A multicenter, prospective, randomized, controlled trial of open reduction--internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Distal Humerus Fractures in the Elderly: When to Fix and When to Replace?

Distal humerus fractures in the elderly population can be difficult to manage because of substantial articular comminution, poor bone quality, and soft tissue compromise. Important patient considerations for treatment include physiologic age, mental status, activity level, and independence with activities of daily living. Elderly patients may be reliant on their upper extremity as a weight-bearing limb when using a walker or rising to stand which creates additional demand. The goal of surgical treatment is to recreate a stable, painless elbow with a functional range of motion to preserve independence for daily activities and mobilization. The main surgical treatment options are open reduction and internal fixation and arthroplasty. Here, we discuss indications and operative goals in each clinical scenario.

Osteochondral allograft transplantation for complex distal humeral fractures assisted by 3D computer planning and printing technology: technical note

PURPOSE

The surgical treatment of comminuted distal humeral articular fractures (DHF) is challenging and is jeopardized by the high rate of complications. The study aims to describe the application of osteochondral allograft (OCA) transplantation for the treatment of complex DHF assisted with a 3D printed specific instrumentation.

METHODS

Retrospective study. Inclusion criteria were the presence of an articular multi-fragmented DHF treated with frozen OCA. Clinical, self-reported and radiographic outcomes were collected every 6 months. CT were performed at 2 years FU.

RESULTS

Four patients were included. At a mean follow-up of 37.3 months (24-49) MEPS, DASH and VAS were 90 (80-100), 11.8 (0-25) and 1 (0-3) points, respectively. Not significant complication or reoperation was recorded. Graft healing was observed in 3 cases. In all cases, we observed arthritic progression after 2 years of follow-up.

CONCLUSION

OCA transplantation can be considered a reliable and safe procedure in patients affected by a complex DHF.

LEVEL OF EVIDENCE

Level V. Technical Notes.

Involvement of the medial and lateral epicondyles in distal humeral coronal shear fractures: Case series and literature review

PURPOSE

Epicondyle involvement in capitellar and trochlear fractures is often considered a simple associated lesion that does not substantially change treatment or prognosis. Although theoretically predicted in reviews, case series almost never report elbow prosthesis use in comminuted coronal shear injuries associated with epicondylar fracture in the elderly. The purpose of this study is to focus on this underestimated injury pattern that can be a negative risk factor for treatment and prognosis.

METHODS

We retrospectively reviewed all cases with coronal shear fracture of the distal humerus treated from 2016 to 2019. Fractures were classified according to Dubberley. Open reduction and internal fixation (ORIF) were performed when possible. Partial or total elbow replacement was used in severely comminuted fractures with epicondylar involvement in four elderly patients.

RESULTS

Nineteen consecutive patients were selected (mean age: 62.4 years), of which 10 had type 3A/3B fractures, and seven had both medial and lateral epicondylar involvement. The mean follow-up duration was 31.78 months. The average Mayo Elbow Performance Index (MEPI) score was 81.05 points, with 7 excellent, 8 good, 1 fair, and 3 poor results. The average MEPI score of Dubberley's type 1 and type 2 was better than that of type 3 (mean: 92 vs. 72, p = 0.02). Further, the results of average range of motion were better in patients who had sustained Dubberley types 1 and 2 lesions than those with Dubberley type 3 lesion (mean: 133° vs. 85°, p = 0.002). Two patients out of three who required intra-operative conversion to total elbow arthroplasty had poor outcomes.

CONCLUSIONS

The simultaneous presence of fracture of one or both epicondyles are usually associated with severe joint comminutions and makes ORIF more challenging, especially among elderly women. In these cases, primary total elbow prosthesis implantation could be a valid treatment option.

Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis

BACKGROUND

Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years.

METHODS

We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating.

RESULTS

Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01).

CONCLUSIONS

This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.

Type III open complete articular fractures of the distal humerus: case series outcomes after orthoplastic reconstruction

Background

Open complete articular injuries of this distal humerus are rare injuries which are challenging to manage. The study unit aims to present a small case series of Gustilo-Anderson type III open complete articular fractures which have undergone a single-stage definitive fixation and soft-tissue coverage, presenting their functional outcomes.

Methods

Retrospective case series identifying all type IIIB AO 13-C3 distal humeral fractures from the unit trauma database. The primary outcome was the Oxford Elbow Score. Secondary outcomes included deep infection, nonunion, and reoperation.

Results

A total of six patients were identified, (four open type IIIA, 2 type IIIB). All patients underwent single-sitting definitive fixation and soft-tissue coverage. Mean range of motion arc was 90 degrees. The median Oxford Elbow Score was 35 (range 21-43), representative of mild to moderate arthritis. One patient (n = 1) developed deep infection at 24 months and required reoperation. All patients (n = 6) proceeded to union at the latest follow-up. We present a case report of a 59-years-old patient who sustained a type IIIB, AO 13-C3 distal humeral fracture who underwent single-sitting definitive fixation and flap coverage.

Conclusion

This case series reports that positive functional outcomes representative of mild/moderate arthritis at short to midterm follow-up can be achieved after definitive fixation and soft-tissue coverage in a single sitting, including when the soft tissue is deficient. This is a rare injury which is under-reported in the literature.

Results of the distal humeral hemiarthroplasty Latitude in distal humeral unreconstructable fractures treatment in patients older than 65 years old

AIM

The aim of this study is evaluate clinical and radiographic outcomes of Latitude elbow hemiarthroplasty in the treatment of articular distal humerus multifragmentary fractures in patients older than 65 years.

MATERIAL AND METHODS

We included those patients older than 65 years who sustained an unreconstructable articular distal humeres fracture and it was replace with a Latitude hemiarthroplasty. We excluded those with a minimum follow up less than 2 years. The clinical outcomes were assessed with Mayo Elbow Performance Score (MEPS). Range of motion, pain, complications and elbow radiological assessments were recorded at the final follow up.

RESULTS

We have found that after a mean follow-up of 5 years, the five patients included in the study have mild pain in the elbow. They have recovered a median flexion arch of 100°, with a 10° extension lag. The MEPS was considered as good in all the cases. There were not any instability or prosthesis loosening, but two patients developed a moderate proximal cubitus wear.

