How To Approach Monteggia-Like Lesions In Adults

Background Monteggia-like lesions encompass a wide spectrum of forearm and elbow fractures associated with dislocations, subluxations and ligamentous lesions. Many attempts have been made to classify these injuries, not only to understand their pathology but also to develop optimal treatments. Unfortunately, although some of these classifications are complete, they are complex, not immediately usable and not exhaustive. An orthopedic surgeon who aims to rapidly treat this kind of injury needs a visual classification and knowledge of the best surgical approach. Objectives According to our wide experience in treating these rare lesions and taking advantage of our mistakes, we suggest a practical guide to best surgically approach the various types of Monteggia like lesions. Some technical tips and pitfalls are also described. Study Design & Methods In the past 24 months, we treated 15 Monteggia-like lesions (10 females and 5 males). We used different surgical approaches and devices chosen on the base of different fracture patterns and on our pre-operative planning. The average age of the patients was 60,1 y.o. (min 31-max 75). All patients were available for clinical and radiological review. The mean follow-up was 9 months (6 to 24 months). Results X-rays check showed in 10 cases the fracture healing and an asymptomatic nonunion of some fragments in other three. Two patients had symptomatic nonunion and needed bone grafting and revision plating at a mean time of 6 months after surgery. Three patients had asymptomatic loosening of the radial head prosthesis. Heterotopic ossification was present in 10 cases (66 %). Mayo Elbow Performance Score results were good, with a mean value 66.7 (5 - 100): 3 excellent (20%), 6 good (40%), 3 fair (20%), and 3 poor (20%). The mean QUICK-DASH score was 27,3 (5,7 - 59,09): 5 excellent (33%), 5 good ( 33%), 2 fair ( 14%) and 3 poor ( 20%). The mean pronation and supination of the forearm was 70° (0° to 90°) and 65° (0° to 90°), respectively. The mean flexion of the elbow was +120° ( from 90° fixed flexion to 140°). The mean extension of the elbow was -30° (from -60° fixed extension to 0°). Conclusions Our results are fair and good, not excellent. This is probably due not only to the complexity of these lesions but also to surgical mistakes. Monteggia like lesions requests a precise pre-operative planning. Every hardware option should be available in the operating room. Since any error could be fatal in performing and completing all surgical steps, these lesions do not allow any mistake.