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

Arthroplasty as primary treatment for distal humeral fractures produces reliable results with regards to revisions and adverse events: a registry-based study

BACKGROUND

Primary prosthetic replacement has become an accepted method for the treatment of complex distal humeral fractures. The present study investigated implant survival and adverse events related to this procedure based on available Swedish registries and examined the completeness of the Swedish Elbow Arthroplasty register.

MATERIALS AND METHODS

Patients treated in Sweden with a primary elbow replacement due to a distal humeral fracture between 1999 and 2014 were identified through 3 different registries: The Swedish Elbow Arthroplasty Register, National Board of Health and Welfare inpatient register, and local registries of all orthopedic departments. Prosthetic survival was examined using Cox regression analysis with Kaplan-Meier plots. Adverse events, defined as medical treatment of the affected elbow besides revision, were analyzed separately. The study included 406 elbows in 405 patients, and no register was complete.

RESULTS

Implant survival at 10 years was 90% (95% confidence interval, 85%-96%), but only 45 patients had an observation time of 10 years or more because 46% of the patients had died, resulting in a mean observation time of 67 (standard deviation, 47) months. An increase in the use of hemiarthroplasties and a proportional decrease of total elbow arthroplasties was detected. There were 18 revisions (4%), and 26 patients (6%) experienced an adverse event, of whom 16 (4%) required surgery. The completeness of the Swedish Elbow Arthroplasty Register regarding primary arthroplasty was 81%.

CONCLUSION

Primary arthroplasty as treatment of distal humeral fractures produces reliable results with regards to revisions and other adverse events.

Heterotopic ossification after total elbow arthroplasty: a systematic review

BACKGROUND

Heterotopic ossification (HO) is a known complication that can arise after total elbow arthroplasty (TEA). In most cases, it is asymptomatic; however, in some patients, it can limit range of motion and lead to poor outcomes. The objective of this review was to assess and report the incidence, risk factors, prophylaxis, and management of HO after TEA.

METHODS

A systematic search was conducted using MEDLINE, Embase, and PubMed to retrieve all relevant studies evaluating the occurrence of HO after TEA. The search was performed in duplicate, and a quality assessment of all included studies was performed.

RESULTS

A total of 1907 studies were retrieved, of which 45 were included involving 2256 TEA patients. HO was radiographically present in 10% of patients and was symptomatic in 3%. Fewer than 1% of patients went on to undergo surgical excision of HO, with outcomes after surgery reported as good or excellent as assessed by range of motion and the Mayo Elbow Performance Score. HO appears more likely to develop in patients undergoing TEA because of ankylosis, primary osteoarthritis, and distal humeral fractures. Surgical intervention is more likely to be required in patients in whom HO develops after TEA performed for ankylosis and post-traumatic osteoarthritis.

CONCLUSION

HO is an uncommon complication after TEA, with most patients in whom HO develops being asymptomatic and requiring no surgical management. Routine HO prophylaxis for TEA is not supported by the literature. The effectiveness of prophylaxis in high-risk patients is uncertain, and future studies are required to clarify its usefulness.

A Cadaveric Study of Cutaneous Vascular Anatomy about the Elbow Using Computed Tomography Angiography

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc.

Prevention and management of early treatment failures in elbow injuries

The appropriate management of early treatment failures in patients with elbow injuries requires the identification of the cause of failure. In this work, six types of elbow injury are considered: (i) identification of early failed reduction of a dislocation or fracture-dislocation of the elbow should lead to a repeat reduction procedure, testing for elbow instability, and ligament repair, followed by the use of a hinged external fixator to allow early mobilisation. Differentiating an isolated dislocation from a dislocation combined with a fracture of the coracoid process is crucial. Re-implantation of the coronoid process allows repair of the ligaments and restoration of stability in the sagittal plane; (ii) early secondary displacement of a distal humeral fracture after internal fixation is usually due to insufficient fixation confined to a single humeral pillar. If both humeral pillars are fractured, then both must be repaired; (iii) early treatment failure of an intra-articular distal humeral fracture in an elderly patient with bone loss warrants distal humeral hemiarthroplasty or total elbow arthroplasty; (iv) in fractures of the olecranon, treatment failures are due to insufficient fixation or to a mistaken diagnosis of trans-olecranon fracture-dislocation; (v) in fractures of the radial head, causes of early revision include excessive tilting of the head in radial neck fractures, with secondary displacement due to insufficient internal fixation, and adverse effects on the wrist of radial head resection performed without assessing the ulnar variance. In patients with radial head fractures, no treatment decisions can be made before performing an anteroposterior radiograph of the wrist; (vii) in fracture-dislocations of both the radius and ulna, accurate reduction of the ulnar fracture is a pre-requisite to proper reduction of the radio-humeral and proximal radio-ulnar joints. An early postoperative assessment, within 10 days after surgery, is of paramount importance to re-evaluate the initial treatment and, if needed, to introduce modifications. Early failure of the initial treatment of an elbow injury should lead to the prompt implementation of corrective measures: follow-up anteroposterior and lateral radiographs must be obtained on day 8 to ensure the diagnosis of initial treatment failure and to allow the institution of an appropriate management strategy; the dogma stating that the elbow should never be immobilised remains valid, and every effort should be made to ensure that mobilisation starts as early as possible.

High rate of reoperation and conversion to total hip arthroplasty after internal fixation of young femoral neck fractures: a population-based study of 796 patients

Background and purpose - Most often, the goal of non-geriatric femoral neck fracture surgery is to preserve the native hip joint. However, reoperations for painful implants, osteonecrosis, and nonunion are common. We determined the reoperation rate and time-to-reoperation following internal fixation of these fractures in a large population cohort. Patients and methods - This retrospective cohort study included patients between the ages of 18 and 50 years old who underwent internal fixation for a femoral neck fracture during 1997-2013. Patients were followed until December 2013. Primary outcomes were reoperation rate and time-to-reoperation. Time-to-event analysis was performed to estimate the rate of any reoperation and for THA specifically, while testing the dependency of time-to-reoperation on secondary variables. Results - 796 young femoral neck fracture patients were treated with internal fixation during the study period (median age 43 years, 39% women). Median follow-up was 8 years (IQR 4-13). One-third underwent at least 1 reoperation at a median 16 months after the index surgery (IQR 8-31). Half of reoperations were for implant removal, followed by conversion to total hip arthroplasty. 14% of the cohort were converted to THA. The median time to conversion was 2 years (IQR 1-4). Neither female sex nor older age had a statistically significant effect on time-to-reoperation or time-to-THA conversion. Interpretation - Following internal fixation of young femoral neck fracture, 1 in 3 patients required a reoperation, and 1 in 7 were converted to THA. These data should be considered by patients and surgeons during treatment decision-making.

