Early revision of Monteggia-variant fractures

Purpose

Monteggia-variant fractures involve a fracture of the proximal ulna combined with a radiocapitellar dislocation and/or additional injuries to the radial head. These injuries are associated with severe outcomes, high complication rates, and frequent need for revision surgery. This study aimed to investigate strategies for early revision following failed operative treatment of these injuries.

Methods

We retrospectively included all patients over 18 years of age who underwent revision surgery within the first 3 months after failed initial treatment of a Monteggia-variant fracture due to persistent instability or mechanical failure between October 2013 and December 2018 at our institution. We reviewed the reasons for revision, the operative strategies used, and the clinical and radiological outcomes of these patients.

Results

Twenty-seven patients, with a mean age of 57.9 ± 17 years (range: 21–94 years), were included in the study. Nineteen patients (70.4%) underwent revision due to instability, and 10 patients (37%) underwent revision due to failed osteosynthesis. For the revisions, the collateral ligaments were reconstructed in 63% (n = 17), a radial head prosthesis was implanted in 51.9% (n = 14), and re-osteosynthesis of the ulna and additional osteosynthesis were performed in 40.7% (n = 11) and 29.6% (n = 8), respectively. The coronoid was reconstructed in 22.2% (n = 6), and a radial head resection was performed in 14.8% (n = 4). In three cases, total elbow arthroplasty was performed, and in six cases, an additional external fixator was applied. All reconstructive procedures successfully stabilized the elbow. The mean functional arc for extension-flexion at final follow-up was 79 ± 29° (range: 20–115°).

Conclusions

Common reasons for revision surgery in Monteggia-variant fractures include ulnohumeral or radiohumeral instability, often due to missed coronoid fractures, collateral ligament injuries, or absence of the radial head.