日小整会誌（J Jpn Ped Orthop Ass）23（2）：441 449, 2014.
第 24 回日本小児整形外科学会学術集会 JPOA Asian Fellows

Old Monteggia Treatment with Open Reduction and
Z - Lengthening Technique with Annular Ligament Reconstruction
Perajit Eamsobhana, M.D
Kamolporn Keawpornsawan, M.D
Department of Orthopedics and Rehabilitation,
Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand

Abstract：Background： The purpose of the study is to evaluate the clinical and radiographical outcomes after open reduction and Z-lengthening technique with annular ligament reconstruction for the treatment of a chronic Monteggia fracture-dislocation.
Methods： The authors postoperatively investigated the clinical and radiographical outcomes
for ten children with a chronic Monteggia fracture. The study group included seven boys andthree girls mean age of nine years and one month at the time of open reduction. Each patient
had been treated with open reduction of the radial head combined with ulna osteotomy and elongation, bending with z- plasty technique and annular ligament reconstruction. Clinical and radiographical outcomes were reviewed over a mean duration of follow-up of thirty-eight months.
Results： The postoperative Mayo Elbow Performance Index（MEPI）at the time of follow-up
ranged from 95 to 100 and no poor results. The radial head remained in a completely reduced position in ten patients. In three patients, osteoarthritic changes were observed at the radiohumeral
joint. Radiographically, there were seven good, three fair, and no poor results.

A fair radio-

graphic result was obtained in the patients who had undergone open reduction more than three
years after the injury and two patients was operation at the age of eleven and thirteen years old.
Conclusions： Good clinical and radiographical outcomes can be expected if open reduction for
the treatment of a chronic Monteggia fracture is performed when the patient is less than twelve
years of age or within three years after the injury. Open reduction and Z-lengthening techniquewith annular ligament reconstruction for the treatment of a chronic Monteggia fracture-dislocation is safe with good results without bone graft. No nonunion is report in our series.

Intoroduction

plains of bony prominent, slight or moderate elbow pain, decreased elbow ﬂexion, valgus defor-

Chronic Monteggia lesion in children is often

mity of the elbow, and neurologic problems

missing diagnosed. The ulna mostly has plastic（sensory or motor loss caused by a tardy ulnar

deformation with radial head dislocation, which

nerve palsy or a posterior interosseous nerve

may not obvious to the clinician. The neglected

4）
6）
7）
9）
13）
16）
.
palsy）

radial head dislocation is diagnosed several

Chronic Monteggia lesion is defined, as themonths after the injury when the patient com-dislocation is not reduced and still present 4

Key words：chronic Monteggia, open reduction, annular ligament reconstruction, z-lengthening
日本小児整形外科学会雑誌 Vol. 23, No. 2, 2014

Old Monteggia Treatment with Open Reduction and Z - Lengthening Technique with Annular Ligament Reconstruction

weeks after injury16）. If it was untreated, theand three girls with a mean age of nine years

dislocated radial head loss its concave articular（range, 6〜13 years）at the time of open reduc-surface and demonstrates hypertrophic changes

tion. All patients were treated surgically andand the humeral capitellum configuration flat-

were followed for at least twenty-four months

tens, thereby limiting the range of elbow ﬂexion（mean 38.8 months； range, 24 to 120 months）
.

13）
14）
16）

and extension. There are many options to

Surgical procedures were described below. A

these problems in growing child, ranging fromskin incision was made beginning at the posteri-observation to radial head resection if patientor and distal of the humerus and goes along dis-18）

has symptoms at skeletal maturity , open re-tal on the lateral side of the radiocapitellar joint,

duction and ulna osteotomy with or without an-passing to the level of the proximal metaphysis

nular ligament reconstruction. Many authorsof the ulna, and extending to the middle part ofhave recommended that a missed radial head

the posterior aspect of the ulna along the bony

dislocation in a child should be treated withborder of ulna. The radiohumeral joint was ap-

open reduction as early as possible once it is di-proached between the extensor carpi ulnaris

agnosed

1）
2）
4）
8）
16）
20）

.

