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Monteggia-like lesions - Behandlungsstrategien und Ein-Jahres-Ergebnisse
No full textIntroduction: The eponym "Monteggia fracture" includes various patterns of complex fracture-dislocations of the proximal ulna and radius, which are not well defined yet. They are frequently described as Monteggia-like lesions or Monteggia equivalent injuries. Until today, these injury patterns have been reported rarely. The objective of this retrospective study was to better define patterns of injury and to document the short-term results of treatment with current fixation techniques.Methods: Ten patients with a Monteggia-like lesion were included in this study and clinical and radiological follow-up examinations at an average of 12.3 months after the trauma were performed. For clinical follow-up the Mayo Modified Wrist Score, the Mayo Elbow Performance Score, the functional rating index of Broberg and Morrey, and the DASH score were utilized.Results: Osteosynthesis of the ulna was performed using a proximally contoured or precontoured LCP (locking compression plate) in all patients. All patients had a fracture of the radial head. All patients with a Mason type III radial head fracture received a cemented bipolar radial head prosthesis. All Mason type II fractures were treated with open reduction and internal fixation using mini screws. In all Mason type I fractures the treatment of the radial head dislocation was by closed reduction. Associated coronoid fractures were stabilized with lag screws through the ulnar plate or with independent lag screws after reduction of the fracture. According to the aforementioned scoring systems good to excellent results could be achieved.Conclusions: Our findings demonstrate that good or excellent short-term results can be obtained if the injury is classified correctly and a standardized surgical treatment of all components of the injury is achieved. Further studies with larger patient populations and longer follow up periods are needed to evaluate long-term effectiveness of this treatment concept.Einleitung: Der Begriff "Monteggia-Fraktur" beinhaltet verschiedene Fraktur- und Verletzungskonstellationen an der proximalen Ulna und des Radius, welche bislang nicht eindeutig definiert wurden. Diese werden häufig als Monteggia-like lesions oder Monteggia-Äquivalent-Verletzungen beschrieben. Diese Verletzungsmuster wurden bis heute nur selten evaluiert. Das Ziel dieser retrospektiven Studie war die Erfassung von Ein-Jahres-Ergebnissen dieser seltenen Verletzungen nach deren Behandlung mit modernen Osteosyntheseverfahren. Methoden: Zehn Patienten mit einer Monteggia-like lesion konnten in die Studie eingeschlossen und durchschnittlich nach 12,3 Monaten posttraumatisch klinisch und radiologisch nachuntersucht werden. Für die Nachuntersuchung wurden der Mayo Modified Wrist Score, der Mayo Elbow Performance Score, der Functional Rating Index von Broberg and Morrey und der DASH Score erhoben.Ergebnisse: Bei allen Patienten erfolgte die osteosynthetische Versorgung der Ulna mittels einer proximalen intraoperativ anmodellierten oder bereits vorgeformten LCP (Locking Compression Plate). Alle Patienten wiesen eine Radiuskopffraktur auf. Alle Patienten mit einer Mason Typ III Radiuskopffraktur erhielten eine zementierte bipolare Radiuskopfprothese. Alle Mason Typ II Frakturen wurden mittels offener Reposition und Minischraubenosteosynthese operativ versorgt. Bei allen Typ I Frakturen erfolgte eine geschlossene Reposition. Begleitverletzungen des Processus coronoideus wurden mittels Zugschraubenosteosynthese behandelt. Bezüglich der ausgewählten Scoring Systeme konnten gute bis exzellente Ergebnisse erzielt werden.Schlussfolgerung: Unsere Ergebnisse demonstrieren, dass nach korrekter Klassifikation und einer standardisierten operativen Behandlungsstrategie gute bis exzellente Ein-Jahres-Ergebnisse erzielt werden können. Weiterführende Studien mit größerem Patientenkollektiv und längerem Nachuntersuchungszeitraum sollten sich zur weiteren Evaluation dieses Behandlungskonzepts anschließen
How To Approach Monteggia-Like Lesions In Adults
No full textBackground
Monteggia-like lesions encompass a wide spectrum of forearm and elbow fractures associated with dislocations, subluxations and ligamentous lesions.