CONCLUSION

Latitude elbow arthroplasty is an option in the distal articular humerus multifragmentary fractures treatment in osteoporotic and ageing patients with satisfactory results as long as the elbow ligamentous stability can be restored.

Lateral epicondyle osteotomy approach for coronal shear fractures of the distal humerus: Report of three cases and review of the literature

BACKGROUND

Coronal shear fractures of the distal humerus are rare injuries and are technically challenging to manage. Open reduction and internal fixation (ORIF) has become the preferred treatment because it provides anatomical reduction, stable internal fixation, and early motion, but the optimal surgical approach remains controversial.

CASE SUMMARY

We report three cases of coronal shear fractures of the distal humerus treated successfully by ORIF via a novel surgical approach, in which lateral epicondyle osteotomy was performed based on the extended lateral approach. We named the novel surgical approach the lateral epicondyle osteotomy approach. All patients underwent surgical treatment and were discharged successfully. All patients had excellent functional results according to the Mayo elbow performance score. The average range of motion was 118° in flexion/extension and 172° in pronation/ supination. Only case 2 had a complication, which was implant prolapse.

CONCLUSION

We demonstrated that the lateral epicondyle osteotomy approach in ORIF is effective and safe for coronal shear fractures of the distal humerus.

A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty

Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions. In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.

Current concepts in distal humeral hemiarthroplasty

Multi-fragmentary intra-articular fractures of the distal humerus remain a challenge for both patients and surgeons. Open Reduction internal fixation remains the gold standard, however in older patients with comminuted fractures this might not be feasible. There is a growing interest in hemi-arthroplasty as a solution for these cases. However the current experience and follow-up in limited. This review article intends to describe the current concepts in elbow hemiarthroplasty in dept. we will discuss the historical use of these implants, as well as the intricacies of more modern devices. Next we will elaborate an surgical planning, approach, and technical pearls. We will lay out a rehab protocol used by the senior author, and with some considerations for the future.

Results of Linked Convertible Total Elbow Arthroplasty for the Management of Distal Humeral Fractures in the Elderly

PURPOSE

Total elbow arthroplasty (TEA) is increasingly used for the management of comminuted distal humeral fractures in elderly patients. There are limited data on the outcome of modern elbow arthroplasty designs in larger patient cohorts. The aim of the current study was to review the outcomes and complications using a cemented convertible TEA system in a linked configuration in patients with distal humeral fractures.

METHODS

Patients with distal humeral fractures treated with TEA and a minimum of 2 years' follow-up were reviewed. Demographic information, patient-reported outcome, functional and radiographic outcome assessments, and complications were reported.

RESULTS

Forty patients met inclusion criteria; 35 were female. Median follow-up was 4 years (range, 2-13 years). Average age of patients at the index procedure was 79 ± 9 years. All implants were linked. Range of motion was: extension 16° ± 13°, flexion 127° ± 14°, supination 79° ± 11°, and pronation 73° ± 20°. Patient-reported outcome scores were: Patient-Rated Elbow Evaluation 37 ± 35, Quick-Disabilities of the Arm, Shoulder, and Hand 31 ± 31, and Mayo Elbow Performance Index 90 ± 18. Seven patients had heterotopic ossification. Lucent lines were noted predominantly in humeral implant zone V. No lucent lines were noted around the ulnar component in any radiographic zone. Complications occurred in 9 patients (22%) and 2 revisions were performed: one for infection and one for a late periprosthetic fracture.

CONCLUSIONS

Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores. No implant-related complications of this convertible implant system were encountered, but longer-term follow-up is needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Total elbow arthroplasty for acute distal humeral fractures with humeral condyle resection or retention: a long-term follow-up study

Background

Open reduction and internal fixation is the gold standard for the operative treatment of intra-articular distal humeral fractures. However, in elderly patients the approach involves a high rate of complications. We reviewed the long-term outcomes of 13 primary total elbow arthroplasties (TEAs) performed to treat acute fractures in non-rheumatoid patients who at the time of trauma were aged less than 70 years. The aim of the study was to establish whether condyle retention enhances hinge stability and influences outcomes in these patients, who are younger than those who typically undergo TEA.

Methods

In 13 consecutive patients with acute distal humeral fractures aged 61-67 years, a linked semi-constrained Coonrad-Morrey prosthesis was implanted. The medial and lateral condylar bone fragments were resected (7 patients) or stabilized to the diaphysis using k-wires or plates (6 patients).

Results

At a mean follow-up of 12 years, the mean Mayo Elbow Performance Score was 88 and patient satisfaction was 85%. Nine patients (70%) did not require surgical revision. All revisions involved the group managed by condyle resection.

Discussion

TEA can be considered in elderly subjects with acute distal humeral fracture. In our patients, resection of the medial and lateral condyle fragments did not influence outcomes, although clinical observation suggested that it involves greater mechanical stress on the hinge, heightening the long-term risk of bushing wear. Condyle fixation with plates or k-wires seems to afford longer implant survival and is recommended in younger patients with higher functional demands.

Complex fractures of the distal humerus in the elderly: primary total elbow arthroplasty or open reduction and internal fixation? Mid-term follow-up

OBJECTIVE

To compare the mid-term outcomes in intra-articular distal humerus fracture (AO/OTA type C) treated with either open reduction-internal fixation (ORIF) or total elbow arthroplasty (TEA) in patients older than 75 years and with more than five years of follow-up.

METHODS

Retrospective study including 24 patients (11 TEA vs. 13 ORIF) with a mean age of 82 years and being all females. Results assessed included (1) radiographic measures; (2) functional results: range of motion, Mayo Elbow Performance Score (MEPS), quick-DASH; and (3) complications.

