jllr_25_20_R2_OA

Original Article
1 1
2 2
3 AQ2 Acute Ulnar Osteotomy versus Gradual Distraction by External Fixator 3
4 to Correct Missed Monteggia Type 1 Fracture‑Dislocation: A Comparative 4
5 5
6 Study 6
7 7
8 Abstract Abdelhakim Ezzat 8
9 Background: Monteggia fracture‑dislocations are complex injuries. These injuries, especially Marei, 9
10 neglected ones, remain a challenge for orthopedic surgeons. The aim of this study is to compare the 10
Mahmoud A.
11 results of acute and gradual ulnar lengthening osteotomies in treating chronic Monteggia fractures in 11
children. Patients and Methods: The study includes two groups of patients, treated at our institution El‑Rosasy
12 12
in the period from April 2014 to September 2018. The first group  (Group A) included nine patients Department of Orthopedics,
13 Unit of Limb Reconstruction
13
14 who were treated by an overcorrective ulnar osteotomy with acute lengthening with bone grafting. 14
and Pediatric Orthopedics,
The second group  (B) includes 11 children who were treated by Ilizarov distraction osteogenesis
15 Tanta School of Medicine, Tanta 15
for differential lengthening of forearm bones. There were 14 boys and 6 girls. The left elbow was University, Tanta, Egypt
16 involved in five patients and the right elbow was involved in 15  patients. According to the Bado
16
17 classification, all fractures were classified as Bado type I with anterior radial head dislocation. The 17
18 average age at the time of surgery was 7 years and 4 months. Results: The mean interval from the 18
19 injury to surgical interference was 8.6 months. There was a significant improvement of the elbow 19
20 range of motion and Mayo elbow performance score. In group B, the mean external fixation time 20
21 was 9.7  weeks  (range from 9 to 15  weeks). The mean total treatment time was 12.3  weeks  (ranged 21
22 from 12 to 16 weeks). Superficial pin‑tract infection occurred in all cases and was managed without 22
23 further sequelae. Conclusions: Both approaches yielded equally good results. The open surgery 23
approach entails a more invasive procedure, but more convenient to the patient and no arduous
24 24
postoperative follow‑up is needed. On the contrary, differential lengthening of forearm bones is a
25 percutaneous procedure with the application of Ilizarov principles in a controlled biological manner;
25
26 with no graft materials are needed. Both techniques effectively reduced the radial head. 26
27 27
28 Keywords: Ilizarov, missed Monteggia fracture, reconstruction, ulnar osteotomy 28
29 29
30 30
Introduction deformity of the elbow, chronic pain and
31 disability, limitation of elbow flexion and 31
32 Monteggia fracture‑dislocations are 32
forearm rotation, overgrowth of the radial Submitted: 23-Sep-2020
33 complex injuries usually comprising 33
AQ3
head, and tardy ulnar neuritis.[3] Revised: ???
34 fractures of the ulna associated with Accepted: 14-Dec-2020 34
radiocapitellar dislocation and proximal Missed or chronic Monteggia lesions are Published: ***
35 35
36 radioulnar joint dissociation. These rare not uncommon. This may be attributed to 36
37 injuries constitute <1% of all forearm the lack of experience or diagnostic skills. Address for correspondence: 37
38 fractures in children. They occur mostly Successful treatment of those types of Dr. Abdelhakim Ezzat Marei, 38
39 between 4 and 10 years of age.[1] These injuries is achieved by the restoration of a Department of Orthopedics, 39
normal alignment of the ulna to obtain a Unit of Limb Reconstruction
40 injuries, especially neglected ones, remain 40
and Pediatric Orthopedics,
41 a challenge for orthopedic surgeons. concentric reduction of the radial head.[4] Tanta School of Medicine, 41
42 Diagnosis is frequently missed in up to 33% Treatment of chronic Monteggia lesions Tanta University, Tanta, Egypt. 42
43 of cases. After 4 weeks, the condition can remains challenging and numerous
E‑mail: abdelhakimezzat@ 43
gmail.com
44 be called “chronic Monteggia.” Neglected procedures were introduced, e.g., ulnar 44
45 cases usually develop malunion of the ulnar osteotomy, open reduction of the radial 45
46 fracture and soft‑tissue contractures of the head dislocation with or without annular 46
47 proximal radioulnar and radiocapitellar ligament reconstruction. Differential
Access this article online 47
48 joints, making reduction difficult.[2] Missed lengthening of the ulna through a proximal Website: 48
49 Monteggia lesions can lead to valgus ulnar osteotomy, so that the radial head is
www.jlimblengthrecon.org
49
50 This is an open access journal, and articles are gradually reduced without open surgery is
DOI: 10.4103/jllr.jllr_25_20 50
51 distributed under the terms of the Creative Commons another approach. The aim of this study
Quick Response Code: 51
52 Attribution‑NonCommercial‑ShareAlike 4.0 License, which 52
allows others to remix, tweak, and build upon the work
53 non‑commercially, as long as appropriate credit is given and How to cite this article: Marei AE, El‑Rosasy MA. 53
54 the new creations are licensed under the identical terms. Acute ulnar osteotomy versus gradual distraction by 54
external fixator to correct missed Monteggia type 1
55 fracture‑dislocation: A  comparative study. J  Limb 55
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.
56 com Length Recon 2020;XX:XX-XX. 56