and anconeus muscles and fibrous tissue wasEven though many authors agree that open

removed. The radial head was exposed, and the

reduction is necessary to reduce the radial head,state of the cartilage of the radial head was as-

opinions still diﬀer regarding the need for recon-

sessed. The remnant of annular ligament was

struction annular ligament and the need for

identified and used for augment in the recon-over correction of the ulna. Patient age and in-struction of annular ligament with triceps fascia.

terval time from injury to operation are also the

In all cases, an ulnar osteotomy with Z-lengthen-important factors that affect the surgical out-

ing technique was performed ﬁrst, and then thecome after open reduction.

radial head was reduced. An ulnar osteotomy

From 2001, ten children with a chronic Mon-with z-lengthening was performed in all patientsteggia fracture-dislocation have been managedwith Bado Type 1,in Bado type 3 the ulna os-

with open reduction of the radial head combined

teotomy was performed to corrected varus de-with Z-lengthening ulnar osteotomy and annularformity but bending and lengthening was not

ligament reconstruction. The present report de-performed. The ulna was stabilized with a plate

scribes our surgical technique as well as thecontaining four to seven screw holes（Fig. 1）.

clinical and radiographic outcomes.
Materials and Methods

After reduction of the radial head and ﬁxationof the ulna with a plate, annular ligament reconstruction was performed at the level of the radi-

During the period from 2001 to 2009 ten chil-

al neck with triceps fascia and augment withdren with a missed radial head dislocation after

the remnant of annular ligament18）in all case.

a Monteggia fracture were managed consecu-

Radiocapitelium pinning was used in seven casetively at our hospital with open radial head re-depend on stability after reduction of radial

duction combined with Z-lengthening ulnar os-

head intraoperative. Suction drain was applied

teotomy and annular ligament reconstruction

at the osteotomy site. Postoperatively, a castwith additional radiocapitelium pinning in seven

was applied with the elbow ﬂexed to 90 degrees

patients. The study group included seven boys

and the forearm in a supination position in Bado

日本小児整形外科学会雑誌 Vol. 23, No. 2, 2014

Old Monteggia Treatment with Open Reduction and Z - Lengthening Technique with Annular Ligament Reconstruction

defined a full flexion-extension arc as 140 degrees, full pronation arc as 80 degrees, and fullsupination arc as 85 degrees.
Radiographic assessment all patients had routine anteroposterior and lateral radiographs ofthe elbow, which were checked for deformity of
the radial head, osteoarthritic changes, and dislocation or subluxation of the radial head. The
deformity of the radial head was evaluated on
the anteroposterior and lateral radiographs according to Kim et al.12）. Radial head hypertrophy
was determined by measuring the diameter ofthe radius at the widest portion of the metaphysis adjacent to the physis（a）and the narrowest
portion of the neck just proximal to the bicipital
tuberosity（b）. If a/b was ＞ 1.5, radial head hypertrophy was considered to be present. Subluxation of the radial head was considered to be
Fig. 1．Ulnar osteotomy with Z lengthening technique and fixation with eight holes plate, withoutbone graft.

present when a line drawn down the center ofthe radial neck did not pass through the central
one-third of the capitellum on the lateral radiograph. The radiographic results were divided

type 1. The immobilization period was approxi-

into three categories： good（complete reduction

mately six weeks following surgery. Radiocapite-of the radial head without osteoarthritic changes

lium pin was removed at 6 weeks. After remov-of the elbow）, fair（reduction with radial head

al of the cast, active elbow motion was encouraged.

subluxation or osteoarthritic changes of the el-

Return to physical activity was allowed after ra-bow）,and poor
（radial head dislocation）.

diographic union was seen. There was no specific physiotherapy program.