Cost-effectiveness analysis of total elbow arthroplasty versus open reduction-internal fixation for distal humeral fractures

BACKGROUND

Total elbow arthroplasty (TEA) and open reduction-internal fixation (ORIF) are 2 viable surgical treatment options for acute, intra-articular distal humeral fractures in elderly patients. Whereas recent systematic reviews and randomized trials have suggested that TEA and ORIF result in similar functional outcome scores, no previous study has assessed the comparative cost-effectiveness between TEA and distal humeral ORIF in this specific demographic.

METHODS

A Markov model was created with the highest-level data available from the literature depicting transitioning health states based on treatment strategies. To populate the quality-of-life data points in the model lacking in the literature, a survey was conducted of patients at 2 referral institutions who underwent TEA or ORIF for acute, intra-articular distal humeral fractures via the European Quality of Life, 5 Domains (EQ-5D) questionnaire at least 2 years postoperatively. Cost data from 2016 for each strategy were used to calculate the comparative cost-effectiveness of TEA versus ORIF.

RESULTS

For patients aged 65 years, the total cost of TEA was $19,407 compared with $20,669 for ORIF. The effectiveness of TEA and ORIF was 8.17 and 7.72, respectively. Overall, the incremental cost-effectiveness ratio of TEA ($2375.76/quality-adjusted life-year) was favored more than ORIF ($2677.26/quality-adjusted life-year).

CONCLUSION

These findings suggest TEA is a slightly more cost-effective procedure than ORIF for most elderly patients who sustain acute, intra-articular distal humeral fractures. Still, the unique limitations, complications, and revision rates for each strategy must be carefully weighed for each patient when making a decision.

Total Elbow Arthroplasty Versus Open Reduction and Internal Fixation for the Management of Distal Humerus Fractures in the Elderly

Distal humerus fractures, which are challenging injuries seen in geriatric patients, are often repaired using open reduction and internal fixation or total elbow arthroplasty. This updated meta-analysis, which includes more recent open reduction and internal fixation techniques, examined outcomes following distal humerus fractures repaired using open reduction and internal fixation vs total elbow arthroplasty. Although distal humerus fractures treated with total elbow arthroplasty achieved statistically higher functional scores relative to those treated with open reduction and internal fixation, this difference was not clinically significant. Furthermore, the authors found no early difference in the use of either open reduction and internal fixation or total elbow arthroplasty in the management of distal humerus fractures. Choice of treatment should be based on patients' long-term demands and anticipated need for implant longevity. [Orthopedics. 2019; 42(1):22-27.].

Comparative Study for Assessment of Functional Outcome of Intraarticular AO Type C Distal Humerus Fractures Treated by Parallel Plating

BACKGROUND

Complex distal end of humerus fractures are one of the most challenging cases in orthopedics. There is a paucity of literature on outcomes of parallel reconstruction plates using olecranon osteotomy technique along with large sample size. This study focuses primarily on rate of various complications encountered in intraarticular AO Type C distal humerus fractures.

MATERIALS AND METHODS

In this prospective study, we included 94 patients with isolated closed intraarticular AO type C distal and humerus injuries. Exclusion criteria were polytrauma, open injuries, and pathological fractures (except osteoporosis). The followup was done immediate postoperatively, 6 weeks, 6 months, 1 year and at 2 years. Range of motion (ROM), Mayo Elbow Performance Score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH) score was recorded at each visit. Assessment of union was done based on X-ray. Patients were classified into two groups; Group 1 - patients without complications (n = 64) and Group 2 - with one or more complications.

RESULTS

The average duration of surgery was 2 h and 15 min. The complication rate was 31.9% (30/94), however, a total of 45 complications were noted. The difference between ROM in the two groups was statistically significant (P < 0.05), however, the difference between MEPS and DASH score was not statistically significant. The most common complication found was ulnar nerve neuropathy.

CONCLUSION

Parallel plating using olecranon osteotomy is an acceptable approach for this fracture, but due to inherent nature of this injury, it has its own set of complications which must be counseled before surgery and active participation of patient is required to obtain realistic expectations and goals for the future.

Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice

OBJECTIVES

The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden.

METHODS AND FINDINGS

The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011.

CONCLUSIONS

There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact.

The expanding use of total elbow arthroplasty for distal humerus fractures: a retrospective database analysis of 56,379 inpatients from 2002-2014

OBJECTIVES

Distal humerus fractures are challenging to treat, with significant morbidity. Precontoured distal humerus locking plates and total elbow arthroplasty implants have become available in the past 15 years, potentially offering the promise of improved outcomes. However, national data regarding the usage of and in-hospital complications associated with these implants is scarce. Therefore, we aimed to determine if the incidence of inpatients with distal humerus fractures treated with arthroplasty or open reduction and internal fixation (ORIF) changed over time. Secondarily, we sought to determine what demographic factors were associated with arthroplasty versus fixation and compare inpatient outcomes.

METHODS

Inpatients over 50 years old with operatively treated closed distal humerus fractures were identified between 2002 and 2014 in the Nationwide Inpatient Sample, a nationally representative, all-payer database. Patient demographic factors were associated with treatment type. Outcomes examined included complications, mortality, length-of-stay, and charges; multivariable logistic regression compared associations with treatment.

RESULTS

Of 56,379 inpatients undergoing surgery, the proportion undergoing arthroplasty rose 2.3-fold from 4.8% to 10.9% from 2002 to 2014 (OR 1.039/year [95% CI [1.016-1.062]). Annual patient volume remained similar. Arthroplasty patients were older than those undergoing fixation (75.5 vs. 71.0 years, p < 0.001), more likely to be female (83.1% vs. 75.4%, p < 0.001), and less likely to be treated at a rural hospital (OR 0.601, 95% CI 0.445-0.812, p < 0.001). There was no significant difference in comorbidities. Arthroplasty patients had similar inpatient medical complication (7.1% vs. 7.8%, OR 0.998, p = 0.988) and mortality rates (0.38% vs. 0.94%, OR 0.426, p = 0.102), a decreased length of stay (by 0.3 days, p = 0.032), but increased hospital charges (by $12,033, p < 0.001).

