A 26-year-old male patient experienced a car accident and was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus with massive bone defects and severe intra-articular involvement, without neurovascular injuries or other associated injuries. Within 24 h after the injury, he was treated by surgical debridement, negative pressure vacuum sealing drainage, and immobilization by casting in a local hospital. Due to severe contamination and a poor soft tissue condition, the wound was surgically debrided again and closed 15 days later. Two months after the initial operation, the wound had finally healed, and the soft tissue was in good condition, without infection or effusion. The CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) levels returned to normal, and the patient was transferred to our department for additional treatment.
The patient’s height was 175 cm, and his weight was 130 kg. The preoperative anteroposterior (AP) and lateral X-rays (see Fig. 1) and 3D-CT scans (see Fig. 2) of the right elbow joint showed massive bone defects at the supracondylar level as well as a comminuted articular surface. According to the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) criteria, the fracture was classified as a type 13-C3 fracture [7]. The physical examination revealed pseudarthrosis at the fracture site, which made it much more difficult to reconstruct the distal humerus.
Surgical procedure
After the induction of general anesthesia, the patient was placed in the supine position with elbow flexion and forearm crossing chest [8], and a longitudinal incision was made along the midline of the posterior aspect of the elbow and medially curved at the olecranon tip. The ulnar nerve was dissected carefully and protected by a rubber strip, and then, a V-shaped osteotomy was performed in the proximal olecranon. The proximal bone fragment and triceps muscle were flipped upward to expose the distal part of the humerus.
Then, we removed all the fibrous scar tissue as well as the anterior and posterior capsules to release the elbow. The dead bones and redundant calli were debrided until fresh bone was evidently revealed, and then the bone callus was kept for grafting. The original articular cartilage was preserved to the greatest extent possible, but the trochlear groove was too severely comminuted to be reconstructed. Therefore, the fracture fragments and adhesive fibrous tissue were removed to facilitate reconstruction.
The trochlear and capitellar articular surfaces of the distal humerus were aligned with the olecranon and radial head articular surfaces, respectively. Then, we measured the width of the trochlear groove defect, harvested a cylindrical autograft of an appropriate size and shape from the iliac crest, and inserted the graft into the defect to reconstruct the distal humerus. The cortical bone surface of the graft was directed towards the articular cavity but was located 2 mm proximal to the cartilage. We stabilized the distal fragments using K-wires (Kirschner wires) for temporary reduction. Then, the intercondylar fracture was converted to a supracondylar fracture of the distal humerus.
Next, the humeral shaft and both columns were reduced. First, the medullary canal was opened by a 3.5 mm diameter drill to promote fracture healing. The supracondylar bone defects were measured to be approximately 3 cm at the medial column and 5 cm at the lateral column. We performed shortening by 2 cm at the supracondylar level. Then, 2 pieces of autografts harvested from the iliac crest were trimmed according to the size and shape of the bony defects to reconstruct the medial and lateral columns, respectively. The cortical bone was directed outward, and the cancellous side was directed inward. The total bone loss was estimated by measuring the humeral length. Then, K-wires were inserted for temporary fixation.
Finally, to optimize the stability of the bony structure, the distal humerus was stabilized using anatomical locking compression plates via a parallel configuration (Zimmer Biomet, USA). Several K-wires were left for the fixation of the tiny fragments.
After internal fixation, the elbow joint exhibited almost full range of motion during passive flexion and extension (see Fig. 3). The remaining iliac crest autografts and bone callus were cut into several strip-shaped bone chips and implanted around the supracondylar level.
Finally, the olecranon osteotomy site was reduced and fixed by tension band wires. We performed subcutaneous transposition of the ulnar nerve using soft tissue sling to prevent direct contact and irritation from the hardware. The muscles and deep fascia were sutured carefully to cover the bone grafts and internal fixation site. The donor site was closed by direct suturing.
After the surgery, standard AP and lateral radiographs of the elbow joint were taken to evaluate the quality of reconstruction (see Fig. 4).
The drainage tube was removed 24 h after surgery. Active exercises of the hand and wrist, isometric contractions of the biceps and forearm muscles, and active elbow flexion and extension exercises were initiated on the second day after surgery.
Follow-up results
Routine follow-ups were carried out. The fracture healed at 3 months postoperatively, and the radiographs showed the presence of a continuous callus passing through the fracture line. Six months after the index surgery, the patient had a painless elbow joint and almost full recovery (125° elbow flexion and 0° extension, 90° forearm supination and 65° pronation). The Mayo elbow performance score (MEPS) was 100 (excellent).
Three years after the index surgery, the patient came to our department for hardware removal due to psychological factors. He was pain free at the affected elbow joint. The flexion-extension range of motion was 130–0°, and the supination-pronation range of rotation was 90–80°. The MEPS was 100 points. The patients was very satisfied.
Secondary displacement or the loss of reduction, implant loosening or internal fixation breakage, and obvious articular degeneration were not observed. No other postoperative complications, such as infection, nonunion, delayed union, ulnar nerve symptoms, or donor site pain, occurred after the initial internal fixation procedure. After hardware removal, the overall bony structure of the affected elbow joint remained intact with only a partial deformity at the lateral column, which had no significant influence on the overall functional outcome (see Fig. 5).