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Objective Analysis of Coronoid Approaches: Cadaveric Model
Jennifer Peterson, MD; Xavier Simcock, MD; Peter J. Evans, MD, PhD; Steven Maschke, MD
Cleveland Clinic Foundation, Cleveland, OH
Introduction: Complex or isolated coronoid fractures are often treated through medial approaches like the over-the-top (OTT) or the flexor carpi ulnaris split (FCU split) approach. These often yield limited visibility and difficult working arcs for placement and fixation of the coronoid plate. At our institution, the flexor pronator tenotomy (FPT) approach to the medial side of the elbow has evolved into the preferred method for fracture fixation. The purpose of our study is to assess exposure and ease of instrumentation with this surgical approach in a cadaveric model. We hypothesized that the flexor pronator tenotomy would provide greater surface area visibility and improved accessibility for fixation.
Materials and Methods: Twelve adult cadaveric elbows were used for this study. The mean age was 64 years (range 54-78 years): ten male and two female specimens, six right and six left elbows. Each elbow underwent a sequence of three surgical approaches: 1. OTT 2. FCU split 3. FPT. After each approach, the exposed surface area was captured with a digital photograph and measured using the Image J software. Two 0.45in k-wires were placed at the ulnar and radial most aspects of the exposure. This angle was measured with both a manual and a digital goniometer. A coronoid plate was placed in an optimal position given the approach. We assessed ease of fixation based on ability to access four quadrants of a variable angle guide for various screw positions in the plate. The repeated ANOVA test, paired t-test and chi-square tests with p <0.05 were used for statistical analysis.
Results: The mean exposed surface areas for the OTT and FCU split approaches were 318mm2 (SDą89mm2) and 373mm2 (SDą89mm2) respectively. The exposed surface area for the FPT was on average 512mm2 (SDą141mm2) (OTT: p=1.52x10-4, FCU split: p=2.44x10-3). The mean working arcs for the OTT and the FCU split approaches were 59° (SDą11°) and 64° (SDą13°). The mean working arc for the FPT approach was 94° (SDą11°) (OTT: p=1.16x10-4, FCU split: p=5.28x10-4). The access to each screw position was significantly improved with the tenotomy (p=1.51x10-4).
Conclusion: Anatomically, this study shows a significant improvement in visualization and working angle to the coronoid with the flexor pronator tenotomy approach in comparison to the OTT or FCU split approaches. Clinically, this allows for increased exposure for this relatively uncommon and complex fracture where poor reduction and fixation can lead to instability and poor long-term outcomes.
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