© 2020 Journal of Limb Lengthening & Reconstruction | Published by Wolters Kluwer - Medknow 1
 AQ1 Marei and El‑Rosasy: Running title missing???

1 is to compare the outcome of both techniques, investigate Technique of overcorrective osteotomy 1

2 their merits and shortcomings, and when to use either. 2
After the administration of general anesthesia, and under
3 3
Patients and Methods tourniquet, the proximal ulnar shaft was exposed through
4 4
a longitudinal incision placed directly on the subcutaneous
5 This is a retrospective study of 20 cases of missed 5
border. The incision was extended proximally above the
6 Monteggia fracture‑dislocation treated in our department in 6
olecranon by approximately 2 cm. The lateral skin flap
7 the period from April 2012 to September 2016. Our series 7
was elevated to expose the Kocher interval  (interval
8 included 14 boys and 6 girls. The right elbow was involved 8
between the anconeus and the extensor carpi ulnaris) which
9 in nine patients, and the left elbow was involved in the 9
was used to expose the radiocapitellar articulation. The
10 remaining 11  patients. All the injuries were classified as 10
11 ulnar osteotomy was done at the healed fracture site or 11
Bado type I. approximately 2.5 cm from the coronoid process in cases
12 12
13 The average age at the time of operative interference was with plastic deformation. The radiocapitellar joint was 13
14 9  years  (range 5  years to 13  years and 7 months). The carefully debrided from any interposed tissue that could 14
15 average time interval between the traumatic incident and prevent the reduction of the radial head. The osteotomy was 15
16 the surgery was 8.7 months  (range 2–18 months). One manipulated till a concentric radiocapitellar reduction was 16
17 child presented with posterior interosseous nerve palsy. obtained. The position that could maintain joint reduction 17
18 All the patients had limitation of elbow flexion before was at approximately 1 cm of lengthening with an apex 18
19 surgery with a mean Mayo elbow performance score of dorsal and slightly ulnar. A small reconstruction plate 19
20 75.5.[5] was contoured with a dorsal‑ulnar apex. The distraction 20
21 of the osteotomy site was done by a lamina spreader. 21
Nine patients  (Group A) underwent overcorrective The plate was applied and radiocapitellar reduction was
22 22
osteotomy of the ulna with acute lengthening, plate assessed in various positions using fluoroscopy. Iliac
23 23
fixation, and iliac bone grafting. All those patients had bone graft was harvested and added to the osteotomy
24 24
25 open reduction of the dislocated radial head. A long arm site. Soft tissue was closed tightly over the joint without 25
26 cast was applied till osteotomy healing. annular ligament reconstruction. If there are remnants of 26
27 The remaining 11  patients  (Group B) underwent gradual the annular ligament, they were re‑approximated over the 27
28 correction of the deformed ulna by means of the circular radial head or sutured to the ulnar periosteum by 2‑0 or 3‑0 28
29 external fixator. The ulna was lengthened with gradually nonabsorbable sutures. A freer elevator was used to reduce 29
30 increasing the posterior apex of the osteotomy. The the annular ligament over the radial head. Wounds were 30
31 dislocated radial head was gradually reduced to its original closed and an above elbow splint was applied that was 31
32 positioned without the need for open reduction. The frame changed to a long arm cast on the 3rd day. 32
33 was removed after the consolidation of the regeneration. Technique of gradual correction by circular fixator 33
34 The choice of either technique was done randomly after 34
35 a detailed discussion with the parents about the merits, Under general anesthesia and no tourniquet was used, a 35
36 difficulties, and complications of each method. preconstructed Ilizarov frame was applied to the forearm. 36
37 The frame was formed of a proximal half ring and 37
38 Patients were followed clinically and radiographically. distal full ring connected by two hinges. The axis of the 38
39 Physiotherapy was advised. The Mayo elbow performance hinges was located at the level of ulnar osteotomy in the 39
40 score was used to assess the postoperative function coronal plane to allow dorsal angulation of the lengthened 40
41 at the final follow‑up. Patients were categorized as ulnar osteotomy site. The frame was fixed proximally by 41
42 excellent (>90), good (89–75), fair (74–60), and poor (<60). two 4‑mm half pins inserted into the proximal ulna in a 42
43 Table  1 summarizes the preoperative data separately in posterior to anterior direction and attached to the proximal 43
44 both groups. half ring. The distal fixation consists of two 4‑mm half 44
45 pins inserted into the ulnar diaphysis and attached to the 45
46AQ4 Table 1: ??? full ring. To maintain the distal radio‑ulnar relationship, 46
47 one half pin was inserted into the radius diaphysis, with 47
48 the forearm in full supination, and this pin was attached 48
49 to the distal full ring. Figure  1 shows the final assembly 49
50 of the fixator. A  percutaneous osteotomy, using multiple 50
51 drill holes and osteotome, was then performed in the 51
52 proximal ulnar metaphysis 1 cm distal to the coronoid 52
53 process. The ulnar osteotomy was axially distracted after 53
54 7 days at a rate of 1 mm per day until the radius head is 54
55 seen pulled down well‑below the capitellum. Then, angular 55
56 distraction was performed to produce posterior angulation 56