Many attempts have been made to classify these injuries, not only to understand their pathology but also to develop optimal treatments.
Unfortunately, although some of these classifications are complete, they are complex, not immediately usable and not exhaustive. An orthopedic surgeon who aims to rapidly treat this kind of injury needs a visual classification and knowledge of the best surgical approach.
Objectives
According to our wide experience in treating these rare lesions and taking advantage of our mistakes, we suggest a practical guide to best surgically approach the various types of Monteggia like lesions. Some technical tips and pitfalls are also described.
Study Design & Methods
In the past 24 months, we treated 15 Monteggia-like lesions (10 females and 5 males). We used different surgical approaches and devices chosen on the base of different fracture patterns and on our pre-operative planning. The average age of the patients was 60,1 y.o. (min 31-max 75). All patients were available for clinical and radiological review. The mean follow-up was 9 months (6 to 24 months).
Results
X-rays check showed in 10 cases the fracture healing and an asymptomatic nonunion of some fragments in other three. Two patients had symptomatic nonunion and needed bone grafting and revision plating at a mean time of 6 months after surgery.
Three patients had asymptomatic loosening of the radial head prosthesis. Heterotopic ossification was present in 10 cases (66 %).
Mayo Elbow Performance Score results were good, with a mean value 66.7 (5 - 100): 3 excellent (20%), 6 good (40%), 3 fair (20%), and 3 poor (20%).
The mean QUICK-DASH score was 27,3 (5,7 - 59,09): 5 excellent (33%), 5 good ( 33%), 2 fair ( 14%) and 3 poor ( 20%).
The mean pronation and supination of the forearm was 70° (0° to 90°) and 65° (0° to 90°), respectively. The mean flexion of the elbow was +120° ( from 90° fixed flexion to 140°). The mean extension of the elbow was -30° (from -60° fixed extension to 0°).
Conclusions
Our results are fair and good, not excellent. This is probably due not only to the complexity of these lesions but also to surgical mistakes.
Monteggia like lesions requests a precise pre-operative planning. Every hardware option should be available in the operating room. Since any error could be fatal in performing and completing all surgical steps, these lesions do not allow any mistake
Monteggia-like lesions: Preliminary reports and mid-term results of a single center
No full textBackground and aim of the work: Monteggia-like lesions are complex and rare elbow injuries. A detailed classification and a proper surgical treatment can provide quite good functional and radiological outcomes. The aim of this retrospective study was to evaluate the mid-term results of Monteggia-like lesions surgical treatment. The other purpose was to investigate whether the complexity of ulna and radius fractures could be prognostic factors of insufficient functional results. Methods: Seven women and five men, with a mean age of 59,25 years who had sustained a Monteggia-like lesion were followed up clinically and radio-logically after surgical treatment. The Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QUICK-DASH) score were used for evaluation at a mean of 17,5 months postoperatively (12-26). The range of movement (ROM), patients’ satisfaction and neurological symptoms were also investigated. Osteolysis, implant loosening and heterotopic ossification were graded. Pearson’s test was used to correlate the different classification systems used (AO/OTA, Bado and Jupiter, PURCCS, Ma-son) with MEPS and QUICK-DASH score. Results: The mean MEPS was 84,92 (65 to 100). The mean QUICK-DASH score was 18,75 (0 to 34,1). The mean active pronation and supination was 72,5° and 59,17°, respectively. The mean active ROM of the elbow was 101,43°. Heterotopic ossifications were absent in six cases but were found in six. No statistically significant correlation was found between the analyzed vari-ables. Conclusions: Quite good functional results can be obtained in Monteggia-like lesions if injury pattern is recognized and each component of the injury is addressed. Further studies are needed to determine any prognostic factors. (www.actabiomedica.it)
Wrist disarticulation associated with Monteggia fracture
No full textA 50-year-old man, right-handed farmer, was admitted to the emergency department after undergoing an agriculture accident. Physical examination on admission revealed a left wrist disarticulation with a deformity of the ipsilateral elbow and forearm (A and B). Plain radiography showed a fracture of the ulna shaft as well as dislocation of the radial head. This radiological finding, also called Monteggia fracture-dislocation, was associated with a radiocarpal amputation of wrist-joint (C and D). Monteggia fracturedislocation with wrist amputation is an uncommon condition. The patient was treated successfully with closed reduction of the elbow dislocation and internal fixation of the ulna fracture. The evolution was satisfactory.Pan African Medical Journal 2015; 2
