, radial head dislocation may be well tolerated for several months or even years. In the long term, however, osteoarticular remodelling results in loss of joint congruence, pain and, eventually, osteoarthritis. Radiographs must therefore be obtained on an emergency basis and analysed with great care to avoid missing a Monteggia fracture.

Chronic posterior subluxation or dislocation of the radial head is uncommon and difficult to treat. To restore radiocapitellar alignment, procedures such as deepening of the notch using a high-speed burr have been described, but they can result in cartilage damage. We hypothesized that a radial notch labralization using soft tissue could improve radiocapitellar tracking without violating the joint surface.

A radial notch labralization was performed in 3 patients with chronic posterior subluxation of the radial head and developmental dysplasia of the radial notch in the setting of complex recurrent instability of the elbow. A soft tissue graft (typically a portion of an allograft hamstring tendon) was used to create a meniscus-like bumper posteriorly, thereby deepening the radial notch and reducing its radius of curvature. A corrective anterior opening wedge ulnar osteotomy was also performed to realign the radial head with the capitellum.

At a mean follow-up of 32 months, all 3 patients were pain free and had maintained a stable joint, with a functional range of motion. Each patient gave a rating of either “Greatly Improved” or “Almost Normal” on the Summary Outcome Determination scale. Radiographs performed during the last follow-up showed improved radiocapitellar alignment.

Chronic posterior subluxation or dislocation of the radial head can occur subsequent to developmental joint changes. The radial notch labralization using a soft tissue graft associated with a corrective ulnar osteotomy was successful in restoring radial head stability and avoiding cartilage damage.

To evaluate the mid- to long-term clinical and radiographic outcomes after surgical treatment of chronic anterior dislocation of the radial head in children.

Open reduction was performed in 16 children (mean age, 9.3 years [range, 2.6–13.6 years]) with chronic anterior dislocation of the radial head. Twelve patients had a history of preceding injuries, with a mean interval between injury and surgery of 24 months (range, 2–86 months); 4 patients did not have injuries. Eight patients who had undergone reduction within 16 months were treated by open reduction and ulnar osteotomy. The other 8 patients who had not sustained trauma or had been injured >2 years previously required either annular ligament reconstruction or radial shortening in addition to ulnar osteotomy.

The average preoperative Kim's elbow performance score was 77.2 ± 10.5, which significantly improved to 97.5 ± 5.8 at the final follow-up. The radial head was maintained in a reduced position in 14 patients and was subluxed in 2. Slight osteoarthritic changes of the elbow were observed in 2 patients with good reduction. The functional results were excellent in 15 and were good in 1 patient with an average follow-up of 6.5 years (range, 2.6–15.1 years).

Our surgical procedure provided good mid- to long-term clinical and radiographic outcomes.

The aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children.

This retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling.

Twenty-eight patients were reviewed, at a mean 6 years’ follow-up (range, 2–34 y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation.

Proximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful.

IV (retrospective).

Le but de notre étude était d’analyser les résultats à moyen et long termes de l’ostéotomie de l’extrémité proximale de l’ulna avec et sans ligamentoplastie dans les lésions de Monteggia vieillies chez l’enfant.

Dans cette étude rétrospective, multicentrique de 28 patients, les critères cliniques concernaient la mobilité, la douleur, et le score MEPI ; les critères radiographiques, la ligne de Storen, le head-neck ratio, l’angulation du col radial, et la recherche de remaniements ostéo-arthrosiques.

Vingt-huit patients ont été revus, avec un recul moyen de 6 ans (2–34 ans). Seize patients ont eu une ostéotomie proximale de l’ulna sans ligamentoplastie, 12 patients ont eu une ligamentoplastie. Les deux groupes ont eu une amélioration significative clinique et radiologique. Il n’a pas été retrouvé de différence significative en comparant leurs résultats. Les patients opérés dans un délai inférieur à 1 an présentaient de meilleurs résultats cliniques et radiologiques. Il n’existait pas de corrélation entre l’âge à l’intervention et la qualité des résultats. Les 5 patients ayant eu une broche trans-condylo-radiale ont eu une récidive précoce de la luxation et des remaniements ostéo-arthrosiques. Les trois cas Bado 3 ont eu une récidive précoce de la luxation.

L’intervention de Bouyala donne de bons résultats à long terme, dans les lésions Bado 1, quel que soit l’âge, en cas de prise en charge avant 1 an, en l’absence de remaniement ostéo-arthrosique. L’intérêt de la ligamentoplastie dépend de la complication à traiter.

IV (étude rétrospective).