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 Marei and El‑Rosasy: Running title missing??? AQ1

1 of the proximal ulna pushing the radius head gradually For him, we performed external neurolysis at the time of 1
2 to the position in line with capitellum. The frame was overcorrective osteotomy. Electromyography at 3 months 2
3 tightened and left in place until radiological consolidation after neurolysis showed no recovery potentials. Hence, 3
4 of the ulnar osteotomy [Figure 2]. The radial half pin was tendon transfer was conducted. The patient did not have a 4
5 first removed to allow pro‑supination movements. After palmaris longus, so the flexor digitorum superficialis of the 5
6 full consolidation, the frame was removed and above fourth digit was transferred to the extensor pollicis longus, 6
7 elbow cast was applied in pronation and 100° flexion for and the flexor carpi radialis was transferred to the extensor 7
8 4 weeks to avoid stress fractures at pin‑sites. After which digitorum communis. Figure  4 shows the final range of 8
9 physiotherapy and rehabilitation were conducted. motion of this case. 9
10 10
11 Statistical analysis Discussion 11
12 The comparisons between the two groups were analyzed Missed or chronic Monteggia lesions are not uncommon. 12
13 using the Mann–Whitney test for continuous variables and This may be attributed to the lack of experience or 13
14 Fisher’s exact test for categorical variables. P < 0.05 was diagnostic skills. Successful treatment of those types of 14
15 AQ5 set as the cutoff for the level of significance. SPSS 17.0 was injuries is achieved by the restoration of a normal alignment 15
16 used for statistical analysis. of the ulna to obtain a concentric reduction of the radial 16
17 head.[4] In neglected or chronic Monteggia lesions, the 17
AQ6
18 Results annular ligament is usually avulsed or entrapped preventing 18
19 concentric reduction.[6] 19
The mean follow‑up of the patients was 17 months  (range
20 20
12–24 months). The mean time for the union in cases After aligning the ulnar fracture in acute cases, the radial
21 21
treated by overcorrective ulnar osteotomy was 2.7 head usually reduces with a palpable clunk. This should
22 22
months  [Figure  3]. For cases managed by circular fixator, be monitored fluoroscopically. Feeling a rubbery resistance
23 23
the mean time needed for full consolidation of the may suggest soft‑tissue interposition that can be the
24 24
regenerate was 3.8 months. Pin‑tract infection was reported periosteum or annular ligament.[7]
25 25
in all patients treated by circular fixators and managed
26 26
conservatively with local care and systemic antibiotics. AQ4
27 Table 2: ??? 27
On the last follow‑up, the range of movement in all
28 28
cases showed significant improvement compared to the
29 29
preoperative range. The Mayo score improved significantly
30 30
in both groups. The mean Mayo score in group A was
31 31
32 94.4 and that for group B was 95 at the final follow‑up. 32
33 There was a nonsignificant difference between Mayo elbow 33
34 performance score between the two groups  (P  =  0.97). 34
35 Table  2 summarizes the postoperative data at the final 35
36 follow‑up in both groups. 36
37 One child treated with overcorrective osteotomy 37
38 presented, preoperatively, with a missed Monteggia 38
39 fracture‑dislocation and posterior interosseous nerve palsy. 39
40 40
41 41
42 42
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45 45
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Figure 2: Final consolidation of the bone regenerate at the site of ulnar
55 55
lengthening. Notice the angulation at the osteotomy site and the concentric
56 Figure 1: Final assembly of the circular fixator prior to ulnar osteotomy reduction of the radiocapitellar joint 56