The use of external fixation for the management of acute and chronic Monteggia fractures in children
No full textPurpose The main objective of this study was to retrospectively evaluate the clinical and radiological outcomes of acute (AMF) and chronic Monteggia fractures (CMF) in children treated by closed or open reduction and external fixation (EF). Methods This is a retrospective review of 26 patients with Monteggia fracture. Patients with AMF (time between trauma and surgery less than two weeks) were treated by closed reduction and EF of the ulna (Group A; 15 patients) while those with CMF (time between trauma and surgery more than three weeks) were managed by closed or open reduction and EF of the ulna (Group B; 11 patients). Clinical outcome was evaluated with radiography and the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH). Complications were recorded in both groups. Results No secondary displacement, wire migration, consolidation delays, nonunion, malunion or re-fracture was noted. However, one patient in Group A (6.7%) developed heterotopic ossification of the ulna; the final functional outcome was good (Quick DASH score: 18.2). One case of postoperative redislocation of the radial head was detected in Group B (9.1%). Two patients (7.6%) developed transient pin tract infection. Despite the fact that 16 out of 26 patients (six in Group A and ten in Group B) complained of the clinical appearance and/or had intermittent residual pain on the injured side, the results were essentially the same between the two groups of patients (p > 0.05). Conclusion EF is an alternative for the management of acute and chronic paediatric Monteggia fractures. It provides satisfactory radiological and clinical outcomes with relatively low rates of complications
Radial head volume measurements using quantitative three-dimensional computed tomography images for radial head deformation following missed Monteggia lesions
No full textBackground: In chronic radial head dislocation cases, the radial head may enlarge and become dome-shaped. To date, there is no validated tool to quantify radial head deformation and predict its influence on surgical outcomes. This study assesses the potential value of volume and surface calculations obtained by quantitative three-dimensional computed tomography scanning (Q3DCT) in the workup for a corrective surgery in pediatric patients with missed Monteggia lesions. Material and methods: Ten consecutive pediatric patients with a missed Monteggia lesion were included (2012-2020). The volume and articular surface size of the radial head were calculated using Q3DCT, and a three-dimensional reconstruction of the articular surface relief was depicted in a heat map. The head-neck ratio was calculated and compared to Q3DCT data of missed Monteggia patients and their age-/sex-matched controls. Results: The radial head volume and radial articular surface size did not differ significantly between patients with missed Monteggia lesions and age-/sex-matched controls (volume 1487 mm3 vs. 1163 mm3, P = .32; articular surface size 282 mm3 vs. 236 mm3, P = .33). Optically, heat maps of the articular surface of missed Monteggia patients did not differ notably from control heat maps. A higher head-neck ratio correlated to a larger radial head volume (Pearson r = 0.73; P = .2). Discussion and conclusion: Q3DCT may be an interesting tool in the preoperative workup of pediatric missed Monteggia lesions. Prospective research with larger cohort sizes and data that compares the affected side to the contralateral elbow is needed to assess its true clinical potential
Monteggia fractures: analysis of patient-reported outcome measurements in correlation with ulnar fracture localization
No full textBackground
Monteggia fractures and Monteggia-like lesions result after severe trauma and have high complication rates. Preliminary biomechanical studies suggested a correlation between ulnar fracture localization and clinical result.
Objectives
Key objective was to evaluate whether the site of the ulnar fracture can be correlated to clinical outcome after open reduction and internal stabilization.
Methods
In a retrospective, monocentric study 35 patients who underwent surgical treatment after suffering a Monteggia injury or Monteggia-like lesion were included. Fractures were classified according to Bado and Jupiter, the site of the fracture location at the proximal ulna and regarding the potential accompanying ligamentary injury. In a follow-up examination validated patient-reported outcome measures and functional parameters were evaluated. Furthermore, treatment strategy and complications were analysed.