RESULTS

TEA group vs. ORIF group achieved a mean flexion of 117° ± 9.6° vs. 106° ± 14°, extension loss of 38° ± 17° vs. 30.8° ± 16°, pronation 75° ± 5° vs. 85° ± 7° and supination 75° ± 4° vs. 70° ± 5°. Mean MEPS score was 71.6 vs. 83.6 (p = .183) and mean quick-DASH was 44.8 vs. 42.6 (p = .789). All 13 patients in the ORIF group demonstrated radiographic signs of bone union and none underwent conversion to TEA. Sixty-three percent of the patients in the TEA group underwent re-operation at an average of 72 months (62.4-75.2 months), including three  for periprosthetic fracture and four  for implant loosening. Whereas in the ORIF group, 23% of the patients were re-operated upon excluding olecranon osteotomy hardware, two  for stiffness, and one  for an olecranon tension band wire failure.

CONCLUSIONS

Although there were no differences in mid-term functional outcomes between either treatment, our results suggest that the recent trend towards the use of TEA instead of ORIF in the elderly should be re-examined due to the high rate of complications beyond five  years of follow-up with TEA.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate

Introduction: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. Methods: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. Results: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). Conclusion: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

Complex open elbow fracture Gustilo-Anderson type IIIB treated with the primary elbow arthroplasty: A case report

Total elbow arthroplasty as a treatment option for open elbow fracture is relatively rare described. We reported a 39 years old polytrauma patient with complex open elbow fracture (Gustilo-Anderson type IIIB). The patient presented with large soft tissues defect on dorsal part of the left elbow, ulnar palsy due to the irreparable loss of the ulnar nerve, distal triceps loss due to the complete loss of the olecranon, loss of both humeral condyles with collateral ligaments and complex elbow instability. Only few similar cases have been published. Reconstructive surgery included repetitive radical debridement, irrigation, vacuum assisted closure system therapy, external fixation, coverage of the soft tissue defect with fascia-cutaneous flap from the forearm. Four months after the injury, total elbow arthroplasty with autologous bone graft (from the proximal radius) inserted in the ulnar component, was performed. At 3 years postoperatively, the patient is able to perform an active flexion from 0° to 110° with full prono-supination. Only passive extension is allowed. The ulnar neuropathy is persistent. Patient has no signs of infection or loosening of the prosthesis.

Effects of trochlear fragmentation on functional outcome in coronal shear fractures: a retrospective comparative study

Background

Coronal shear fractures of the distal humerus are rare injuries, and fragmentation of the capitellum and trochlea with posterior comminution is challenging for surgeons. We retrospectively evaluated the functional outcomes of patients with coronal shear fractures managed with open reduction and internal fixation, focusing on the number of trochlea fragments in Dubberley type 3B fractures.

Materials and methods

The functional outcomes of 25 patients, including 8 patients with type 3B fractures, with a mean age (and standard deviation) of 57 ± 20 years, were evaluated at a mean follow-up duration of 15 ± 9 months. Type 3B fractures were classified into two groups: those with two trochlea fragments or less group (group A) and those with three or more fragments (group B). Patient outcomes were assessed with clinical and radiographic examination, range of motion, and the Mayo Elbow Performance scale (MEPS).

Results

Two patients with type 3B in group B experienced nonunion, and two patients with type 3B in group A and 1 patient with type 1B demonstrated avascular necrosis on radiographs. The average MEPS score was 96.3 points (range, 70-100), with 18 excellent, 5 good, and 1 fair results. The average range of motion was 10 ± 8 to 130 ± 12. The MEPS score worsened as Dubberley classification progressed from type 1 to type 3 (98.3 vs. 96.7 vs. 88, P = .014, respectively) and subtypes A to B (97.9 vs. 90, P = .014, respectively). In comparing groups A and B, the MEPS score was significantly worse in group B (93.8 vs. 76.3, P = .006).

Conclusion

Our open reduction and internal fixation results were largely good, although functional outcomes were diminished as Dubberley classification progressed from type 1 to type 3 and subtype A to B. Type 3B fractures with three trochlea fragments or more in the elderly were the most difficult to treat with open reduction and internal fixation and possibly 1-term total elbow arthroplasty.

Skinny wire and locking plate fixation for comminuted intra-articular distal humerus fractures: a technical trick and case series

Introduction

Intra-articular distal humerus fractures present a challenge to orthopedic surgeons. Stable fixation is difficult to achieve in fractures with articular and metaphyseal comminution and osteoporotic bone. Hence, these fractures are more commonly being managed with total elbow arthroplasty. We describe a novel surgical technique that confers stable fixation, allowing for early range of motion resulting in a high rate of union, a functional range of motion, and excellent patient reported outcome scores without the activity restrictions of total elbow arthroplasty.

Methods

Retrospective case series of 30 patients with AO/OTA type B and C intra-articular distal humerus fractures who underwent ORIF from 2014-2019 utilizing a novel surgical technique that focuses on reconstructing a comminuted articular surface through meticulous, transverse fixation of the tiny articular fragments with long, thin Kirchner wires, which are then bent over and trapped under locking compression plates to create a fixed angle support to the metadiaphysis.

Results

Patient mean age of 59 (19-90) years and 61% were female. Median follow up was 1.2 years. Twenty-seven (87%) were type C fractures and 3 (13%) were type B. Five patients (16%) suffered a concurrent ipsilateral upper extremity injury and four (13%) had an open fracture. Two were polytrauma patients. All fractures healed with an average time to union of 11 weeks. Over 80% patients reported no or mild pain at final follow up. Mean arc of elbow motion was 102 degrees, mean QuickDASH score 25.2. Post-operative complications included ulnar nerve paresthesias (38%), wound infection (3.2%), heterotopic ossification (3.2%), and olecranon nonunion (3.2%). Eight patients underwent secondary procedures: 7 (23%) removal hardware, 3(9.6%) capsular release, 2 (6.4%) ulnar nerve transpositions, and 1 (3.2%) total elbow arthroplasty.

Conclusion

We describe a novel surgical technique that we believe results in strong, stable fixation of complex intra-articular distal humerus fractures irrespective of bone quality. In our series, all fractures healed and post-operatively patients reported low levels of pain, achieved excellent elbow range of motion, high patient reported outcome scores. Patients should be counseled about high rates of post-operative ulnar nerve paresthesias that can be expected to improve over time and high reoperation rates for symptomatic hardware.