CONCLUSIONS

For inpatients over 50 years old with operatively-treated distal humerus fractures, use of elbow arthroplasty has expanded, albeit with increased cost. Further studies may help to delineate the long-term costs and benefits, as well as which patients may benefit from each type of implant.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

[Elbow prostheses in rheumatic diseases]

When the elbow is destroyed due to rheumatic diseases, the joint can be replaced by a prosthesis and total arthroplasty. Improved pharmaceutical treatment for rheumatic diseases has, however, reduced the number of implantations in these patients. Reported 10-year survival rates of the implant currently achieve 81-90%.; however, due to limited long-term survival of the implant and high complication rates, total elbow arthroplasty should still be used with caution. Continuous technical improvements in the available prostheses and in surgical techniques could lead in the future to a decline in complications, such as aseptic loosening and infections.

Heterotopic ossification following total elbow arthroplasty

Aim

The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification.

Patients and Methods

A total of 55 total elbow arthroplasties (TEAs) (52 patients) performed between June 2007 and December 2015 were eligible for inclusion in the study (29 TEAs for primary elective arthroplasty and 26 TEAs for trauma). At review, 15 patients (17 total elbow arthroplasties) had died from unrelated causes. There were 14 men and 38 women with a mean age of 70 years (42 to 90). The median clinical follow-up was 3.6 years (1.2 to 6) and the median radiological follow-up was 3.1 years (0.5 to 7.5).

Results

The overall incidence of HO was 84% (46/55). This was higher in the trauma group (96%, 25/26) compared with the elective arthroplasty group (72%, 21/29) (p = 0.027, Fisher’s exact test). Patients in the trauma group had HO of higher Brooker class. The presence of HO did not significantly affect elbow range of movement within the trauma or elective groups (elective arthroplasty, Mann–Whitney U test, p = 0.070; trauma arthroplasty, p = 0.370, Mann–Whitney U test).

Conclusion

HO after total elbow arthroplasty is seen more commonly than previously reported. We have reported a significantly higher rate of HO in TEAs performed for trauma than those performed electively. Cite this article: Bone Joint J 2018;100-B:767–71.

Plate fixation for management of humerus fractures

Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in older patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. When plate fixation is chosen, anatomic reduction and restoration of the medial calcar are important for successful results. Further research is required to minimize complications and determine the optimal surgical candidates for plate fixation. Humeral shaft fractures are generally treated non-operatively. However, certain shaft fractures warrant plate fixation, such as open fractures, those with associated forearm fractures, and those in poly-trauma patients. Choice of surgical approach and plate depends on the location and type of the fracture. The majority of intra-articular distal humerus fractures should be treated with plate fixation. Dual plating is generally accepted as the gold standard treatment, while the optimal surgical approach and plate configuration requires more research.

Total Elbow Arthroplasty Gives Good Functional Outcome in Distal Humerus Fracture with Pre-existing Chronic Elbow Dislocation

Distal humerus fracture with concomitant chronic elbow dislocation is difficult to manage by open reduction and internal fixation, while total elbow arthroplasty (TEA) is an effective treatment for acute fracture or failed internal fixation of distal humerus fracture in elderly patients with osteoporosis. We present a case of an 86-year-old woman who suffered from acute distal humerus fracture in the presence of chronic elbow deformity from elbow dislocation since childhood at the age of 10 years. This was treated with TEA using Coonrad/Morrey prosthesis with long stem and long flange humerus components and cerclage wiring of humeral condyle. Postoperatively, elbow mobilization was started early within a hinged elbow brace. There was no operative complication. At the last follow-up 22 months after surgery, there was no pain and good elbow motion (20–130° flexion–extension arc, full supination and pronation to neutral) was obtained. The Mayo Elbow Performance Score was 100. There was incorporation of the bone graft at the anterior flange with no radiographic loosening of the prosthesis. This case shows that TEA can yield a gratifying clinical result and efficiently resolves two problems with one solution.

The use of Tranexamic Acid in Total Elbow Replacement to Reduce Post-Operative Wound Infection

Background: Incidence of infection following total elbow replacement (TER) is recognised to be higher compared to hip or knee arthroplasty. Extensive swelling following TER can complicate the wound healing which might lead to infection. Tranexamic Acid (TXA) is proven to reduce blood loss peri-operatively which might contribute to better healing outcomes. Our aim is to assess the effect of TXA in wound healing following TER.

Methods: A retrospective review of a single surgeon case series. 10 patients had TER mainly for complicated elbow fractures, four of them were relatively immune-supressed. All patients had 2 grams of TXA and antibiotics intra-operatively. All were reviewed at two weeks following surgery for wound check and removal of surgical clips.

Results: Seven females and three males with a mean age of 81.5 had TER and TXA. The mean level of pre-operative haemoglobin was 134.40 g/l and the mean post-operative level was 122.70g/l. No patient in this series required blood transfusion. At two weeks and six weeks follow-up, all wound healed up with no signs of infection.

Conclusion: TXA has been proven to be safe an effective way of reducing peri-operative bleeding. TXA maintains haemostasis after releasing the tourniquet and therefore reduces the swelling and wound complications post-operatively

Intra-articular fractures of the distal humerus-a review of the current practice

Intra-articular fractures of the distal humerus are complex injuries that can considerably limit elbow function if not treated appropriately. Surgical management is indicated for most intra-articular distal humerus fractures with the goal of restoring elbow range of motion and function. Open reduction and internal fixation (ORIF) with plates and screws has been the preferred surgical option. Double plating is recommended for bicolumnar fractures and plates can be applied either parallel or orthogonal to each other. Surgical approach for ORIF of the distal humerus can be performed through an olecranon osteotomy, but other approaches that preserve the olecranon are also in use, such as the triceps-reflecting, triceps-splitting, paratricipital, and triceps-reflecting anconeus pedicle approach. The ulnar nerve is identified during the approach, followed by either in situ decompression or anterior transposition. Elbow arthroplasty has also emerged as a viable alternative to ORIF for fixation of these fractures in elderly patients with poor bone quality.