Results
Mean patient age was 51.9 years (± 18.0). 69% were females (n = 24). Follow-up took place after 50.5 months (± 22.1). Fractures were classified according to Bado (I:2, II:27, III:4, IV:2). Bado II-fractures were further classified according to Jupiter (A:7, B:16, C:3, D:1). Cases were divided into subgroups depending upon the distance of the ulnar fracture site in respect to its distal endpoint (A: 7 cm). Average overall MEPS was 84.1 (± 19.0). Oxford elbow score and DASH were 37.2 (± 10.5) and 20.4 (± 20.5). Average extension capability reached − 7° (± 7.5). Mean flexion was 134.8° (± 19.7). Average pain according to visual analogue scale was 1.6 (± 1.9). We found no differences between the subgroups regarding the PROMs. Subgroup A displayed a worse extension capability (p = 0.027) and patients were significantly older (p < 0.01). Comparing patients with and without fracture of the radial head, we observed no differences. Patients with an accompanying injury of the coronoid process displayed higher pain levels (p = 0.011), a worse functionality (p = 0.027) and overall lower scoring in PROM.
Conclusion
The presented results suggest that in Monteggia fractures and Monteggia-like lesions, the localization of the ulna fracture can give a hint for its postoperative outcome. However, we could not confirm the hypothesis of an increasing instability in ulnar fractures located further distally (high severity of the potential ligamentous injury). Intraarticular fractures or injuries with a close relation to the joint have a worse prognosis, especially if the coronoid process is injured.
Trial registration Registration was done with ClinicalTrials.gov under NCT05325268
Going Beyond Counting First Authors in Author Co-citation Analysis
No full textThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Delayed lipoprotein oxidability and atherosclerosis progression by soy proteins in rabbits fed cholesterol-rich diet
No full textMitomycin C in highly myopic eyes - Author reply
No full textOphthalmology. 2005 Feb;112(2):208-18; discussion 219.
Mitomycin C modulation of corneal wound healing after photorefractive keratectomy in highly myopic eyes.
Gambato C, Ghirlando A, Moretto E, Busato F, Midena E.
SourceRefractive Surgery Service and Antimetabolite Therapy Research Unit, Department of Ophthalmology, University of Padova, Padova, Italy.
Abstract
PURPOSE: To evaluate the role of topical mitomycin C in corneal wound healing (CWH) after photorefractive keratectomy (PRK) in highly myopic eyes.
DESIGN: Prospective, double-masked, randomized clinical trial.
PARTICIPANTS: Seventy-two eyes of 36 patients affected by high (>7 diopters) myopia.
METHODS: In each patient, one eye was randomly assigned to PRK with intraoperative topical 0.02% mitomycin C application, and the fellow eye was treated with a placebo. Postoperatively, mitomycin C-treated eyes received artificial tears (3 times daily, tapered in 3 months), whereas the fellow eye was treated with fluorometholone sodium 2% and artificial tears (3 times daily, tapered in 3 months).
MAIN OUTCOME MEASURES: Uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), contrast sensitivity, manifest refraction, and biomicroscopy. Contrast sensitivity was determined using the Pelli-Robson chart. Corneal confocal microscopy documented CWH.
RESULTS: Mean follow-up was 18 months (range, 12-36). No side effects or toxic effects were documented. At 12-month follow-up examination, UCVAs (logarithm of the minimum angle of resolution) were 0.4+/-0.48 and 0.5+/-0.53 (P = .03) in mitomycin C-treated eyes and corticosteroid-treated eyes, respectively. At 1 year, corneal haze developed in 20% of corticosteroid-treated eyes, versus 0% of mitomycin C-treated eyes. At 12, 24, and 36 months, corneal confocal microscopy showed activated keratocytes and extracellular matrix significantly more evident in untreated eyes (Ps = 0.004, 0.024, and 0.046, respectively).
CONCLUSION: Topical intraoperative application of 0.02% mitomycin C can reduce haze formation in highly myopic eyes undergoing PRK.
Comment in
Ophthalmology. 2006 Feb;113(2):357; author reply 357-8
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