Survival and outcome of total elbow arthroplasty for distal humeral fracture at long term follow-up

Background Total elbow arthroplasty is an accepted procedure for the treatment of acute comminuted distal humeral fractures in elderly. Few long-term outcomes are available. The purpose of this study was to examine long-term clinical and radiological outcomes of prosthesis performed (January 2002-June 2015) for complex intra- fractures of the distal humerus (AO/C) in patients older than 65 years with low functional demands. Materials and Methods Further inclusion criteria were: the availability of a clinical and radiological follow-up of minimum 5 years and pattern of closed fracture. Demographic data and characteristics of patients were collected. All patients were clinically and radiographically assessed after 2 and 5 years from surgery. Results Twelve patients were included with complete available data. The mean follow-up was 7.6 years. Five patients reported a worsening of the elbow functionality through the follow-ups. Five subjects had complications. There were no cases of revision surgery. The quality of fixation showed a progressive worsening with increase of radiolucency both on humeral and ulnar side. The recorded MEPS showed no correlation with the grade of periprosthetic osteolysis. Polyethylene bushing wear was scored of grade 2 in one subject who had showed type 4 Morrey radiolucency. Discussion and Conclusions Total elbow arthroplasty is an effective and reliable procedure for comminuted fractures of the distal humerus in elderly, although the incidence of complications can not be considered as negligible. For the majority of these patients, a well-performed implant will give them a well-functioning elbow for their remaining life.

Coronal shear fractures of the capitellum and trochlea: interobserver variability in classifying the fracture and the need for a computed tomography scan for the correct surgical planning

Background

To determine interobserver agreement in the classification by X-rays and by computed tomography (CT) scan of the coronal shear fractures of the capitellum and trochlea as well as the agreement between these two tests.

Methods

Patients with coronal shear fractures of the capitellum who were managed at our center between January 2008 and December 2017 were included. This retrospective cohort study was carried out with the approval of the ethics committee of our institution (Nº: IIBSP-Cod-2019-02, Ref. 19/070). Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated. Three observers analyzed the preoperative X-rays from all the cases. Each one of them independently classified the fractures according to the Bryan and Morrey classification (with the modification of McKee et al). The interobserver agreement was calculated by Cohen kappa coefficient. The same methodology was used to analyze the CT scan. Thereafter, one single value was determined for each X-ray and CT scan, from the good interobserver agreements. Finally, the agreement between the global X-ray classification and the global CT scan classification was calculated using the agreement percentage and the Cohen kappa coefficient.

Results

There were 3 males and 6 females, with a mean age of 47 years (range, 18-83). The mean follow-up period was 18 months (12-40). The average Mayo Elbow Performance Index score was 85 (range, 65-100) points. The complications were nonunion in one patient (11 %), degenerative arthritis in 7 (78 %), joint step-off in 5 (55%), and heterotopic ossification in 7 (78%). The agreement analysis between the global X-ray classification and the global CT scan classification showed a 57.1% agreement, with a kappa coefficient of −0.167. These values imply the absence of agreement.

Conclusion

Our results demostrated that simple X-rays do not allow for the adequate interpretation of distal humeral coronal plane fractures. Although an acceptable interobserver agreement was found, there is no agreement when the same fractures were analyzed by CT scan. The authors routinely recommend CT scan to assess the extent of the fracture and perform surgical planning.

Differences in 30-day outcomes between inpatient and outpatient total elbow arthroplasty (TEA)

BACKGROUND

As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings.

METHODS

The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables-age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities-between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups.

RESULTS

Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04).

CONCLUSION

Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA.

Indications and outcome in total elbow arthroplasty: A systematic review

BACKGROUND

Total elbow arthroplasty (TEA) is the established treatment for end-stage rheumatoid arthritis but improved surgical techniques have resulted in expanded indications. The aim of this study is to review the literature to evaluate the evolution of surgical indications for TEA.

METHODS

A systematic review of PubMed and EMBASE databases was conducted. Case series and comparative studies reporting results after three types of primary TEA were eligible for inclusion.

RESULTS

Forty-nine eligible studies were identified (n = 1995). The number of TEA cases published annually increased from 6 cases in 1980 to 135 cases in 2008. The commonest indication for TEA throughout the review period was rheumatoid arthritis but its annual proportion reduced from 77% to 50%. The mean Mayo Elbow Performance Score significantly improved for all indications. Three comparative studies reported statistically improved functional outcomes in rheumatoid arthritis over the trauma sequelae group. Complication and revision rates varied; rheumatoid arthritis 5.2-30.9% and 11-13%, acute fracture 0-50% and 10-11%, trauma sequelae 14.2-50% and 0-30%, osteoarthritis 50% and 11%, respectively.

DISCUSSION

TEA can provide functional improvements in inflammatory arthritis, acute fractures, trauma sequelae and miscellaneous indications. Long-term TEA survivorship appears satisfactory in rheumatoid arthritis and fracture cases; however, further research into alternative surgical indications is still required.

Reoperation Risk After Total Elbow Arthroplasty Versus Open Reduction Internal Fixation for Distal Humerus Fractures in Elderly Patients

OBJECTIVE

To compare reoperation risk after total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF) for intra-articular distal humerus fractures in elderly patients.

DESIGN

Retrospective comparative.

SETTING

Five percent Medicare Part B claims database.

PATIENTS

Patients older than 65 years of age with closed distal humerus fractures undergoing TEA or ORIF from 1996 to 2016.

INTERVENTION

TEA and ORIF.

MAIN OUTCOME MEASURE

Reoperation risk based on multivariate Cox proportional hazards modeling.

RESULTS

A total of 142 TEA and 522 ORIF cases were identified. TEA patients had a greater age and Charlson Comorbidity Index , as well as a higher prevalence of rheumatoid arthritis and osteoporosis than ORIF patients (P < 0.05). Although reoperation risk was lower for TEA than that for ORIF within the entire cohort (11.3% vs. 25.1%; hazard ratio = 0.49; P = 0.014), no significant difference was found for TEA and ORIF performed between 2006 and 2016 (12.6% vs. 18.4%; hazard ratio = 0.73; P = 0.380). The death rate was 65.5% in the TEA group at 3.6 years and 55.7% in the ORIF group at 4.9 years.