Osteosynthesis of AO/OTA 13-C3 distal humeral fractures in patients older than 70 years

OBJECTIVE

The purpose of this retrospective case series was to examine the AO Foundation and Orthopaedic Trauma Association (AO/OTA) 13-C3 distal humeral fractures treated with open reduction-internal fixation (ORIF) in patients older than 70 years.

METHODS

During an 8-year period, 21 patients older than 70 years with AO/OTA 13-C3 distal humeral fractures were treated with ORIF performed by 2 senior upper extremity traumatologists. There were 16 patients with >1 year of follow-up, with a mean age of 78 (70-84) years.

RESULTS

At a mean follow-up of 4 years (1-8 years), all 16 patients demonstrated radiographic signs of bone union. Three patients underwent reoperations, including irrigation and débridement for postoperative infections (n = 2) and removal of implant for symptomatic olecranon intramedullary screw (n = 1). The mean postoperative total arc of ulnohumeral motion was 97° (80°-145°), including a mean flexion of 117° (106°-126°) and flexion contracture of 20° (14°-26°). The mean pronation was 69° (55°-85°), and supination was 78° (74°-9°0). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (standard deviation, 6.9; confidence interval, 15.4-22.8), and the mean Mayo Elbow Performance Score was 91 (standard deviation, 8.2; confidence interval, 86-95).

CONCLUSIONS

ORIF remains a reliable option for treatment of AO/OTA 13-C3 distal humeral fractures in elderly patients. Excellent clinical outcomes can be achieved with preservation of motion and arm function through anatomic reduction, rigid internal fixation, and early mobilization.

Ulnar Nerve Management with Distal Humerus Fracture Fixation: A Meta-Analysis

Ulnar nerve dysfunction following distal humerus fractures is a well-recognized phenomenon. There is no consensus regarding optimal handling of the ulnar nerve during surgical management of these fractures between in situ management and transposition. Using an electronic database to identify retrospective studies involving surgical fixation of distal humerus fractures yielded 46 studies, 5 trials meeting the authors' inclusion criteria, totaling 362 patients. An overall incidence of 19.3% for ulnar neuropathy was identified. Of those patients undergoing in situ release, the incidence was 15.3%. Of those who underwent transposition, there was a 23.5% incidence of ulnar neuropathy.

Distal Humeral Fractures-Current Concepts

Background:

Distal humerus fractures constitute 2% of all fractures in the adult population. Although historically, these injuries have been treated non-operatively, advances in implant design and surgical technique have led to improved outcomes following operative fixation.

Methods:

A literature search was performed and the authors’ personal experiences are reported.

Results:

This review has discussed the anatomy, classifications, treatment options and surgical techniques in relation to the management of distal humeral fractures. In addition, we have discussed controversial areas including the choice of surgical approach, plate orientation, transposition of the ulnar nerve and the role of elbow arthroplasty.

Conclusion:

Distal humeral fractures are complex injuries that require a careful planned approach, when considering surgical fixation, to restore anatomy and achieve good functional outcomes.

Challenges and Solutions in Management of Distal Humerus Fractures

Background

Management of distal humerus fractures remains a challenge for trauma surgeons and advancements in treatment options continue to be made to achieve the best results for patients presenting with these complex fractures. Our aim in this article is to provide the surgeons with a detailed review of current literature to help them make an evidence based decision when faced with managing such complex injuries in their surgical practice.

Methods

This is a comprehensive review of the current literature that details various aspects of distal distal humerus fractures such as classification, surgical anatomy, surgical approaches, treatment options, choices of devices, outcomes and complications.

Results

With the advancements in techniques and equipment, there has been improvement in patients' outcomes following surgical management of these fractures and a large proportion of these patients are able to achieve pre-injury level of function. The contoured locking plates have enabled successful fixation of many of these fractures that were previously considered unfixable. For those not amenable to surgical fixation, total elbow arthroplasty and elbow hemiarthroplasty are considered as good alternatives.

Conclusion

Since the days where the 'bag of bones' technique was the preferred method of treating these complex injuries, techniques and outcomes have advanced greatly. However, they still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Operative Distal Humerus Fractures in Older Patients: Predictors for Early Complications Based on a National Database

BACKGROUND

Open reduction internal fixation (ORIF) and total elbow arthroplasty (TEA) have both been utilized in the treatment of distal humerus fractures in patients over 65 years of age. Comparisons of early complications between these procedures have not been well described.

QUESTIONS/PURPOSES

The purpose of this study is to evaluate complication rates in the treatment of distal humerus fractures in elderly patients and to utilize prediction models to identify risk factors associated with postoperative complications. Additionally, to compare ORIF and TEA treatment.

METHODS

A retrospective case series was performed by querying the National Surgical Quality Improvement Program for both ORIF and TEA performed for distal humerus fractures in patients over the age of 65 years between 2005 and 2014. We examined both preoperative risk factors and complications within 30 days in these three groups.

RESULTS

The sample included 216 ORIF and 65 TEA cases. No outcomes examined differed significantly between treatment groups. The most common outcome for both groups was bleeding requiring transfusion (8%). The observed effect size for the association between procedure and the composite morbidity outcome indicated little to no association (phi = 0.004). Furthermore, no presurgery variables were found to be significantly associated with procedure type. The only predictor with a significant independent association with the composite outcome, regardless of procedure type, was ASA class 3/4.

CONCLUSION

Clinical complications were low no matter the type of treatment. Low preoperative hematocrit was a risk factor in both ORIF and TEA.

Distal Humerus Fractures in the Elderly Population

Distal humerus fractures present complex challenges in the elderly patient. These fractures often occur in patients who are living independently but have poor bone quality and low physiologic reserve, thus complicating management decisions and treatment. The goal is a painless, functional, stable elbow that allows completion of the activities of daily living. Nonsurgical management is reserved for those who cannot tolerate surgery. Open reduction and internal fixation is the preferred choice in fractures amenable to rigid fixation and early motion. Although total elbow arthroplasty provides improved early function and similar overall outcomes in appropriately selected patients, it has the potential to cause devastating complications. With modern technology and treatment principles, as well as early definitive treatment by an experienced specialist, predictable return to function can be expected.