Results

At the time of follow-up, all patients were in-

A summary of the preoperative data is shownterviewed and examined individually by two ofin Table 1. In total ten patients, eight were clas-

the authors by interview and physical examina-

siﬁed as Bado type I, and two were classiﬁed astion is interpreted by Mayo Elbow Performance

Bado type III. Anteroposterior and lateral radio-

15）

as excellent（90 0r ＞ 90 points）,
Index （MEPI）

graphs of the elbow revealed that all patientsgood（75〜89 points）
fair（60〜74 points）
and poor

had a complete dislocation of the radial head；（＜ 60 points）.

the direction of the dislocation was anterior in

Pre operative and postoperative ROM, ex-eight patients and anterolateral in two. Radialpressed as the sum of the ﬂexion-extension arc

head deformity was observed in three patients,

and pronation-supination arc, was determined

loss of concavity of the radial head was seen inwith a goniometer using standard method. We

two of these patients, and hypertrophy of the
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Old Monteggia Treatment with Open Reduction and Z - Lengthening Technique with Annular Ligament Reconstruction

Table 1．Clinical data of the ten children in the Study
Pt. No. Sex

Injury Age Bado Type Age at Operation Preop Delay（mo） Treatment

f/u
（mo）

1

M

5yr

UO ＋ OR ＋ AR

38

2

M

8yr

III

11yr

36

UO ＋ OR ＋ AR

72

3

M

3yr

I

7yr

24

UO ＋ OR ＋ AR ＋ TP 36

4

M

5yr

I

8yr

36

UO ＋ OR ＋ AR ＋ TP 24

5

M

3yr

I

6yr

36

UO ＋ OR ＋ AR ＋ TP 39

6

M

5yr

I

9yr

24

UO ＋ OR ＋ AR ＋ TP 25

7

F

8yr

III

9yr

8

UO ＋ OR ＋ AR ＋ TP 24

8

M

8yr

I

13yr

60

UO ＋ OR ＋ AR ＋ TP 28

9

F

6yr

I

7yr

8

UO ＋ OR ＋ AR ＋ TP 29

10

F

3yr

I

13yr

120

UO ＋ OR ＋ AR

I

8yr

36

24

UO：ulna osteotomy, OR：open reduction of radial head, AR： Annular ligament reconstruction,TP： transradiocapitella pin, F/u, duration of follow-up
Table 2．Pre and Post operative range of motion and complications
Before Surgery

After Surgery

complication

Pt. No. Pro-0-sup

Flex-0-ext

Pro-0-supFlex-0-ext

160-0-70120-0-0

80-0-85130-0-0‑2

50-0-70120-0-0

70-0-80130-0-0‑3

60-0-80120-0-0

60-0-80140-0-0-

4

60-0-80

100-30-30

70-0-80

120-30-30‑

580-0-80120-0-0

80-0-80130-0-0

broken of transradiocapitella pin

660-0-80120-0-0

80-0-85

140-0-0

broken of transradiocapitella pin

780-0-80120-0-0

80-0-85

140-0-0‑860-0-80120-0-0

70-0-80130-0-0‑980-0-80120-0-0

80-0-85

140-0-0‑1050-0-80

100-0-0

70-0-80

120-10-10

re-dislocation＊ Complication ： broken of transradiocapitella pin, re-dislocation

radial head was noted in one patient. The over-cases with temporary radiocapitelium pinningall postoperative clinical results, radiographic re-no dislocations were seen at 24-month follow-up.

sults, and complications are shown in Table 2

Osteoarthritic changes of the radiohumeral joint

and 3. The average MEPI score at the time ofwere observed in three patients； the changes

the latest follow-up was 99.5, with all excellent

were mild in all three patients.

clinical results. No patient complained of pain.

Mean interval between the injury and open

None of the patient complained of limitations of

reduction was 38.8 months. Hypertrophy of thedaily life. At the time of the latest follow-up, theradial head was found in, all of who showed ra-radial head was maintained in a completely re-dial head deformity had undergone surgery

duced position in all of the patients. Redisloca-

more than three years after the initial injury.

tion of the radial head was observed in one pa-

On the basis of our radiographic evaluation

tient post operatively（patient no.10）but in thecriteria, seven patients were rated as good,

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Old Monteggia Treatment with Open Reduction and Z - Lengthening Technique with Annular Ligament Reconstruction

