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01-08-2020 | Forearm Fracture | Letter to the Editor
Letter to the Editor regarding “Does overcorrection cause any negative effect on pediatric missed Monteggia lesion?”
Published in: European Journal of Orthopaedic Surgery & Traumatology | Issue 6/2020
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With great interest, we read the article of Musikachart et al. [1] who presented surprising results that warrant further pertinent discussion. Their results are completely contradictory to our current understanding of surgical restoration following chronic Monteggia lesions [2‐4]. Unfortunately, the authors failed to provide an explanation for their findings, and, moreover, we believe that these results have to be interpreted with caution due to several major flaws:
1.
The two groups were small and not comparable since the time-from-injury ranges varied severely. Group 1 had a duration of up to 120 months compared to just up to 60 months in group 2. Although joint incongruency due to dysplastic changes of the radial head can, in our experience, already be expected much sooner after injury (e.g., 6–12 months after injury), it will always be present after so many years of dislocation, and hence, reduction techniques will likely fail. Unfortunately, the authors did not report the intraoperative grade of radial head deformation since this would have helped to anticipate the further course of stability. All patients should be carefully evaluated for dysplastic changes to the radial head prior to attempted reduction.
2.
The radiological outcome is graded into four classes according to Rahbek et al. [5]. This has been wrongly cited because Rahbek reported good results in complete reduction without osteoarthritic changes, fair results in radial subluxation or osteoarthritic changes and poor result in dislocation of the radial head [5]. In particular, grading a radiological result “fair” or “good” based on the amount of subluxation could cause misinterpretation of the data.
3.
As stated by the authors, only 20% in the overcorrection group (vs. 54.55% in group 1) had annular ligament reconstruction (ALR) which could explain the inferior outcomes. When additionally assessing the authors' results in Table 3, it came to our attention that the 6 cases with non-excellent results in the radiographic analysis (radial head subluxation to dislocation) had no ALR at all compared to 6/15 in the other group. This factor might be a relevant confounder and likely be the explanation for the decreased radiocapitellar stability.
4.
Lastly, it has not been mentioned which the patients of the cohort underwent pinning of the radiocapitellar joint. This would lend more attention to existing intraoperative (in)stability and help to better interpret the results. Pinning the radiocapitellar joint could mask a wrong angulation of the osteotomy or an impossible reduction due to radial head dysplasia. The only case clarified by images shows a pin used in one of two cases that dislocated posteriorly. In this case, no ALR was done and the radial head seems dysplastic.