Journal of Limb Lengthening & Reconstruction | Volume XX | Issue XX | Month 2020 3

 AQ1 Marei and El‑Rosasy: Running title missing???

1 The interval between the anconeus and the extensor carpi forearm rotation and elbow flexion, overgrowth and early 1
2 ulnaris  (Kocher interval) provides an adequate exposure physeal closure of the radial head, and late ulnar nerve 2
3 of the radiocapitellar articulation.[8] Another approach that palsies.[12] Early diagnosis and treatment are fundamental 3
4 is more extensile was introduced by Boyed.[9] Keeping the to reduce these sequelae. However, there are still some 4
5 forearm pronated during the exposure helps protect the complications reported after surgical treatment of such 5
6 posterior interosseous nerve. Anterior, Henry’s approach cases, including elbow stiffness or instability, nonunion 6
7 to the radiocapitellar articulation was also described as a or malunion of the osteotomies, growth disturbance 7
8 method of reduction, with better exposure of the nerve, or avascular necrosis of the radial head, nerve injury, 8
9 that also facilitates neurolysis, when needed. Synostosis infection, and degenerative arthritis.[13] 9
10 was reported in some series with Boyd’s and Kocher’s 10
11 approach. However, both approaches facilitate annular Although reconstruction and joint relocation provide the 11
12 ligament reconstruction.[10] best results,[14] Hirayama et al. recommended avoiding joint 12
13 reduction in neglected cases with deformation of the radial 13
Numerous procedures were introduced to treat chronic head or capitellum. A normal concave radial head articular
14 14
Monteggia injuries, e.g., ulnar osteotomy, open reduction surface and normal shape and contour of capitellum
15 15
of the radial head dislocation with or without annular are important prerequisites for reduction.[15] Reduction
16 16
ligament reconstruction, radial osteotomy, and radial head after more than 3  years was also reported to increase the
17 17
excision at the end of the growth.[11] incidence of complications.[16]
18 18
19 Chronic lesions may be complicated by progressive valgus Restoration of the alignment of the ulnar shaft is the most 19
20 deformity of the elbow, restricted motion, especially crucial step to achieve a concentric reduction. Many authors 20
21 recommend concurrent reconstruction of the annular 21
22 ligament in conjugation with ulnar osteotomy.[17] But in our 22
23 series, we did not find this important. Reconstruction of the 23
24 annular ligament remains controversial. Annular ligament 24
25 reconstruction may, however, increase the incidence 25
26 of elbow stiffness, heterotopic ossification, radio‑ulnar 26
27 synostosis, or avascular necrosis of the radial head.[18] Plate 27
28 fixation provides a sufficient stability for the lengthened 28
29 and angulated ulna. Bone grafting of the osteotomy site 29
30 was done in the overcorrective osteotomy group. This has 30
31 been supported in a number of series.[13] 31
32 32
33 Lammens et  al., first described the principles of gradual 33
a b c d ulnar lengthening and angulation using Ilizarov external
34 34
35 Figure 3: (a and b) preoperative radiographs of a case of neglected Bado fixator to reconstruct the elbow.[19] This was followed by 35
type 1 Monteggia fracture dislocation. (c and d) Postoperative radiographs
36 of the same case 3 months after acute over-corrective osteotomy and bone several case reports with satisfactory outcomes.[20] To the 36
37 grafting, showing concentric reduction of the radiocapitellar joint best of our knowledge, there are no studies comparing 37
38 38
39 39
40 40
41 41
42 42
43 43
44 44
45 45
46 a b c 46
47 47
48 48
49 49
50 50
51 51
52 52
53 53
d e
54 54
Figure 4: Final range of motion of a case suffering from posterior interosseus nerve palsy. The patient was treated by acute over-corrective ulnar osteotomy
55 55
and lengthening. Three months later the patient underwent tendon transfer. (a and b) Flexion, extension range; (c and d) supination, pronation range, (e)
56 fingers and thumb extension after tendon transfer 56

