Internal brace augmentation in elbow varus posteromedial rotatory instability (VPMRI) allows early rehabilitation and prevents stiffness

Abstract

Purpose

Varus posteromedial rotatory instability (VPMRI) involves anteromedial coronoid fracture (AMCF), lateral ulnar collateral ligament (LUCL), and medial collateral ligament (MCL) injury. There is no general consensus regarding the surgical treatment, but most surgeons recommend internal fixation of the coronoid along with primary ligament repair. This methodology involves postoperative immobilization to allow ligament healing, occasionally associated with stiffness. Augmentation of one/or both collateral ligaments using a non-absorbable suture tape as an internal brace in VPMRI cases was the subject of the presented study. This method allows brace-free initiation of full elbow range of motion while protecting bony and soft tissue healing.

Methods

17 patients (13 males and four females) with VPMRI were treated in the center from 2017 to 2021 with internal brace augmentation of collateral ligament along with ORIF (Open reduction & internal fixation)/ reconstruction of the coronoid fragment. All patients were actively mobilized early after surgery. Patients who completed a minimum follow up of 24 months were included in the study. Clinical examination findings at follow-up assessment included ROM (range of motion) recording and instability testing, including special instability tests such as moving valgus stress test, lateral pivot shift test, Posterolateral rotatory drawer test, and gravity-assisted varus stress test. Disabilities of arm, shoulder and hand (DASH) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Visual Analogue Score (VAS), and SEV (Simple Elbow values) were assessed and noted at follow-up.

Results

At 43 months of mean follow-up, none of the patients had significant postoperative contracture, and none had any clinically apparent signs of instability or suffered subluxation or re-dislocation. Postoperative radiographs showed complete fracture/graft healing with no signs of subluxation in all patients. The mean range of motion of the patients was 6.2⁰ (1.0⁰-11.3⁰) to 139.1⁰ (136.2⁰–142.0⁰), with a mean Oxford elbow score (OES) of 42.0 (39.9–44.7). The mean DASH (Disability of Arm, Shoulder & Hand) score was 11.4 (6.7–16.1), the mean MEPS (Mayo Elbow Performance Score) was 91.2 (86.3–96.0), the mean Visual Analogue Score (VAS) score was 0.6 (0.1–1.2), and the mean Simple Elbow value (SEV) was 85.4% (81.1-89.8%).

Conclusion

Internal brace augmentation with a non-absorbable suture tape in the setting of VPMRI is a safe and helpful adjunct to coronoid repair/reconstruction and primary ligament repair and allows early mobilization and recovery of elbow stability and range of motion.