Şenol AKMAN, MEHMET MESUT SÖNMEZ, Ramazan Erden ERTÜRER, Mustafa Faik SEÇKİN, ADNAN KARA, İrfan ÖZTÜRK

Travma sonrası heterotopik ossifikasyon ve ankiloz gelişen dirseklerde cerrahi tedavi sonuçları

Amaç: Travma sonrası veya geçirilen dirsek ameliyatları sonrası gelişebilen heterotopik ossifikasyon dirsek fonksiyonlarının tamamen kaybıyla sonuçlanabilmektedir. Bu çalışmada travma sonrası gelişen heterotopik ossifikasyona bağlı dirsek ankilozu görülen hastaların cerrahi tedavi sonuçları değerlendirildi. Çalışma planı: Yüksek enerjili travma sonucunda gelişen dirsek çevresi kırıkları nedeniyle cerrahi tedavi uygulanan ve sonrasında dirsek ekleminde heterotopik ossifikasyon ve ankiloz oluşan yedi hasta (6 erkek, 1 kadın; ort. yaş 36; dağılım 23-55) çalışmaya alındı. İki hastada parçalı olekranon kırığı ve dirsek çıkığı, beş hastada parçalı eklemiçi distal humerus kırığı vardı. Üç hastada açık kırık vardı. İki hastada sağ dirsek, beş hastada sol dirsek etkilenmişti. Hastalardan biri kafa travması nedeniyle 22 gün yoğun bakımda tedavi görmüştü. Başlangıç tedavisi olarak altı hasta plak osteosentezi ile tedavi edilirken, bir hastada gergi bandı tekniği kullanıldı. Dirsek eklemi çevresi kırığına yönelik ameliyatlardan ortalama 24 gün sonra (dağılım 20-32 gün) çekilen grafilerde heterotopik ossifikasyon odakları saptandı. Hastalar heterotopik ossifikasyonun takibi ve olgunlaşması açısından ardışık konvansiyonel radyografi ve sintigrafi ile ortalama 11 ay (dağılım 7-15 ay) takip edildi. Takip sırasında, dirsek eklem hareketlerinde fonksiyonel kaybın giderek artışı ve dirsek ekleminde ankiloz gelişmesi nedeniyle cerrahi tedavi uygulandı. Hastaların tümünde Hastings tip IIIC ankiloz vardı ve Mayo dirsek performans skoru ortalaması 50.7 (kötü) idi. Üç hastada posterior, dört hastada çift kolon insizyon kullanıldı. Ulnar sinirin ve lateral ve medial kollateral bağların korunduğu ameliyatlarda posterolateral kapsüler gevşetme, heterotopik ossifikasyonun çıkarılması, olekranon fossanın temizlenmesi ve olekranon ucunun rezeksiyonu yapıldı. Kapsüler gevşetme tamamlandıktan sonra kıkırdak patolojileri incelendi. Dört hastada eklem yüzeylerinde belirgin kıkırdak hasarı saptanmazken, üç hastada eklem kıkırdağının ileri derece hasarlı olduğu görüldü. Hastalar son kontrollerde Mayo dirsek performans skoru ile değerlendirildi. Ortalama takip süresi 23.4 ay (dağılım 10-36 ay) idi. Sonuçlar: Tüm olgularda ameliyat sonunda hareket açıklığı ve eklem stabilitesi kontrol edildi ve eklem hareket açıklığının tam ve stabil olarak kazanıldığı görüldü. Son kontrollerde Mayo dirsek performans skoru üç hastada iyi, bir hastada orta, üç hastada kötü bulundu. Kötü sonuçların hepsi, ameliyat sırasında eklem kıkırdağının bozuk olduğu görülen hastalardan elde edildi. Çıkarımlar: Travma veya geçirilen dirsek ameliyatları sonrası heterotopik ossifikasyon ve ankiloz gelişmiş dirseklerde, heterotopik ossifikasyon odaklarının temizlenmesi ile birlikte dirseğin gevşetme ameliyatları, eklem kıkırdağının büyük oranda hasarlanmadığı olgularda tatminkar sonuçlar vermektedir.

The results of surgical treatment for posttraumatic heterotopic ossification and ankylosis of the elbow

Objectives: Heterotopic ossification which may develop following elbow injuries or elbow surgery may result in complete loss of elbow functions. We evaluated the results of surgical treatment for ankylosis of the elbow due to posttraumatic heterotopic ossification. Methods: The study included seven patients (6 males, 1 female; mean age 36 years; range 23 to 55 years) who developed heterotopic ossification and ankylosis of the elbow joint following surgical treatment of high-energy fractures in the circumference of the elbow. Two patients had comminuted olecranon fractures and elbow luxation, and five patients had comminuted intra-articular distal humeral fractures. Three patients had open fractures. Involvement was in the right elbow in two patients, and in the left elbow in five patients. One patient was monitored and treated in the intensive care unit for head trauma for 22 days. Initially, six patients were treated with plate osteosynthesis and one patient with tension band wiring. Foci of heterotopic ossification were detected on the radiographs taken after a mean of 24 days (range 20 to 32 days) following surgical treatment of fractures. The patients were followed-up with conventional radiography and scintigraphy for a mean of 11 months (range 7 to 15 months) before surgical treatment, during which functional loss in elbow joint movements deteriorated and ankylosis developed. All the patients had Hastings type IIIC ankylosis and poor Mayo elbow performance scores (mean score 50.7). A posterior incision was used in three patients, and a double-column incision was used in four patients. At surgery, the ulnar nerve and the lateral and medial collateral ligaments were preserved, and a posterolateral capsular release, removal of heterotopic ossification, purging of the olecranon fossa, and resection of the tip of the olecranon were performed. After completion of capsular release, cartilage pathologies were evaluated. Four patients were found to have no definite cartilage damage, whereas in three patients the joint cartilage was seriously damaged. At final controls, the patients were assessed with the Mayo elbow performance score. The mean follow-up period was 23.4 months (range 10 to 36 months). Results: In all cases, the range of motion and stability of the elbow joint were controlled and were found to be complete and stable at the end of the operation. At final controls, the Mayo elbow performance scores were good in three patients, moderate in one patient, and poor in three patients. All the patients with a poor elbow score had severe joint cartilage damage intraoperatively. Conclusion: Patients who develop heterotopic ossification and ankylosis of the elbow following trauma or elbow surgery may benefit from removal of heterotopic ossification foci and elbow relaxation procedures provided that there is not severe damage to the articular cartilage.

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