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1 between acute ulnar overcorrective osteotomy and gradual In: Morrey  BF, editor. The Elbow and its Disorders. 3rd ed. 1
2 correction by distraction osteogenesis. Philadelphia: WB Saunders; 2000. p. 82. 2
3 6. Tan  JW, Mu  MZ, Liao  GJ, Li  JM. Pathology of the annular 3
The incidence of radial nerve injury with Monteggia ligament in paediatric Monteggia fractures. Injury 2008;39:451‑5.
4 4
lesions is approximately 10%–20%, making it the most 7. Tompkins DG. The anterior Monteggia fracture: Observations on
5 5
common complication. Nerve recovery is the role in most etiology and treatment. J Bone Joint Surg Am 1971;53:1109‑14.
6 6
cases, usually by the 3rd month. Neurolysis through a 8. Park H, Park KW, Park KB, Kim HW, Eom NK, Lee DH. Impact
7 of open reduction on surgical strategies for missed monteggia 7
separate anterolateral approach was required in some series
8 fracture in children. Yonsei Med J 2017;58:829‑36. 8
to restore nerve function.[21]
9 9. Boyd  HB. Surgical exposure of the ulna and proximal one 9
10 Regarding our study, the small sample sizes in both groups third of the radius through one incision. Surg Gynecol Obstet 10
11 remain, however, an important limitation. 1940;71:86‑8. 11
12 10. Wang MN, Chang WN. Chronic posttraumatic anterior 12
13 Conclusions dislocation of the radial head in children: thirteen cases treated
13
by open reduction, ulnar osteotomy, and annular ligament
14 The open surgery is preferred in cases necessitating reconstruction through a Boyd incision. J  Orthop Trauma 14
15 exposure of the radial head, e.g., heterotopic ossification 2006;20:1‑5. 15
16 requiring open excision and posterior interosseous nerve 11. Di Gennaro GL, Martinelli A, Bettuzzi C, Antonioli D, Rotini R. 16
17 palsy which needs nerve exploration. The differential Outcomes after surgical treatment of missed Monteggia fractures 17
18 in children. Musculoskelet Surg 2015;99 Suppl 1:S75‑82. 18
lengthening approach is best suited for chronically
19 12. Holst‑Nielson  F, Jensen  V. Tardy posterior interosseus nerve 19
dislocated radius head with excessive proximal migration. palsy as a result of an unreduced radial head dislocation in
20 The choice of either technique is based on the preoperative 20
Monteggia fractures: A  report of two cases. J  Hand Surg Am
21 requirements of each case and detailed discussion with the 1984;9:572‑5. 21
22 parents or caregivers regarding the merits and difficulties of 13. Hasler  CC, Von Laer  L, Hell  AK. Open reduction, ulnar 22
23 each method and the expected outcomes. osteotomy and external fixation for chronic anterior dislocation 23
24 of the head of the radius. J Bone Joint Surg Br 2005;87:88‑94. 24
25 AQ7 Ethical approval 14. Fowles  JV, Sliman  N, Kassah  MT. The Monteggia lesion in 25
26 children. Fracture of the ulna and dislocation of the radial head. 26
The authors declare that all investigations were conducted
J Bone Joint Surg Am 1983;65:1276‑82.
27 in conformity with ethical standards. Informed consent for 27
15. Hirayama  T, Takemitsu  Y, Yagihara  K, Mikita  A. Operation for
