Patients are satisfied, have stable elbows 19 years after triceps tendon graft surgery

Issue: July 2016

GENEVA — At a mean follow-up of 19 years, patients treated for posterolateral elbow instability with lateral collateral ligament reconstruction done with an ipsilateral triceps tendon graft had stable elbows. The mean Mayo Elbow Performance Scores deteriorated minimally, from 92 points to 88 points between the first and most recent follow-up examinations, according to results presented at the 17th EFORT Annual Congress.

During his presentation, Christian Kastenskov, MS, of Copenhagen, Denmark, noted additional outcomes were evaluated with the VAS pain score and modified Oxford elbow score (OES). Investigators used hand-held goniometer readings to determine elbow range of motion and performed radiographs to assess patients’ elbows at long-term follow-up.

“We found all our patients had a stable elbow, which is a better result than most other studies, and the development of osteoarthritis [OA] has not been researched in any other study to our knowledge,” Kastenskov said.

Christian Kastenskov

Ipsilateral triceps tendon graft

In all, 18 patients with an acute traumatic dislocation originally underwent surgery between 1993 and 1999 for reconstruction and reinforcement of the lateral collateral ligament of the elbow. During the procedure, the surgeon inserted a triceps tendon graft from the ipsilateral elbow through bone tunnels and fixed it with bone anchors.

In 2015, 14 patients underwent a re-examination, at which time investigators evaluated range of motion (ROM) and stability of the operated elbow. The researchers also assessed pain with a VAS score (range 0 to 10; in which 10 is most painful) and other pain outcome measures. Eleven of the patients also had their elbows radiographed.

“None of our patients reported any pain during rest, and the patients had a VAS mean of 2.6 during activity. None reported symptoms of locking at the joint at the time of examination,” Kastenskov said.

Stability seen on testing

Investigators assessed ROM in 2003 and at the latest follow-up with a hand-held goniometer. At the initial follow-up, eight patients had lost elbow ROM. At the most recent follow-up, four of those patients presented with changed ROM. Two patients each had slightly increased and slightly decreased ROM.

“None of the patients who had normal ROM at the first follow-up had any loss at the second follow-up,” according to Kastenskov.

Kastenskov and colleagues evaluated the patients’ elbow stability with forced motion varus, valgus and rotation, as well as pivot shift stress, moving valgus and arm chair push-up tests. Results of those tests showed the patients had stable elbows, although he noted two of them had apprehension with the pivot shift stress test.

In terms of function, “The mean functional elbow score without testing strength was, in 2003, 70 and 72 at the latest follow-up,” Kastenskov said. Based on results of the Danish version of the OES, patients were satisfied with their final elbow function, he noted.

Figure 1. This patient in the series studied developed mild osteoarthritis following triceps tendon graft lateral collateral ligament reconstruction for elbow instability.

Source: Kastenskov C

In the radiograph assessment, investigators studied the presence of calcifications, osteophytes, joint space narrowing and subchondral sclerosis in 11 patients at the final follow-up. Based on these features, they rated each patient’s elbow as having severe, mild or no OA. They found OA in five of those patients, which was rated severe in one patient and mild in four patients.

“This is, of course, concerning that this high amount had OA, but we did not find any difference in any outcome score between the different groups with and without OA,” Kastenskov said.

Kastenskov told Orthopaedics Today Europe, “This is [a] rare surgery. Using a one-incision technique with triceps tendon graft gives reliable and lasting results. Though, we observed a high proportion of patients with radiographic arthrosis, but without pain, locking or decreased ROM. The development of elbow joint arthrosis may decrease the surgical result in the coming years.” – by Susan M. Rapp

References:

Kastenskov C, et al. Paper #977. Presented at 17th EFORT Annual Congress — A combined programme in partnership with swiss orthopaedics; 1-3 June 2016; Geneva.

Olsen BS, et al. J Bone Joint Surg Br. 2003;85:342-346.

For more information:

Christian Kastenskov, BS, can be reached at Shoulder and Elbow Section, Department of Orthopaedic Surgery, University Hospital of Copenhagen, KAS Herlev, Herlev Ringvej 75, DK-2730, Denmark; email: christian.kastenskov@gmail.com.

Disclosure: Kastenskov reports no relevant financial disclosures.