Study design:
This is a retrospective comparative study of two series of intercondylar humerus fractures surgically treated over a period of eleven years from 2010 to 2020 with two different methods at our orthopedics and traumatology department.
In our inclusion criteria, we used the AO/OTA classification of distal humerus fractures [4]. (Fig. 1) to enroll all adult patients treated surgically for type C fracture of the distal humerus using open reduction and internal fixation (ORIF) with perpendicular or parallel plate.
Minimum follow-up recommended was 18 months. Exclusion criteria were patients younger than 18 years, patients who had an extra-articular or pathological fracture, other fixation procedures, incomplete records and follow-up period less than 18 months.
In total, 50 patients met our criteria and were divided in two groups:
Group A: Internal fixation using parallel plating method (29 patients). (Fig. 2)
Group B: Internal fixation using orthogonal plating method (21 patients). (Fig. 3)
Patients:
A total of 50 patients recruited in the study (19 women and 31 men), with a mean age of 44,4 years ±11,5 (range 21–70 years) were included.
All the 50 patients were followed for a minimum 18 months (range 2.0–3.7 years).
The demographics for both groups are shown in Table 1.
Five patients had open fractures: 4 were grade I, and one was grade II, according to the criteria defined by Gustilo and Anderson [5].
For open fractures, debridement, irrigation, and plate fixation were performed on the date of admission. All other patients were stabilized within 4 days of injury.
Two patients had additional fractures of the forearm bones, two others had additional olecranon fractures and one patient had an ipsilateral tibia shaft fracture.
One patient had neurologic symptoms.
Surgical technique:
All patients were placed in the supine position on the operating table, with the arm supported on the arm board table. A tourniquet was applied as far proximally.
Chevron olecranon osteotomy was performed for all patients.
In the Orthogonal group, the fracture was exposed and Kirschner wires (K-wires) were employed for temporary fixation of the reduction. After the initial stabilization, 1 or 2 lag screws were utilized to stabilize the lower part of the distal humerus. Subsequently, the extraarticular fracture component underwent reduction and stabilization with either K-wires or reduction forceps. Two plates were then strategically positioned in a postero-lateral and medial orientation in an orthogonal manner. The surgeon prioritized performing plate fixation on the column initially to enhance the ease of anatomical reconstruction and mitigate the risk of significant bone loss
In the Parallel plating group, we initially achieved temporary fixation using K-wires positioned near the subchondral level to prevent interference with screw passage from the plates to the distal fragments. However, in instances of significant comminution in the distal fragment, fixation was accomplished using a 2.7- or 3.5-mm interfragmentary screw. Subsequently, two precontoured plates were positioned along the medial and lateral supracondylar ridges, approximately 180 degrees apart. Once the plates were preliminarily applied, distal introduction of medial or lateral screws became necessary, demanding additional distal fragments to ensure stable fixation of intraarticular fragments and secure anchoring of plates. The screws for distal fragments traversed the plate, contributing to stability at the supracondylar level and engaging as many articular fragments as possible.
In both groups, an olecranon osteotomy site was fixed with the placement of tension-band wire.
Functional and clinical evaluation:
At final follow-up, our patients were assessed for functional impairment using the Mayo Elbow performance score (MEPS) [6].
This scoring system consists on the assessment of pain, arc of motion, stability, and a patient rating of daily function as shown in figure 4
MEPS of 75 or more is considered satisfactory.
Radiological evaluation:
All patients were monitored by frontal and lateral radiographs of the elbow.
The radiological evaluation criteria were as follows:
● Time to consolidation: the disappearance of the line in the medial and lateral abutment.
● Pseudarthrosis: the persistence of the fracture line between one or more bone fragments.
- The most frequent site is the metaphysis-diaphysis associated with a material fracture.
- It is often due to rigid mounting.
● Malunion:
- These are a source of joint stiffness.
- They are divided into articular and extra-articular malunion.
● Removal of hardware.