A chronic Monteggia lesion is defined as an unreduced dislocation of the radiocapitellar joint that presents at least four weeks after injury. There is considerable controversy with regards to treatment of these chronic lesions. Options range from open reduction to observation. The authors provided this retrospective review of 15 cases of chronic Monteggia lesions. These injuries were seen at two institutions over a five-year period. There were 15 patients with a mean age of about 8 years. The chronicity of the missed Monteggia lesion ranged from six weeks to two years time. Before surgery, all patients reported pain and limited range of motion. All patients underwent open reduction of the radial head and reconstruction of the annular ligament with or without ulnar osteotomy.
The radial head and ulnar deformity were exposed through the same lateral incision. Fascia from the forearm was used to reconstruct the annular ligament. The fascia was harvested while maintaining a base at the proximal extent. The malunited ulna was osteotomized and stabilized with an intramedullary technique. The annular ligament was reconstructed by passing the fascia around the neck of the radius and securing it back to itself. Radiographs were used to confirm reduction of the radiocapitellar joint. Mean follow up consisted of four years duration. There was relatively small loss of pronation measuring 16º in six cases and there was loss of supination measuring 10º in two cases. The arc of flexion was noted to be improved and there were no cases of non-union of the osteotomy. One patient had posterolateral dislocation and refused further surgery. Another patient had persistent subluxation but no functional problems.
The authors present compelling evidence for open reduction of the radial head, correction of the ulnar deformity and reconstruction of the annular ligament with fascia. The authors’ technique resulted in minimal loss of forearm rotation and maintenance of reduction in 13 of the 15 patients. The authors do stress that correction of the ulnar deformity is a prerequisite to radial head reduction. They also indicate that the operation has many potential problems considering the close proximity of the ulnar and radial nerves. Nonetheless, in the carefully selected patient, open reduction of chronic Monteggia lesions can be successful in the pediatric patient.
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J Pediatr Orthop