CONCLUSIONS

TEA was associated with a decreased reoperation risk compared with ORIF, although this difference did not exist for more recent procedures after popularization of the locking plate technology and half of the reoperations after ORIF were for instrumentation removal. The high death rate within several years of the index procedure may contribute to the low TEA revision rate beyond the short-term when following patients into the medium and long term. Further study comparing TEA and locked plating using prospective, randomized data with long-term follow-up and functional outcomes is warranted.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Limited Fixation, Olecranon Sparing Approach, for Management of Geriatric Intra-Articular Distal Humerus Fractures

Purpose

We propose that geriatric comminuted intra-articular distal humerus fractures can be effectively treated with a limited fixation approach aimed at achieving varus/valgus stability with columnar fixation, but allowing intra-articular comminution to heal by secondary congruency against an intact olecranon, thus avoiding an olecranon osteotomy.

Methods

Fifty-six elderly patients with AO 13-C type fractures, who underwent surgical fixation with ≥12-months of follow-up were retrospectively reviewed. Thirty patients were treated with intra-articular open reduction internal fixation (ORIF) with an olecranon osteotomy and 26 patients were treated with our limited fixation (L-ORIF) approach. Outcomes were range of motion (ROM), complications, additional surgery, and patient-reported outcome measures (PROMIS).

Results

At final follow-up, the average elbow ROM was 97° (40°-155°) in the ORIF group and 86.5° (20°-145°) in the L-ORIF group. There was a trend toward more complications and additional surgery in the ORIF group. PROMIS scores for pain were 53.1 and 52.14, and PROMIS functional scores were 41.7 and 41.4 in the ORIF and L-ORIF group respectively. No differences in outcomes were statistically significant.

Conclusion

A limited fixation technique based on achieving varus/valgus stability with columnar fixation, demonstrated equivalent outcomes in elderly patients with intra-articular distal humerus fractures when compared to intra-articular ORIF with an olecranon osteotomy.

Total Elbow Arthroplasty for Distal Humerus Fractures

Distal humerus fractures in elderly patients are challenging due to poor bone quality and may threaten the independence of elderly patients due to loss of functional range of motion. Total elbow arthroplasty has gained popularity in the treatment of these injuries. This video demonstrates total elbow arthroplasty in an elderly patient with a comminuted distal humerus fracture.

Triceps-Sparing Total Elbow Arthroplasty for Distal Humerus Fracture: The Lateral Paraolecranon Approach

Distal humerus fractures in the elderly are a difficult problem to treat. Open reduction internal fixation has a high rate of complications, particularly because osteopenia compromises what is already tenuous fixation in a metaphyseal fracture. Total elbow arthroplasty is a more predictable outcome and easier recovery for these patients. However, most surgeons perform a low volume of total elbow arthroplasty. In addition, traditional exposure requires detachment of the triceps tendon. The lateral paraolecranon approach maintains the central tendon attachment to the olecranon while still facilitating relative ease of the procedure. Patients are allowed full active use of the triceps postoperatively, which is very helpful for polytrauma patients and those who are already dependent on assistive devices for ambulation.

Novel exploration of 3D printed personalized total elbow arthroplasty to solve the severe bone defect after internal fixation failure of comminuted distal humerus fracture: A case report

RATIONALE

Severe bone defect could often occur after removing the fractured fixation plates of comminuted fracture in the distal humerus. The reoperation of internal fixation or conventional total elbow arthroplasty could hardly restore the anatomy structure and function of the elbow. However, a novel exploration of 3-dimensional (3D) printed personalized elbow prosthesis was presented in this work. This is a rare and successful treatment for the severe bone defect after removing the fractured fixation plates of comminuted distal humerus fracture.

PATIENT CONCERNS

A 60-year-old male patient was admitted to the hospital with the chief complaint of right elbow joint pain and limitation of motion for 10 years. He suffered from an open reduction with internal fixation surgery 10 years ago due to a fall injury-induced right distal humerus fracture.

DIAGNOSES

Plain radiographs and computed tomography scan revealed fracture lines, fracture displacement, and fixator breakage in the right distal humerus. Pain, swelling, and limitation of motion could be found in the physical examination. Fixation failure and nonunion after internal fixation of comminuted distal humerus fracture were considered.

INTERVENTIONS

The patient was treated with 3D printed personalized TEA and functional rehabilitation exercises.

OUTCOMES

No severe complications were observed during the 36 months follow-up. The patient could complete the daily activities without pain. The hospital for special surgery score increased from 15 points before surgery to 90 points 36 months after surgery.

LESSONS

The 3D printed personalized prosthesis could successfully reconstruct the anatomical structures and function of the elbow joint with a severe bone defect. The 3D printed personalized total elbow arthroplasty might provide a feasible method for treating the complex elbow joint diseases in the elderly.

Primary Linked Total Elbow Arthroplasty for Acute Distal Humerus Fracture Management: A Systematic Review of Clinical Outcome

Backgroud

The treatment of distal humerus fractures is often challenging in osteoporotic elderly patients. Total elbow arthroplasty (TEA) is a salvage option for non-reconstructable fractures. The aim of this systematic review was to evaluate the clinical evidence for primary TEA in patients with acute distal humeral fractures.

Methods

Literatures were searched through PubMed, Ovid/Medline, Cochrane, Google Scholar, and Embase databases with the keywords, “distal humerus fracture,” “total elbow arthroplasty,” and “outcome” according to the MeSH (Medical Subject Headings) index for English-language studies published from April 2009 to April 2019. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Results

Ten articles with a total of 269 patients were included in the review. The Bryan-Morrey approach was the most common surgical approach (33.7%) with triceps reflecting (42%) for triceps tendon management. The most common implant design used was the Coonrad-Morrey system (83%). The mean postoperative motion arc was 102.3° for flexion-extension and 145.8° for pronation-supination. The average functional outcome score was 89.5 with Mayo Elbow Performance Score (MEPS). An excellent MEPS was found in studies with less than 7 days of average time from injury to surgery. The overall complication rate was 21.5%.

Conclusions

The current review showed favorable outcome of primary linked TEA for acute distal humerus fractures. Despite the promising functional outcomes, the complication rate was still considerably high. This systematic review will give surgeons help in explaining to patients regarding the expected outcome after primary TEA for acute distal humerus fractures.