The challenging surgical treatment of closed distal humerus fractures in elderly and octogenarian patients: radiographic and functional outcomes with a minimum follow-up of 24 months

INTRODUCTION

The main purpose of this retrospective, non-randomized, case series study was to evaluate the clinical and radiographic outcomes of distal humerus fractures (DHFs) in a consecutive series of elderly patients operatively treated by two surgeons, and second, to identify proper indications for two elderly age ranges and two fracture pattern groups.

MATERIALS AND METHODS

From January 2009 to June 2014, 51 patients (pts) underwent open reduction and internal fixation (ORIF) using the locking compression plate (LCP) distal humerus plate (DHP) system at our institution. Medical records and radiographs were retrospectively assessed. Patients were divided into 3 groups according to gender, age (pts <85 years, pts ≥85 years) and AO classification (13-B1-B2-C1-C2 or 13-C3). All subjects completed MEPS, Quick-DASH and SF-36 PCS/MCS scores at final follow-up, and statistical analysis was performed.

RESULTS

36 patients (20 women, 16 men), mean age 80.3 years, with AO type 13-B and 13-C DHFs were included with a mean follow-up of 56 months (range 24-92). The most common mechanism of trauma was a fall from ground level (55.6%). The mean MEPS was 78.9 points, Quick-DASH 28.4, SF-36 PCS 48.3 and MCS 48.9. There was statistically significant evidence that having a 13-C3 fracture leads to worse results in MEPS, Quick-DASH and SF-36. The female gender correlates with worse results in SF-36. The patients ≥85 years had a worse prognosis according to Quick-DASH and SF-36, while the AO 13-C3 pattern obtained the worst ROM outcomes versus AO 13 B1-B2-C1-C2 (normal ROM 0°-140°): mean ROM 24°-114° vs 10°-130°, mean flexion deficit 26° vs 10°, mean extension deficit 24° vs 10°, respectively). Complications were presents in 36.1% of patients, overall belonging to the AO type 13-C fracture pattern and to the group ≥85 years.

CONCLUSION

These study data seem to confirm our hypothesis that plate fixation for DHFs guarantees adequate fracture osteosynthesis and satisfactory functional outcomes at medium to long-term follow-up, not only in elderly patients, but also in octogenarian osteoporotic patients (≥85 years) with 13-C1 and 13-C2 fracture patterns, while an alternative solution should be considered for type C3 fractures, even in a primary trauma setting.

First-line management of distal humerus fracture by total elbow arthroplasty in geriatric traumatology: Results in a 21-patient series at a minimum 2years' follow-up

INTRODUCTION

Total elbow arthroplasty (TEA) is one option in distal humerus fracture in elderly osteoporotic patients.

HYPOTHESIS

The study hypothesis was that, in patients aged 70years or more, TEA provides functional results and ranges of motion compatible with everyday activity, with a complications rate equal to or lower than with internal fixation, and no loss of autonomy or cognitive impairment.

MATERIAL AND METHODS

In this retrospective study, 21 patients receiving TEA for distal humerus fracture were included. Mean follow-up was 3.2years, with functional (Quick DASH and MEPS), cognitive (MMSE), autonomy-related (ADL) and radiological assessment (Morrey).

RESULTS

Mean MEPS was 84 and QuickDASH 32.4. Mean extension deficit was 22°, and mean flexion 125°. There was no loss of autonomy or cognitive impairment. The complications rate was 9.5%. There were no revision surgeries.

DISCUSSION

TEA proved reliable in comminuted distal humerus fracture in elderly patients. Functional results were comparable to those in the literature, and the complications rate was lower. Long-term implant survival needs confirmation to validate this option as a treatment of choice in these indications in geriatric traumatology.

TYPE OF STUDY

Retrospective non-comparative, single-center.

LEVEL OF EVIDENCE

4.

Total Elbow Arthroplasty for Distal Humeral Fractures: A Ten-Year-Minimum Follow-up Study

BACKGROUND

Total elbow arthroplasty is commonly considered for elderly patients with comminuted distal humeral fractures. Satisfactory short-term outcomes have been reported, but long-term outcomes are unknown. Our purpose was to assess the long-term outcomes of total elbow arthroplasty after distal humeral fracture and to determine differences between elbows with or without inflammatory arthritis at the time of fracture.

METHODS

Forty-four total elbow arthroplasties were performed after distal humeral fracture; those patients were followed for a minimum of 10 years and were evaluated with regard to pain, motion, Mayo Elbow Performance Scores, complications, and reoperations. The outcomes in elbows with and without inflammatory arthritis were compared. Kaplan-Meier survivorship analysis was performed.

RESULTS

Total elbow arthroplasty provided good pain relief and motion; the mean visual analog scale for pain was 0.6, the mean flexion was 123°, and the mean loss of extension was 24°. The mean Mayo Elbow Performance Score was 90.5 points, with 3 patients scoring <75 points. Five elbows (11%) developed deep infection, treated surgically with component retention (3 acute) or resection (2 chronic). Implant revision or resection was performed in 8 elbows (18%): 3 for infections (1 reimplantation and 2 resections), 3 for ulnar loosening (associated with periprosthetic fracture in 1), and 2 for ulnar component fractures. Additional periprosthetic fractures were observed in 5 elbows. The survival rates for elbows with rheumatoid arthritis were 85% at 5 years and 76% at 10 years, and the survival rates for elbows without rheumatoid arthritis were 92% at both 5 and 10 years. The most relevant risk factor for revision was male sex (hazard ratio, 12.6 [95% confidence interval, 1.7 to 93.6]).

CONCLUSIONS

Selective use of total elbow arthroplasty to treat fractures of the distal part of the humerus for infirm, less active older patients and patients with inflammatory arthritis has acceptable longevity in surviving patients, but at the cost of a number of major complications.

LEVEL OF EVIDENCE

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

Why does total elbow arthroplasty fail today? A systematic review of recent literature

BACKGROUND

Total elbow arthroplasty is a relatively uncommon type of arthroplasty, which has undergone several design changes in the past four decades. However, research on improvement requires knowledge of failure mechanisms that can be addressed. Therefore, we conducted a systematic review on modes of failure of total elbow arthroplasty.

METHODS

We conducted searches on PubMed/Medline, Embase and Cochrane databases to identify studies describing modes of failure of primary total elbow arthroplasties. The results were coupled per type of total elbow arthroplasty and individual arthroplasty models.