28 participation in the study was obtained from the parents. 28
chronic dislocation of the radial head in children. Reduction by
29 osteotomy of the ulna. J Bone Joint Surg Br 1987;69:639‑42. 29
30 Financial support and sponsorship 30
16. Nakamura  K, Hirachi  K, Uchiyama  S, Takahara  M, Minami  A,
31 Nil. Imaeda  T, et al. Long‑term clinical and radiographic outcomes 31
32 after open reduction for missed Monteggia fracture‑dislocations 32
33 Conflicts of interest in children. J Bone Joint Surg Am 2009;91:1394‑404. 33
34 There are no conflicts of interest. 17. Hui  JH, Sulaiman  AR, Lee  HC, Lam  KS, Lee  EH. Open 34
reduction and annular ligament reconstruction with fascia of
35 35
the forearm in chronic monteggia lesions in children. J  Pediatr
36 References 36
Orthop 2005;25:501‑6.
37 1. Babb A, Carlson WO. Monteggia fractures: Beware! S D J Med 18. Oner FC, Diepstraten AF. Treatment of chronic post‑traumatic 37
38 2005;58:283‑5. dislocation of the radial head in children. J  Bone Joint Surg Br 38
39 2. David‑West  KS, Wilson  NI, Sherlock  DA, Bennet  GC. Missed 1993;75:577‑81. 39
40 monteggia injuries. Injury 2005;36:1206‑9. 19. Lammens  J, Mukherjee  A, Van Eygen  P, Fabry  G. Forearm 40
41 3. Kim  HT, Conjares  JN, Suh  JT, Yoo  CI. Chronic radial head realignment with elbow reconstruction using the Ilizarov fixator. 41
42 dislocation in children, Part  1: Pathologic changes preventing A case report. J Bone Joint Surg Br 1991;73:412‑4. 42
stable reduction and surgical correction. J  Pediatr Orthop 20. Exner  GU. Missed chronic anterior Monteggia lesion. Closed
43 2002;22:583‑90.
43
reduction by gradual lengthening and angulation of the ulna.
44 4. Rahbek  O, Deutch  SR, Kold  S, Søjbjerg JO, Møller‑Madsen  B. J Bone Joint Surg Br 2001;83:547‑50. 44
45 Long‑term outcome after ulnar osteotomy for missed Monteggia 21. Spinner  M, Freundlich  BD, Teicher  J. Posterior interosseous 45
46 fracture dislocation in children. J Child Orthop 2011;5:449‑57. nerve palsy as a complication of Monteggia fracture in children. 46
47 5. Morrey  BF, An  KN. Functional evaluation of the elbow. Clin Orthop Relat Res 1968;58:141‑5. 47
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Journal of Limb Lengthening & Reconstruction | Volume XX | Issue XX | Month 2020 5

Author Queries???
AQ1: Please provide running title.
AQ2: Kindly check the article title provided in Front page “Over‑corrective Ulnar Osteotomy versus Gradual Distraction
by External Fixator to Correct Missed Monteggia Type  1 Fracture‑Dislocation; a Comparative Study” please
confirm.
AQ3: Kindly provide revised date.
AQ4: Kindly provide physical table for Tables 1 and 2.
AQ5: Please provide complete manufacturer details such as company name, city, state and country for “SPSS” as per
style.
AQ6: References 4 and 13 were identical to references 6 and 20, respectively. Hence, references 6 and 20 had been
deleted from the reference list and from the text as per style, and subsequent references have been renumbered in
the text and in the reference list. Please check.
AQ7: Kindly check whether the text is needed or not.

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