Functional outcome following elbow release and hardware removal after bicolumnar fixation of distal humeral fractures

INTRODUCTION

Intra-articular fractures of the distal humerus are typically treated with bicolumnar plate fixation. Despite prompt and accurate reduction and fixation, there is a high rate of complications post-surgical fixation. The purpose of this study was to determine the indications, technique, and outcomes of patients who had undergone an elbow release and hardware removal following bicolumnar plate fixation for an intra-articular fracture of the distal humerus.

METHODS

Patients who had undergone an elbow release and hardware removal by a single surgeon following bicolumnar fixation of an intra-articular fracture of the distal humerus were identified. Patients were contacted to participate in a chart review and to return to clinic for a follow-up visit. Patients who returned for a follow-up visit completed the DASH (Disabilities of the Arm, Shoulder and Hand), the MEPS (Mayo Elbow Performance Score), and the SF-36.

RESULTS

Forty-two patients were included in the final analysis. The average time from the original injury to the elbow release procedure was 17.5 months. There was an improvement of 33° in the mean flexion-extension arc following the procedure (p<0.001). The mean DASH score was 21 (SD=19) and the mean MEPS score was 82 (SD=16). There was a high rate of post-traumatic osteoarthritis (n=30). Two patients underwent a total elbow arthroplasty (TEA). One patient sustained a re-fracture of the distal humerus, and subsequently underwent repeat bicolumnar fixation. There were four reoperations (10%): two patients had a revision release of contracture and two patients underwent a closed manipulation.

CONCLUSIONS

It appears safe to remove both plates and to re-intervene relatively early. There is a modest but consistent improvement in flexion-extension arc, and the re-operation rate is low. Although there is a high rate of post-traumatic arthritic change radiographically, TEA was rare, and elbow-based outcome scores were good, although not normal.

Elbow hemiarthroplasty versus open reduction and internal fixation for AO/OTA type 13 C2 and C3 fractures of distal humerus in patients aged 50 years or above: a randomized controlled trial

Background

Intraarticular distal humeral fractures of AO/OTA type 13 C2 and C3 pose a surgical challenge despite the evolution of surgical implants and techniques. Open reduction and internal fixation (ORIF) is often preferred as the first choice of treatment, but the results vary and are sometimes disappointing. Total elbow arthroplasty (TEA) has been widely used for fractures that are not amenable to ORIF in elderly patients, but the mechanical complications remain a challenge, especially in active patients. Elbow hemiarthroplasty (EHA) provides a modern alternative that might avoid the mechanical complications and weight bearing restrictions related to the linked articulation in semi-constrained TEA. No studies have compared the results of EHA to that of ORIF, but case series have reported promising results.

Methods/design

This is a study protocol describing an investigator-initiated, non-blinded randomized controlled trial comparing the outcome of EHA with ORIF for AO/OTA type 13 C2 and C3 fractures of the distal humerus in patients who are 50 years or older. Forty-four patients with AO/OTA type 13 C2 and C3 fractures of distal humerus will be randomized to either EHA or ORIF. The Oxford Elbow Score (OES) will be used as primary outcome. Mayo Elbow Performance Score (MEPS), pain severity score (VAS), range of motion, and patient satisfaction will be used as secondary outcomes. Reoperations, complications, and the length of sick leave will be recorded. The patients will be examined after the operation and at 3 months and 1, 2, 5, and 10 years.

Discussion

The main objective of this study is to investigate the best treatment option for AO/OTA type 13 C2 and C3 fractures of distal humerus in patients aged 50 years or above. We hypothesize that EHA results in fewer complications and superior functional outcome compared with ORIF and that the mechanical complications related to the linked articulation of TEA can be avoided.

Trial registration

ClinicalTrials.gov, PRS, NCT04163172. Registered November 13, 2019. https://clinicaltrials.gov/ct2/results?cond=&term=evori&cntry=&state=&city=&dist= (Table 2).

The protocol has been approved by The Scientific Ethics Committee of the Capital Region of Denmark (Jr. no.: H^{− 19,035,590}).

The processing of personal data has been approved by the Danish Data Protection Agency (Jr. no. P-2019-246). Inclusion started on February 1, 2020.

Comparison of open reduction and internal fixation with total elbow arthroplasty for intra-articular distal humeral fractures in older age: a retrospective study

Background

Intra-articular distal humeral fractures can be surgically challenging. It remains under discussion whether open reduction and internal fixation (ORIF) or total elbow arthroplasty (TEA) is more beneficial for treatment of the elderly. This study aimed to compare the clinical and functional outcomes of ORIF and TEA for managing intra-articular distal humerus fractures in patients aged 65 years or older.

Methods

Patients who underwent ORIF (n=28) or TEA (n=43) for in intra-articular distal humerus fracture between May 2008 and December 2018 were reviewed. Range of motion, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiologic outcomes, and surgical complications were evaluated at the final follow-up visit.

Results

The ORIF and TEA groups showed a mean arc of flexion–extension of 97°±21° and 101°±12°, respectively. The mean MEPS and DASH scores were 94±15 and 27±12 points, respectively, in the ORIF group and 81±27 and 47±28 points in the TEA group. This difference was statistically significant. The incidence of total complications was similar between the groups.

Conclusions

In patients older than 65 years with intra-articular distal humerus fracture, ORIF had better outcomes than TEA.

Distal humerus nonunion: evaluation and management

Despite recent improvements in surgical implants and techniques, distal humerus nonunion does occur between 8% and 25% of the time.

Careful identification and improvement of any modifiable risk factors such as smoking, metabolic disorders, immunosuppressant medications, poor nutritional status and infection is mandatory.

A recent computed tomography scan is paramount to determine the nonunion pattern, assess residual bone stock, identify previously placed hardware, and determine whether there is evidence of osteoarthritis or malunion of the articular surface.

Internal fixation is the treatment of choice in the majority of patients presenting with reasonable bone stock and preserved articular cartilage; total elbow arthroplasty is an appealing alternative for elbows with severe destruction of the articular cartilage or severe bone loss at the articular segment, especially in older, female patients. Internal fixation requires not only achieving a stable fixation, but also releasing associated elbow contractures and the liberal use of bone graft or substitutes.