RESULTS

A total of 70 articles were included in this systematic review. 9308 individual total elbow arthroplasties were identified with 1253 revisions (13.5%). Aseptic loosening was the most prevalent reason for revision (38%), followed by deep infection (19%) and periprosthetic fractures (12%).

CONCLUSION

Revision rates have been found similar to a systematic review published in 2003. The revision percentage of total elbow arthroplasty for rheumatoid arthritis is significantly higher than for trauma and post-traumatic osteoarthritis. Aseptic loosening was seen less in linked implants. Infections and periprosthetic fractures did not differ between linkage design groups. Aseptic loosening remains the most frequent cause for revision of primary total elbow arthroplasty. Therefore, more research on the occurrence, progression and risk factors of aseptic loosening should be performed and lead to higher implant survival.

Discovery Elbow System: clinical and radiological results after 2- to 10-year follow-up

BACKGROUND

Discovery Elbow System (DES) is a semi-constrained prosthesis, mainly used for patients with rheumatoid arthritis (RA).

METHODS

Records from 79 patients with RA (90 DES arthroplasties) were reviewed; 47 patients with 55 DES elbows were re-examined. Range of motion (ROM) of both elbows, upper limb function, and quality of life (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Elbow Performance Score [MEPS], and the RAND 36-Item Health Survey [RAND-36]) were assessed. Cementing quality was assessed, and radiolucent lines measured from plain radiographs. Mean follow-up was 64 (range 24-123) months.

RESULTS

Pre-operatively to post-operatively, mean elbow flexion improved from 120° to 146° (p < 0.001) and mean extension lag improved from 29° to 24° (p = 0.02), respectively. At follow-up, mean supination was 66°, mean pronation was 69°, and mean grip strength was 14 kg. Grip strength and ROM (except supination) were similar between the DES elbow and contralateral un-operated elbow. Mean post-operative MEPS was 93 points (excellent, n = 38; good, n = 14; fair, n = 2; and poor, n = 1). Mean DASH score was 43 points. The RAND-36 showed that physical functioning, physical role functioning, bodily pain, and general health were lower than the Finnish reference values. Primary cementing was challenging, and radiolucent lines appeared during follow-up. Four prostheses were revised because of aseptic loosening (n = 3) and periprosthetic fracture (n = 1).

CONCLUSION

DES provides significant improvement in patient's flexion-extension arc. Cementing of the elbow prosthesis was challenging; radiolucent lines appeared during the 5-year follow-up, but their clinical relevance remains unclear. First-generation locking screws may loosen over time.

LEVEL OF EVIDENCE

Level IV.

Functional Results of Communited Intra-articular Distal Humerus Fractures Treated with Bicolumnar Plating

INTRODUCTION

Communited intra-articular distal humerus fractures are commonly encountered in orthopaedic practice and they are present with unique difficulties for internal fixation. This problem is especially worse in the elderly due to osteoporotic bone.

AIM

To evaluate the intermediate term results (minimum follow up of two years) of communited intra-articular distal humerus fractures treated with bicolumnar plating with or without olecranon osteotomy in elderly Indian population.

MATERIALS AND METHODS

Sixty three consecutive patients operated with bicolumnar plating for communited intra-articular distal humerus fractures at the tertiary care centre were identified in the time period between 2009 and 2013. All patients had an age more than 60 years at the time of surgery. A minimum follow up of two years post surgery was a mandatory criteria. The Disabilities of Arm and Shoulder and Hand (DASH) score and the Mayo Elbow Performance (MEP) score calculated along with complete range of motion.

RESULTS

The mean follow-up was 38 months. All patients achieved fracture union with mean MEP and DASH scores being 85 ± 15.5 and 21.4 ± 4.9 respectively. These scores although poor were comparable to the opposite side (90 and 12.2 respectively). Also the mean supination-pronation arc and flexion-extension arc was 156 degrees and 105 degrees respectively. This is well within the functional range of elbow. The mean block to extension was at 15 degrees with a mean maximal flexion of 120 degrees.

CONCLUSION

Our study conclusively establishes that excellent functional outcome can be achieved with open reduction and internal fixation in Type C distal humerus fractures in elderly including the ones that are communited. Total elbow arthroplasty although a viable option, gives similar results to a well done internal fixation with added cost.

Hemiarthroplasty for the treatment of distal humeral fractures: midterm clinical results

BACKGROUND

Total elbow arthroplasty is a treatment for unreconstructable distal humeral fractures; however, longevity of the implant remains a concern in younger, more active patients. Distal humeral hemiarthroplasty (DHH) offers an alternative with multiple advantages.

METHODS

This is a retrospective study of 10 patients who underwent DHH for distal humeral fractures during a 4-year period (2008-2012) by a single surgeon. Patients underwent testing of range of motion, Mayo Elbow Performance Score, Disabilities of Arm, Shoulder and Hand, visual analog scale, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons scores. Average patent age at surgery was 71.9 years (range, 56-81 years); average follow-up was 73.2 months (range, 36-96 months).

RESULTS

Patients maintained improvements in Mayo Elbow Performance Scores (mean, 89.23; range, 75-100) and Disabilities of Arm, Shoulder and Hand scores (mean, 33.71; range 11.2-55.1), along with no significant decrease in range of motion compared with 1 year after surgery. Mean visual analog scale was 2.43 (range, 0-5), Single Assessment Numeric Evaluation was 74.14 (range, 50-100), and American Shoulder and Elbow Surgeons score was 72.14 (range, 48.33-100). Participants had an average flexion of 128.7° (range, 95°-142°), extension deficit of 27.1° (range, 0°-45°), supination of 79.1° (range, 45°-90°), and pronation of 73.3° (range, 50°-90°). No heterotopic ossification, elbow dislocations, or subluxations were observed. Complications included 1 fracture and 1 complaint of prominent hardware. Two patients died, and 1 patient was lost to follow-up.

CONCLUSION

This midterm review suggests that DHH may be an effective treatment for certain distal humeral fractures. The data suggest that elbow range of motion and functional use are maintained from comparison with short-term studies. Additional studies must be conducted to further define the role of DHH for complex fractures of the distal humerus.

Limits of internal fixation in long-bone fracture

Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without reaming are preferable.

