Combined Medial and Lateral Approach Versus Paratricipital Approach in Open Reduction and Internal Fixation for Type C Distal Humerus Fracture: A Randomized Controlled Study

Abstract

Objective: Olecranon osteotomy and paratricipital approaches were widely used in the treatment of type C distal humerus fracture but some disadvantages exist, so a combined medial and lateral approach was designed. The objective of this study was to investigate and compare the clinical outcomes of combined medial and lateral approach with the paratricipital approach in open reduction and internal fixation of type C distal humerus fractures.

Methods: From May 2018 to April 2020, 37 patients with type C distal humerus fracture who accepted open reduction and internal fixation in our hospital were enrolled in this study. All cases were randomly divided into two groups according to the surgical approach: combined medial and lateral approach group (19 cases), paratricipital approach group (18 cases). All of the patients received open reduction and double vertical plates fixation. The operation and follow-up indexes, including operation time, blood loss, incision length, triceps muscle strength, flexion-extension arc of elbow and forearm rotation arc, were recorded and compared. Caja score was used to assess the quality of fractures reduction. Mayo Elbow Performance Score (MEPS) was used to evaluate the elbow function in the follow-up. Complications such as incision infection, ulnar nerve injury, degenerative osteoarthritis, and heterotopic ossification were analyzed.

Results: The differences in age, gender, and AO classification of fractures between two groups were not statistically significant (p > 0.05). The sum of medial and lateral incision length of combined approach group was longer than the midline incision of paratricipital approach group (15.4 ± 0.8 vs. 14.6 ± 0.8, p < 0.05), but there was no significant difference in operation time (103.5 ± 10.2 vs. 106.0 ± 8.8, p > 0.05), blood loss (71.3 ± 24.5 vs. 72.8 ± 24.6, p > 0.05), and Caja score (16.05 ± 5.67 vs. 15.56 ± 5.66, p > 0.05). During the follow-up, the MEPS of combined approach group was higher than that of paratricipital approach group at 3 months postoperatively (80.5 ± 5.7 vs. 68.9 ± 8.1, p < 0.05), but there was no significant difference in MEPS at 6 months postoperatively (83.9 ± 6.6 vs. 79.7 ± 7.0, p > 0.05) and at the last follow-up (86.8 ± 7.1 vs. 86.9 ± 7.7, p > 0.05) between the two groups. There was no significant difference in triceps muscle strength (p > 0.05), flexion-extension arc (126.8 ± 5.3 vs. 128.9 ± 6.0, p > 0.05), and forearm rotation arc (163.2 ± 5.3 vs. 163.6 ± 4.8, p > 0.05) at the last follow-up. Although the incidence of complication of combined approach group (15.8%) was lower than that of paratricipital approach group (22.2%), the difference was not statistically significant (p > 0.05).

Conclusions: The combined medial and lateral approach was an effective and safe way of open reduction and internal fixation for type C distal humerus fractures. Compared with the paratricipital approach, the combined medial and lateral approach could restore the elbow function more quickly postoperatively, and the long-term results were comparable.

Keywords: Combined Medial and Lateral Approach; Distal Humerus Fractures; Open Reduction and Internal Fixation; Paratricipital Approach; Type C Fractures.

FIGURE 1

Intraoperative images of the combined medial and lateral approach. (A) The lateral incision. (B) The medial incision. (C) The lateral ligamentous complex was dissected from the lateral epicondyle of the humerus. (D) The ulnar nerve was dissected and protected in a medial approach. (E) The lateral column of the distal humerus was reduced and fixed with an anatomical locking plate. (F) Fixation of the medial column with an anatomical locking plate

FIGURE 2

A 44‐year‐old female patient with type C3 distal humerus fracture was treated with a combined medial and lateral approach. (A) Preoperative anteroposterior and lateral films of the elbow. (B) Preoperative CT three‐dimensional reconstruction films. (C) Anteroposterior and lateral X‐ray films immediately after fixation with double plates. (D) Anteroposterior and lateral X‐ray films at 12 months postoperative. (E) Anteroposterior and lateral X‐ray films at 18 months postoperative showed the fracture had healed. (F) The posterior lateral and medial incision scars. (G) The flexion and extension of the left elbow was partly limited at 18 months postoperative. (H) The pronation‐supination of the left forearm was normal at 18 months postoperative

FIGURE 3

A 39‐year‐old male patient with left distal humerus fracture was treated through a combined medial and lateral approach. (A) Preoperative X‐ray films of distal humerus fracture. (B) Anteroposterior and lateral X‐ray films immediately after operation. (C) Anteroposterior and lateral X‐ray films at 2 months after operation. (D) Anteroposterior and lateral X‐ray films at 12 months postoperative. (E) Anteroposterior and lateral X‐ray films at 18 months postoperative showed the fracture had healed. (F) The image of medial and lateral incision scars. (G) The flexion and extension of the left elbow at 18 months postoperative. (H) The pronation‐supination of the left forearm at 18 months postoperative

FIGURE 4

A 32‐year‐old male patient with type C distal humerus fracture was treated with a paratricipital approach. (A) Preoperative anteroposterior and lateral films of the elbow. (B) Preoperative CT three‐dimensional reconstruction films. (C) Anteroposterior and lateral X‐ray films immediately after fixation with double plates. (D) Anteroposterior and lateral X‐ray films at 3 months postoperative. (E) Anteroposterior and lateral X‐ray films at 1 year postoperative showed the fracture had healed. (F) The posterior midline incision scar. (G) The flexion and extension of the left elbow at 1 year postoperative. (H) The pronation‐supination of the forearm at 1 year postoperative