Although reported union rates after internal fixation of distal humerus nonunions are excellent (over 95%), the complication rate remains very high, and unsatisfactory results do occur.

Cite this article: EFORT Open Rev 2020;5:289-298. DOI: 10.1302/2058-5241.5.190050

Coronal shear fractures of the distal humerus: Current concepts and surgical techniques

Coronal shear fractures of the distal humerus are a unique subset of distal humeral fractures which entail partial or complete articular fractures of the distal humerus without involvement of the columns. The very distal nature of these fragments, their small size and propensity for comminution render them challenging to treat surgically. The purpose of this article is to describe the classification, outcomes and surgical techniques currently used for the treatment of these fractures using the available literature and authors' clinical experience.

Primary Total Elbow Replacement for Treatment of Complex Distal Humerus Fracture: Outcomes of Short-term Follow-up

Background

High complication rate after open reduction and internal fixation can lead to use of primary total elbow replacement (TER) in treatment of complex distal humerus fractures in elderly patients. The purpose of this study was to investigate the short-term outcomes and complications after primary TER in patients with complex distal humerus fracture.

Methods

Nine patients with acute complex distal humerus fracture were treated by primary TER using the semiconstrained Coonrad-Morrey prosthesis. The mean age of patients was 72.7 years (range, 63–85 years). Clinical and radiographic outcomes were evaluated over a mean follow-up of 29.0 months (range, 12–65 months) using visual analog scale (VAS) score for pain; Mayo elbow performance score (MEPS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; and serial plain radiographs. Complications were also evaluated.

Results

At the final follow-up, mean VAS, MEPS, and Quick-DASH scores were 1.2, 80.5, and 20, respectively. The mean range of motion was 127.7º of flexion, 13.8º of extension, 73.3º of pronation, and 74.4º of supination. There was no evidence of bushing wear or high-grade implant loosening on serial plain radiographs. Three complications (33.3%) comprising two periprosthetic fractures and one ulnar neuropathy were observed.

Conclusions

Primary TER for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes. However, surgeons should consider the high complication rate after primary TER.

Total Elbow Arthroplasty for Distal Humerus Fractures Provided Similar Outcomes When Performed as a Primary Procedure or After Failed Internal Fixation

OBJECTIVES

To compare clinical and functional outcomes of total elbow arthroplasty (TEA) for distal humerus fractures (DHF) performed either as a primary procedure or after internal fixation.

DESIGN

Retrospective, observational study.

SETTING

Mayo Clinic, Rochester, MN (1998 through 2016).

PATIENTS/PARTICIPANTS

Twenty-two TEA for acute DHF and 66 TEA after previous internal fixation.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures included the Mayo Elbow Performance Score and motion. Reoperation rates and complications were also compared.

RESULTS

The mean time between internal fixation and arthroplasty was 7.3 years, and the main indications for conversion to TEA were nonunion (36%) and posttraumatic osteoarthritis (32%). There were female predominance (70%) and significant differences in age (74 years vs. 60 years, P < 0.0001) and tobacco use (0 vs. 23%; P = 0.02) between the primary and the salvage cohorts, respectively. Cohort demographics were otherwise comparable. TEA provided similar outcomes in both cohorts in terms of the Mayo Elbow Performance Score (acute 85, salvage 81, P = 0.32) and motion (acute 95/82/75 degrees, salvage 112/81/72 degrees in ulnohumeral/pronation/supination, P = 0.07/P = 0.85/P = 0.65). Reoperation rates were also similar (36% acute vs. 39% salvage, P = 1.00). Aseptic loosening (2 acute, 8 salvage) and deep infection (2 acute, 7 salvage) were the most common complications.

CONCLUSIONS

The clinical outcomes and reoperation rates of TEA for DHF seem to be similar when performed as a primary procedure or as salvage after previous internal fixation. The benefit of avoiding elbow arthroplasty in the acute setting needs to be balanced with the potential for 2 surgical procedures if internal fixation was to be unsuccessful.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use and outcome of 1,220 primary total elbow arthroplasties from the Australian Orthopaedic Association National Joint Arthroplasty Replacement Registry 2008-2018

Background and purpose - The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) was analyzed to determine trends in use of primary total elbow arthroplasty (TEA), the types of prostheses used, primary diagnoses, reasons for and types of revision, and whether the primary diagnosis or prosthesis design influenced the revision rate.Patients and methods - During 2008-2018, 1,220 primary TEA procedures were reported of which 140 TEAs were revised. Kaplan-Meier estimates of survivorship were used to describe the time to first revision and hazard ratios (HR) from Cox proportional hazard models, adjusted for age and sex, were used to compare revision rates.Results - The annual number of TEAs performed remained constant. The 3 most common diagnoses for primary TEA were fracture/dislocation (trauma) (36%), osteoarthritis (OA) (34%), and rheumatoid arthritis (RA) (26%). The cumulative percentage revision for all TEAs undertaken for any reason was 10%, 15%, and 19% at 3, 6, and 9 years. TEAs undertaken for OA had a higher revision rate compared with TEAs for trauma (HR = 1.8, 95% CI 1.1-3.0) and RA (HR = 2.0, CI 1.3-3.1). The Coonrad-Morrey (50%), Latitude (30%), Nexel (10%), and Discovery (9%) were the most used prosthesis designs. There was no difference in revision rates when these 4 designs were compared. The most common reasons for revision were infection (35%) and aseptic loosening (34%).Interpretation - The indications for primary and revision TEA in Australia are similar to those reported for other registries. Revision for trauma is lower than previously reported.

The fragility of findings of randomized controlled trials in shoulder and elbow surgery

BACKGROUND

Considered the gold standard of study designs, randomized controlled trials' (RCTs) results shape clinical practice, effect policy, and influence reimbursement. The fragility index (FI) can be used to quantitate the relative robustness of RCT results, with higher scores indicating more stout results. Unfortunately, most RCTs in surgery have fragile results. The aim of this study was to report on the FI in addition to a qualitative assessment of recent RCTs within the field of shoulder and elbow surgery.