Distal Humeral Hemiarthroplasty Versus Total Elbow Arthroplasty for Acute Distal Humeral Fractures

For acute distal humeral fractures not amenable to open reduction and internal fixation, total elbow arthroplasty has become an established alternative. However, lifelong activity restrictions designed to prevent early mechanical failure make this a poor option for some patients. This has led to a renewed interest in distal humeral hemiarthroplasty. Using modern implants and techniques, distal humeral hemiarthroplasty has shown outcomes comparable to those of total elbow arthroplasty at short- to mid-term follow-up, with an overall higher but different complication rate. Long-term data are needed, but the available literature suggests that distal humeral hemiarthroplasty be considered as another option on the treatment spectrum in select patient populations. [Orthopedics. 2017; 40(1):13-23.].

[Endoprostheses in geriatric traumatology]

BACKGROUND

Geriatric traumatology is increasing in importance due to the demographic transition. In cases of fractures close to large joints it is questionable whether primary joint replacement is advantageous compared to joint-preserving internal fixation.

OBJECTIVE

The aim of this study was to describe the importance of prosthetic joint replacement in the treatment of geriatric patients suffering from frequent periarticular fractures in comparison to osteosynthetic joint reconstruction and conservative methods.

MATERIAL AND METHODS

A selective search of the literature was carried out to identify studies and recommendations concerned with primary arthroplasty of fractures in the region of the various joints (hip, shoulder, elbow and knee).

RESULTS

The importance of primary arthroplasty in geriatric traumatology differs greatly between the various joints. Implantation of a prosthesis has now become the gold standard for displaced fractures of the femoral neck. In addition, reverse shoulder arthroplasty has become an established alternative option to osteosynthesis in the treatment of complex proximal humeral fractures. Due to a lack of large studies definitive recommendations cannot yet be given for fractures around the elbow and the knee. Nowadays, joint replacement for these fractures is recommended only if reconstruction of the joint surface is not possible.

CONCLUSION

The importance of primary joint replacement for geriatric fractures will probably increase in the future. Further studies with larger patient numbers must be conducted to achieve more confidence in decision making between joint replacement and internal fixation especially for shoulder, elbow and knee joints.

Subjective ulnar nerve dysfunction commonly following open reduction, internal fixation (ORIF) of distal humeral fractures and in situ decompression of the ulnar nerve

The aim of this retrospective study was to investigate the frequency of persistent ulnar affection in patients who underwent open reduction and internal fixation (ORIF) of distal humeral fractures without ulnar nerve transposition or mobilisation. Eighty-two patients (53 women), mean age 62 years, were, at a mean of 48 months, reviewed through medical records and a subjective evaluation form concerning ulnar nerve problems. Ulnar nerve affliction, in most cases regarded as mild, was experienced by 22 patients (27%; 14 women) and significantly associated with multiple surgeries. Three patients had been operated with late neurolysis and one with transposition without reported improvement. The proportion of ulnar nerve dysfunction was equally common regardless of medial or lateral plating. ORIF with plate fixation and without ulnar nerve transposition seems to be an acceptable option for patients with distal humeral fractures. The frequency of ulnar nerve affection in our series does not appear higher than previously reported. Subjective ulnar nerve symptoms were, however, relatively common and appear related to the trauma itself, the surgery, or the post-operative management which highlights the need for further analysis of these factors.

Trends in total elbow arthroplasty in the Medicare population: a nationwide study of records from 2005 to 2012

BACKGROUND

Utilization of total elbow arthroplasty (TEA) has reportedly increased in recent years. Since the introduction of disease-modifying antirheumatic drugs, there has been a reported decline in its use among rheumatoid patients; yet, the shift in indications for TEA remains unclear. This study evaluated trends in TEA utilization from 2005 to 2012 by analyzing the most common indications within the population of Medicare patients.

METHODS

We performed a retrospective review of a comprehensive Medicare patient population database using the PearlDiver supercomputer (Warsaw, IN, USA) for TEA utilization in rheumatoid arthritis (RA), osteoarthritis (OA), distal humerus fracture (DHF), post-traumatic arthritis (PTA), and distal humerus nonunion (DHNU). Total reported incidence of office visits and TEA utilization for each indication was reviewed.

RESULTS

Utilization of TEA remained unchanged (P = .9530) despite a growing Medicare population (P = .0201). There was a significant decline in annual TEA utilization for RA (P = .002) and DHNU (P = .003). No significant change was found in TEA use for DHF, OA, and PTA. A significant increase was noted in total visits coded for OA, RA, and DHNU (P < .001). A significant, strong negative correlation was found for office visit coding and TEA use in RA (r = -0.850; P = .008) and DHNU (r = -0.902; P = .002).

CONCLUSION

From 2005 to 2012, utilization rates of TEA in the Medicare population remained constant. Despite increases in office visits, TEA use for RA and DHNU has declined, likely secondary to improved medical management with disease-modifying antirheumatic drugs and the surgeon's comfort with improved fracture fixation options.

Primary total elbow arthroplasty for distal humeral fractures in elderly patients: a nationwide analysis

BACKGROUND

Displaced intra-articular distal humeral fractures are a challenging injury in elderly patients. High rates of complications have led to the increasing use of total elbow arthroplasty (TEA) for primary treatment. This study presents US nationwide trends in primary TEA for distal humeral fractures in elderly patients (65 years and older) from 2002 to 2012. We hypothesized that there was an increase in the rate of TEA utilization.

METHODS

Data were obtained from the Nationwide Inpatient Sample for the years 2002 to 2012. All inpatients 65 years and older with distal humeral fractures were identified and were divided into 2 subgroups based on the operation they received: (1) TEA and (2) open reduction-internal fixation (ORIF).

RESULTS

Between 2002 and 2012, the annual frequency of TEA for elderly patients with distal humeral fractures increased 2.6-fold, with 147 patients in 2002 and 385 in 2012. In 2012, TEA was performed in 13% of operatively treated distal humeral fractures compared with only 5.1% in 2002 (P < .05). Mean hospital charges increased significantly for both the ORIF and TEA groups from 2002 to 2012. The average hospital charge for TEA in 2012 was $85,365, which was $16,358 higher than that for patients who underwent ORIF (P < .05).

CONCLUSION

The national rate of primary TEA for the acute management of distal humeral fractures in elderly patients has increased significantly over the past 10 years. Given the significant complexity, long-term restrictions, and risks associated with TEA, this increasing trend should be analyzed closely.