Table 3．Radiographic results
Pt. NoRadiographic ﬁnding

Radiographic
results

1

no osteoarthritis change, no subluxation

good

8yr

36mo

2

no subluxation, hypertrophy of radialhead,mild osteoarthritis change

fair

11yr

36mo

3

no osteoarthritis change, no subluxation

good

7yr

24mo

4

no osteoarthritis change, no subluxation

good

8yr

36mo

5

mild osteoarthritis change, no subluxation

fair

6yr

36mo

6

no osteoarthritis change, no subluxation

good

9yr

24mo

7

no osteoarthritis change, no subluxation

good

9yr

8mo

8

no osteoarthritis change, no subluxation

good

13yr

60mo

9

no osteoarthritis change, no subluxation

good

7yr

8mo

10

mild osteoarthritis change, no subluxation

fair

13yr

120mo

three were rated as fair, and none were rated
as poor（Table 3）. The mean MEPI score was

Age atPreop.
Operation Delay（mo）

Discussion

99.5. The mean interval between the injury andPatient age at the time of open reduction andopen reduction was 28 months for the patientsthe interval between a Monteggia fracture andwho were rated as good and 64 months forsurgery, remain controversial. With respect tothose who were rated as fair. The mean age atage, Wilkins proposed that reconstruction

the time of open reduction was 8.7 years for theshould be performed only in patients under 12

patients who were rated as good and 10 years

years old20）. Hirayama et al.6）and Stoll et al.18）rec-for those who were rated as fair .The relation-ommended open reduction for children less thanships between the clinical data at the time often years of age； however, they did not recom-

open reduction and the radiographic results atmend surgery when radial head deformity, ﬂat-the time of follow-up are shown in Table 3. Re-

tening of the capitellum, or valgus deformity of

duction of the radial head was maintained withthe radial neck was present. Horii et al.8）report-

osteoarthritic change in two patients who wereed that open reduction was beneficial for pa-

less than twelve years old at the time of the op-

tients younger than twelve years of age without

eration. No patient who has interval of less thanradial head deformity, and this ﬁnding was con-three years between the injury and the opera-

ﬁrmed by Wang and Chang19）. Our results also

tion had radial head with osteoarthritic change.

show that the older the child at the time of open

When the age at the time of open reduction was

reduction and the longer the interval from inju-

twelve years or more and the interval to open

ry to open reduction, the lower the likelihood of

reduction was longer than three years, three

a good result but in our series has one patient

had osteoarthritic changes of radiohumeral joint.

（no.8）has 13 years old at the time of surgery

One patient（no.8）has good radiologic outcome

and preoperative delay for 60 months shows

even the preoperative delay was 60 months andgood result with no osteoarthritis change. No

the age at surgery was 13 years old.

patient with an age of less than twelve years at
日本小児整形外科学会雑誌 Vol. 23, No. 2, 2014

Old Monteggia Treatment with Open Reduction and Z - Lengthening Technique with Annular Ligament Reconstruction

Fig. 2．
（A,B）Thirteen years old girl with Monteggia Bado type 1, interval from injury to operation is ten years,（C,D）
immediate dislocation post ‒operatively（E）after closed reduction with transradiocapitella pin radial head
was reduced,（F）remove transradiocapitella pin at 6 weeks,（G,H）at follow up 24 months with no subluxation, osteoarthritis of radiohumeral joint was observed.
（Patient No. 10）

the time of open reduction with an interval of

have osteoarthritis change. We cannot conclud-less than three years between the injury anded that patient age more than 12 years old or

open reduction showed subluxation of the radial

preoperative delay more than three years

head or osteoarthritic changes of the radiohumeral

should not performed surgery until we has

joint.

more statistical evident to support the indica-

With regard to the interval between the inju-

tions. However, even if the patient does notry and open reduction, the ﬁndings have varied

meet the criteria, open reduction for a missed

19）

among reports, with Wang and Chang stating

Monteggia fracture-dislocation is still advisablethat the acceptable interval is three years, Stoll

because almost all clinical outcomes of our pa-

18）

3）

tients were improved after surgery. If open re-stating that it is six years. However, none ofduction is to be performed for such patients,

those authors provided statistical evidence tohowever, it should be informed about the highsupport their indications. Our results show thatrisk of subluxation of the radial head and os-

six patients who have preoperative delay moreteoarthritic changes.

et al. stating that it is four years, and Best

than 36 months, only three patients（no. 2,5,10）
日本小児整形外科学会雑誌 Vol. 23, No. 2, 2014

