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Letters to the Editor to:

Scientific Articles:
David Ring, Lawrence Gulotta, and Jesse B. Jupiter
Unstable Nonunions of the Distal Part of the Humerus
J Bone Joint Surg Am 2003; 85: 1040-1046 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Ring responds to, "Would author recommend a different approch"?
David Ring   (20 August 2003)
[Read Letter to the Editor] Would author recommendDifferent approach ?
Prof. Ram Chander Siwach, DR. SONEET AGGARWAL, DR. ZILE SINGH   (18 August 2003)

Dr. Ring responds to, "Would author recommend a different approch"? 20 August 2003
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David Ring,
Surgeon
Massachusetts General Hospital

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Re: Dr. Ring responds to, "Would author recommend a different approch"?

dring{at}partners.org David Ring

We agree that impacted articular and metaphyseal fragments often go unrecognized. For a discussion of this with regards to complex articular fractures see our article published earlier this year in JBJS.

Regarding the use of triceps reflecting approaches for exposure of the distal humerus we have not encountered as many problems as others have reported with an olecranon osteotomy. Olecranon osteotomy gives the best exposure and may be the best way to handle the triceps as the anatomy of the insertion is least disturbed with this method—it returns to near normal once the osteotomy is healed. If one pays attention to the technique of the osteotomy creation and repair, problems will be uncommon. A report of Dr. Jupiter’s experience with olecranon ostetomy will be published shortly in the Journal of Orthopaedic Trauma. The keys of the technique are a chevron shaped osteotomy (Dr. Jupiter prefers apex distal, but I have adopted an apex proximal osteotomy by suggestion of Dr. David Helfet), cracking of the articular surface to create an interdigitating surface, oblique drilling of the K-wires so that the wires engage the anterior ulnar cortex distal to the coronoid process, and a 180-degree bend proximally with impaction of the bent ends beneath the triceps and into the olecranon. The results of olecranon osteotomy are technique- dependent. A carefully created and repaired osteotomy will serve the elbow surgeon well.

A recent paper in JBJS based on mechanical testing of cadavers suggests that small wires do not provide adequate fixation. We believe that study is flawed and does not reflect the clinical situation. We use 0.045-inch Kirschner wires and two 22 gauge stainless steel figure of eight tension wires for repair of an olecranon osteotomy. We have very rarely had broken or loose wires. This is in spite of immediate active elbow exercises. This is a reflection of the power of the tension band concept--a basic engineering fact applied successfully in orthopaedics.

Several triceps reflecting techniques including the Bryan/Morrey exposure, the TRAP, and a modification of Campell’s triceps split used and reported by Michael McKee and his colleagues are alternatives to olecranon osteotomy. We have not found these as useful as an olecranon osteotomy.
Would author recommendDifferent approach ? 18 August 2003
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Prof. Ram Chander Siwach,
Reconstruction and arthroplasty surgeon
PGIMS , ROHTAK, INDIA,
DR. SONEET AGGARWAL, DR. ZILE SINGH

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Re: Would author recommendDifferent approach ?

drrcsiwach{at}yahoo.co.in Prof. Ram Chander Siwach, et al.

Sir, the authors experience and expertise is obvious with the results obtained in the cases. The authors have rightly emphasized the importance of age, sex , demands , dominance of the hand in the article as this is very important for us; where requirements of the patients are different.

We have observed in the fresh cases of intraarticular fractures that there is displacement in the articular fragments that gets compressed in the metaphyseal regions of the humerus and therefore while assembling the articular fragments intraoperatively; the ‘fragment’ is missing. This leads to unstable reduction of the fracture which is a preventable cause of instability and can be avoided if the radiographs are studied carefully preoperatively.

What are the recommendations of the authors in using triceps reflecting anconeus pedicle approach which avoids hardware, non-union complications of the osteotomy of the olecranon and ostearthrosis of the joint thereby easy arthroplasty in case the need arises.