METHODS

A systematic review was performed identifying recently published shoulder/elbow RCTs that included 1:1 allocated parallel study arms, dichotomous primary outcome variables, and statistical significance. The FI was calculated by sequentially modifying outcome groups by exchanging a nonevent in one group to an event until the P value for the outcome comparison, as calculated by the Fisher exact test, was increased above the .05 threshold.

RESULTS

Thirty RCTs were included. The median FI was 4. Sixty percent trials had a FI of 2 or less. Fifty-three percent studies reported that participants were lost to follow-up. In 87.5% of these studies, the losses to follow-up exceeded their respective FIs. Only 53% of studies defined a primary outcome variable and 60% studies performed a prestudy power analysis.

CONCLUSIONS

The median FI reported in the recent shoulder/elbow literature is 4; however, a high proportion of included RCTs display significant methodological concerns. The FI is a useful adjunct to analyze RCT results, but careful analysis of trial methods should be employed in each circumstance before drawing conclusions.

Total Elbow Arthroplasty: Clinical Outcomes, Complications, and Revision Surgery

Total elbow arthroplasty is a common surgical procedure used in the management of advanced rheumatoid arthritis, posttraumatic arthritis, osteoarthritis, and unfixable fracture in elderly patients. Total elbow prostheses have evolved over the years and now include the linked, unlinked, and convertible types. However, long-term complications, including infection, aseptic loosening, instability, and periprosthetic fracture, remain a challenge. Here, we introduce each type of implant and evaluate clinical outcomes and complications by reviewing the previous literature.

Long-term outcomes of total elbow arthroplasty for distal humeral fracture: results from a prior randomized clinical trial

BACKGROUND

Total elbow arthroplasty (TEA) is a reliable treatment for elderly patients with comminuted intra-articular distal humeral fractures. However, the longevity and long-term complications associated with this procedure are unknown. The objectives of this study were to examine long-term outcomes and implant survival in elderly patients undergoing TEA for fracture.

METHODS

Patients from a previously published randomized controlled trial of 42 patients in which TEA was compared with open reduction-internal fixation (ORIF) were followed up long term. Patients were aged 65 years or older with comminuted intra-articular distal humeral fractures. Outcomes included patient-reported grading of function and pain, revision surgical procedures, and implant survival.

RESULTS

Data were obtained for 40 patients, 15 treated with ORIF and 25 treated with TEA, with a mean follow-up period of 12.5 years for surviving patients and 7.7 years for deceased patients. The reoperation rate was 3 of 25 in the TEA group and 4 of 15 in the ORIF group (P = .39). Of the 25 patients with TEAs, only 1 required (early) revision arthroplasty; 7 were living with their original arthroplasty, and 15 died with a well-functioning implant in situ. Three were lost to follow-up.

CONCLUSIONS

TEA is an effective and reliable procedure for the treatment of comminuted distal humeral fractures in the elderly patient. Our study reveals reliable implant long-term survival, with no patient requiring a late revision. For the majority of these patients, a well-performed TEA will give them a well-functioning elbow for life and will be the last elbow procedure required.

Clinical outcomes and complications following primary total elbow arthroplasty using the Latitude prosthesis

BACKGROUND

The Latitude total elbow arthroplasty (TEA) is an implant with limited published data on its performance and outcomes. The aim of this study was to report the short-term outcomes of the Latitude TEA as well as to describe the radiographic outcomes and complications.

METHODS

The Latitude was implanted in 20 patients (23 elbows) in a linked configuration. Patients were recalled to clinic for the assessment of their range-of-motion and compared to preoperative values. Administration of functional outcome measures was also performed.

RESULTS

Mean follow-up was 4.7 years (range, 1 to 7.5 years) with four elbows requiring revision. The flexion-extension arc improved from 86.6 to 101.3 (range, 76 to 126) postoperatively (p = 0.04). The average Disabilities of the Arm, Shoulder, and Hand score was 28.1 (range, 5.8 to 50.4) and the average Mayo Elbow Performance Score was 89.6 (range, 76 to 100), with 83% of elbows scoring in the good or excellent range. Radiolucencies were detected in 60% of patients and 31% of these lucencies progressed in size at the time of follow-up.

CONCLUSIONS

The Latitude prosthesis provides patients with favorable clinical outcomes with improvements in their range-of-motion and a complication rate comparable to other elbow arthroplasty implants.

Bench-to-bedside strategies for osteoporotic fracture: From osteoimmunology to mechanosensation

Osteoporosis is characterized by a decrease in bone mass and strength, rendering people prone to osteoporotic fractures caused by low-energy forces. The primary treatment strategy for osteoporotic fractures is surgery; however, the compromised and comminuted bones in osteoporotic fracture sites are not conducive to optimum reduction and rigid fixation. In addition, these patients always exhibit accompanying aging-related disorders, including high inflammatory status, decreased mechanical loading and abnormal skeletal metabolism, which are disadvantages for fracture healing around sites that have undergone orthopedic procedures. Since the incidence of osteoporosis is expected to increase worldwide, orthopedic surgeons should pay more attention to comprehensive strategies for improving the poor prognosis of osteoporotic fractures. Herein, we highlight the molecular basis of osteoimmunology and bone mechanosensation in different healing phases of elderly osteoporotic fractures, guiding perioperative management to alleviate the unfavorable effects of insufficient mechanical loading, high inflammatory levels and pathogen infection. The well-informed pharmacologic and surgical intervention, including treatment with anti-inflammatory drugs and sufficient application of antibiotics, as well as bench-to-bedside strategies for bone augmentation and hardware selection, should be made according to a comprehensive understanding of bone biomechanical properties in addition to the remodeling status of osteoporotic bones, which is necessary for creating proper biological and mechanical environments for bone union and remodeling. Multidisciplinary collaboration will facilitate the improvement of overall osteoporotic care and reduction of secondary fracture incidence.

Risk factors associated with periprosthetic joint infection after total elbow arthroplasty

BACKGROUND

For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present?

METHODS

The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI.

RESULTS

Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% (n = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections.

CONCLUSIONS

Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis.

LEVEL OF EVIDENCE

Level III: prognostic study.