Regarding the surgical procedures for recon-Old Monteggia Treatment with Open Reduction and Z - Lengthening Technique with Annular Ligament Reconstruction

Fig. 3．Clinical and range of motion of chronic Monteggia left elbow 24 months after surgery.
（Patient No. 10）

struction of the annular ligament, several meth-corrective osteotomy with lengthening. Inoueods have been proposed, such as using a freeand Shionoya9）compared simple correction ver-palmaris longus tendon, pedicled forearm fascia,

sus overcorrection and annular ligament recon-fascia of the triceps, and the remnant of the an-struction and found better results on second

10）nular ligament. Kalamchi also used the torn an-group. The concept of ulnar osteotomy is tonular ligament to stabilize the radial head intighten the interosseous membrane sufficiently

17）

two cases. Seel and Peterson found that the an-to keep the radial head in a correct anatomical

nular ligament was impinged between the radial

position. To preserve all of the interosseoushead and the humerus in all seven of their cas-membrane and to use its tension to pull the ra-

es, and they used it for reconstruction in five.

dial head posteriorly. Proximal ulnar osteotomy

Reconstruction of the annular ligament was

has the advantages of having an unnoticeable

thought to result in limit rotation of the forearm

posterior curvature and avoiding restriction of5）

if it is not properly tensioned . Limit rotation,

forearm rotation because the tension in theespecially in pronation, have been reported after

whole interosseous membrane remains constant.

annular ligament reconstruction. We used annu-

In our series we done ulna osteotomy with pos-lar ligament reconstruction with triceps fascia interior bending and lengthening technique andall patients because most of the patients have

fixed with six to eight holes plate and screws,

preoperative delay more than 24 months and in-this technique not required bone graft and notraoperatively the remnant of annular ligament

nonunion or delayed union in our series. Range

was not healthy enough to use for reconstruc-of motion and MEPI score improve compare totion, but in some case, we can use annular liga-

preoperative.

ment to augment the triceps fascia. Postopera-

This study had several limitations. First, fortive range of motion still has some limitation of

the evaluation of the condition of the radial

pronation but improve compared to preopera-

head, we measured its size and shape with use

tive and all has excellent MEPI score.

of conventional radiographs. Magnetic resonanceTwo types of ulna correction have been pro11）12）

imaging currently has the ability to evaluate theand an angularsize, configuration of the articular surface, andovercorrective osteotomy ﬁxed with plate or in-quality of articular cartilage of the radial head,

posed, a simple correction
6）

6）

tramedullary wire. Hirayama performed over-and it can also display the condition of the radial
日本小児整形外科学会雑誌 Vol. 23, No. 2, 2014

Old Monteggia Treatment with Open Reduction and Z - Lengthening Technique with Annular Ligament Reconstruction

notch of the ulna.

References

In the future, open reduction should be basedon the preoperative anatomical or functional status of the radial head, the radial notch of theulna, and the remnant of the annular ligament
as detected with magnetic resonance imaging orother advance imaging techniques. Second, weused the MEPI as a functional score although it
has not been validated for use in studies of children.
Conclusions
From the viewpoint of performing an open radial head reduction with a posterior bending
elongation ulnar osteotomy combined with anannular ligament reconstruction, we consideredthese two methods to be similar enough to beanalyzed as one group. Last, although multivariate analysis with logistic regression is necessary
to identify signiﬁcant risk factors related to outcome, the number of patients in our study was
insuﬃciently to be analyzed
In this way. Therefore, we could not provethat patients who undergo the operation within
three years after the injury or before the age oftwelve years have a signiﬁcantly higher chanceof obtaining a good result. Despite such limitations, our data support that, if open reduction
for the treatment of a chronic Monteggia fracture dislocation is performed before the patientis twelve years of age or within three years after the injury, good long-term clinical and radiographical outcomes should be expected.
Technique of posterior bending elongation
with Z plasty technique combined with annularligament reconstruction leads to stable reduction of the radial head, safe, no need for bone
grafting and no delay union in our series andwe support this technique to treat chronic Monteggia fracture dislocation.
日本小児整形外科学会雑誌 Vol. 23, No. 2, 2014

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