Elsevier

Injury

Volume 42, Issue 4, April 2011, Pages 366-370
Injury

Triceps-sparing versus olecranon osteotomy for ORIF: Analysis of 67 cases of intercondylar fractures of the distal humerus

https://doi.org/10.1016/j.injury.2010.09.004Get rights and content

Abstract

The purpose of this study was to compare the triceps-sparing approach with olecranon osteotomy regarding their effects on the functional outcomes of intercondylar fractures of the distal humerus managed with open reduction and internal fixation (ORIF), by reviewing 67 cases of intercondylar distal humerus fractures surgically managed with either of the approaches during 2001–2009. The medical records and radiographs of 30 male and 37 female patients, with a mean age of 44.5 years (range, 16–77) and a mean follow-up time of 34.3 months (range, 6–89), were retrospectively reviewed. Flexion, extension, arc of flexion/extension, pronation, supination, arc of pronation/supination and the Mayo Elbow Performance Score (MEPS) were used to assess the functional outcomes of intercondylar distal humerus fractures treated with ORIF through the triceps-sparing approach or olecranon osteotomy. According to the AO Foundation (AO) classification, there were 10 cases of C1, 28 cases of C2 and 29 cases of C3 fractures. At the time of review, all fractures had united. Although there was no overall statistically significant difference in the average flexion, extension, arc of flexion/extension, pronation, supination and arc of pronation/supination between the triceps-sparing group (n = 34) and the olecranon osteotomy group (n = 33), patients above 60 years of age tended to have more extension loss (mean 22.9°, range 0–55°) after ORIF via the triceps-sparing approach, compared with any other surgical approach/age combination group. In the triceps-sparing group, although only 37.5% of patients over the age of 60 years obtained excellent/good MEPS, the rate increased to 100% in patients aged less than 40 years of age (P < 0.05). By contrast, the rate of excellent/good MEPS remained above 80% in all age groups of patients treated with ORIF via olecranon osteotomy. In conclusion, ORIF via the triceps-sparing approach confers inferior functional outcomes for intercondylar distal humerus fractures in patients over the age of 60 years, for whom the olecranon osteotomy approach may be a better choice. However, for patients less than 60 years of age, especially those less than 40 years of age, either approach confers satisfactory outcomes.

Introduction

Intercondylar fractures of the distal humerus (AO type C) constitute approximately 1% of all factures in adults.1, 2 These fractures are often difficult to treat and have an uncertain outcome. Restoration of satisfactory elbow function requires anatomic reconstruction of the articular surface and stable fixation of the fractured fragments to allow early and full rehabilitation.20 As a result, many favour open reduction and internal fixation (ORIF).11, 12 As in all forms of surgery, exposure and access to the structure are critical. Various techniques have been described for approaching the posterior distal humerus, and controversy exists regarding which approach is optimal in minimising complications and enhancing function.17 Olecranon osteotomy has been considered the gold standard, providing excellent exposure and avoiding problems such as disruption of the extensor mechanism, fibrosis and intramuscular nerve injuries.9, 14, 16 On the other hand, osteotomies can be complicated with delayed union, nonunion and prominent hardware.9, 14, 15, 16 In 1982, Bryan and Morrey described an alternative technique of approaching the posterior elbow, in which the triceps mechanism was spared and reflected from medial to lateral without detachment.3 This technique, which is used in total elbow arthroplasty, provides excellent exposure, preserves the triceps mechanism and confers good outcomes for complex intercondylar fractures.3 The purpose of the present study was to compare the triceps-sparing approach with olecranon osteotomy regarding their effects on the functional outcomes of intercondylar fractures of the distal humerus managed with ORIF, by reviewing 67 cases of intercondylar distal humerus fractures surgically managed with either of the approaches.

Section snippets

Patients

The medical records and radiographs of 67 patients with intercodylar (AO type C) distal humerus fractures treated with ORIF via the triceps-sparing approach or olecranon osteotomy by fellowship-trained senior orthopaedic surgeons at Xiangya Hospital (a first-class hospital in China) during 2001–2009 were reviewed. Of the 67 patients, there were 30 males and 37 females, with a mean age of 44.5 years (range, 16–77) and a mean follow-up time of 34.3 months (range, 6–89). According to the AO

Results

At the time of review, radiological evidence of fracture union was present in all patients, with a mean time of 12 weeks (range, 7–18). Patients with an excellent or good MEPS (n = 54) showed full weight bearing without tenderness. All patients with a fair MEPS (n = 11) showed mild pain and those with a poor MEPS (n = 2) showed moderate pain. As shown in Table 1, although there was no overall statistically significant difference in the average flexion, extension, arc of flexion/extension, pronation,

Discussion

The present study compared the triceps-sparing approach with olecranon osteotomy with regard to their effects on the functional outcomes of intercondylar fractures of the distal humerus managed with ORIF. By reviewing 67 cases of intercondylar distal humerus fractures surgically managed with either of the two approaches, we found that ORIF via the triceps-sparing approach would confer inferior functional outcomes for intercondylar distal humerus fractures in patients over the age of 60 years,

Conclusions

The results of this study lead us to preferentially treat intercondylar distal humerus fracture in patients over the age of 60 years with ORIF via olecranon osteotomy. Nevertheless, for patients less than the age of 60 years, especially those less than the age of 40 years, ORIF via either the triceps-sparing approach or olecranon osteotomy can confer comparable satisfactory outcomes.

References (21)

There are more references available in the full text version of this article.

Cited by (70)

  • Management of Bicondylar Distal Humerus Fractures

    2023, Operative Techniques in Orthopaedics
  • Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study

    2022, Journal of Shoulder and Elbow Surgery
    Citation Excerpt :

    Our range-of-motion results are similar to those reported in the literature on distal humeral fractures treated with an OO approach. In the literature, the amount of flexion achieved has been reported as 99°-125°,5,8,38 with an extension deficit of 11°-25°5,8,13,21,38 and a flexion-extension arc of 98°-112°.2,5,21,38 Contracture release is required in 18%-57% of patients treated with osteotomy.6,13

  • Elbow hemiarthroplasty vs. open reduction internal fixation for acute Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 13C fractures—A systematic review

    2022, JSES International
    Citation Excerpt :

    There was 1 RCT32 and 26 case series1-3,6-10,14,18,20-22,24,27,28,30,36,38,42,44-47,50,51 (Table II). Eight case series8,9,20-22,30,45,51 were not clearly classified but were viewed as case series for the purpose of this review. Eight papers met our inclusion criteria.

View all citing articles on Scopus
View full text