The clinical outcome and activity levels of patients under 55 years treated with distal humeral hemiarthroplasty for distal humeral fractures: minimum 2-year follow-up

BACKGROUND

The aim of the present study was to describe the clinical outcomes and activity levels of young patients after distal humeral hemiarthroplasty (DHH).

METHODS

Six patients under 55 years (mean 44 years; range 29 years to 52 years) treated with DHH at a mean postoperative time of 81 months (range 24 months to 133 months) were studied retrospectively. Two other patients had been revised for aseptic loosening and were excluded.

RESULTS

The mean Mayo Elbow Score (MEPS) (88), Subjective Elbow Value (SEV) (89), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) (12) and American Shoulder and Elbow Surgeons (ASES) elbow pain (6), function (23) and satisfaction scores (9) were satisfactory. The mean University of California, Los Angeles (UCLA) activity score was 7.2.

CONCLUSIONS

Although only rarely indicated, DHH has satisfactory clinical outcomes in young patients and allows a higher level of function than is generally advised after total elbow arthroplasty.

Elbow hemiarthroplasty for the management of distal humeral fractures: current technique, indications and results

There has been a growing recent interest in the use of elbow hemiarthroplasty for the treatment of distal humeral trauma in select patients. However, the current available evidence regarding outcome after elbow hemiarthroplasty is limited to case series and biomechanical data. Consequently, the procedure remains unfamiliar to many surgeons. The aim of the present review is to outline the evidence regarding elbow hemiarthroplasty and to use this, along with the author's experience, to better describe the indications, surgical technique and outcomes after this procedure.

Distal humerus fractures: a review of current therapy concepts

Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment.

Total Elbow Arthroplasty in the United States: Evaluation of Cost, Patient Demographics, and Complication Rates

Total elbow arthroplasty (TEA) is utilized in the treatment of rheumatoid and post-traumatic elbow arthritis. TEA is a relatively low volume surgery in comparison to other types of arthroplasty and therefore little is known about current surgical utilization, patient demographics and complication rates in the United States. The purpose of our study is to evaluate the current practice trends and associated in-patient complications of TEA at academic centers in the United States. We queried the University Health Systems Consortium administrative database from 2007 to 2011 for patients who underwent an elective TEA. A descriptive analysis of demographics was performed which included patient age, sex, race, and insurance status. We also evaluated the following patient clinical benchmarks: hospital length of stay (LOS), hospital direct cost, in-hospital mortality, complications, and 30-day readmission rates. Our cohort consisted of 3146 adult patients (36.5% male and 63.5% female) with an average age of 58 years who underwent a total elbow arthroplasty (159 academic medical centers) in the United States. The racial demographics included 2334 (74%) Caucasian, 285 (9%) black, 236 (7.5%) Hispanic, 16 (0.5%) Asian, and 283 (9%) other patients. The mean LOS was 4.2±5 days and the mean total direct cost for the hospital was 16,300±4000 US Dollars per case. The overall inpatient complication rate was 3.1% and included mortality <1%, DVT (0.8%), re-operation (0.5%), and infection (0.4%). The 30-day readmission rate was 4.4%. TEA is a relatively uncommon surgery in comparison to other forms of arthroplasty but is associated with low in-patient and 30-day perioperative complication rate. Additionally, the 30-day readmission rate and overall hospital costs are comparable to the traditional total hip and knee arthroplasty surgeries.

Short-Term Complications of Distal Humerus Fractures in Elderly Patients: Open Reduction Internal Fixation Versus Total Elbow Arthroplasty

Background:

The purpose of this study was to evaluate 30-day postoperative complications of open reduction and internal fixation [ORIF] and total elbow arthroplasty [TEA] for the treatment of distal humerus fractures in elderly patients using a validated national database.

Methods:

Review of the National Surgical Quality Improvement Program (NSQIP) Database identified all elderly patients (>65 years) who underwent TEA or ORIF for the treatment of closed intra-articular distal humerus fractures from 2007 to 2013. Bivariate and multivariate analyses of risk factors for 30-day adverse events as defined by NSQIP between ORIF and TEA groups were assessed using preoperative and intraoperative variables.

Results:

Among the 176 patients with distal humerus fractures, there were 33 TEA and 143 ORIF. There was no difference in age, medical comorbidities, or functional status. Total elbow arthroplasty was associated with an increased odds of severe adverse event compared to ORIF (odds ratio = 1.57, P = .16), although it did not achieve statistical significance. Infection rate was 0.7% in ORIF and 0.0% in TEA (P = .99). Insulin-dependent diabetes and functional status were significant independent predictors of postoperative adverse events. Operative time (165 minutes vs 140 minutes, P = .06) and postoperative length of stay (3.6 days vs 2.3 days, P = 0.03) were longer for TEA compared to ORIF.

Conclusion:

Open reduction and internal fixation and TEA have similar 30-day postoperative complications for the treatment of distal humerus fractures among elderly patients. Despite favorable trends for TEA in recent studies, additional clinical results are needed to understand complications and limitation of TEA.

Level of evidence:

Level III, prognostic study.

Outcome after total elbow arthroplasty: a retrospective study of 167 procedures performed from 1981 to 2008

BACKGROUND

Total elbow arthroplasties (TEAs) are traditionally grouped into linked and unlinked design. The aim was to analyze the difference in clinical outcomes after TEA based on implant design and indication for surgery and to evaluate primary and revision TEAs.

METHODS

A total of 167 TEAs (126 primary and 41 revision TEAs) in 141 patients were evaluated with patient-reported outcome measure by the Oxford Elbow Score (OES) and clinically assessed with the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and standard radiographs.

RESULTS

The mean follow-up was 10.5 years for primary and 7.5 years for revision TEAs. There was no difference in OES or MEPS between linked and unlinked primary TEAs. The OES score in the social-psychological domain was significantly lower in TEAs performed due to fracture (67) compared with rheumatoid arthritis (81; P = .025). ROM in extension-flexion was 116° for primary linked TEAs compared with 110° for primary unlinked TEAs (P = .02). Revision TEAs were associated with a poorer outcome in OES, MEPS, and ROM compared with primary TEAs. Radiographic signs of loosening were seen in 15 primary and 7 revision TEAs at follow-up.

CONCLUSIONS

We found no clinically significant differences in outcomes after linked or unlinked TEAs. Patients with TEAs due to fracture had poorer social-psychological results than rheumatoid arthritis patients. The results after revision surgery were significantly inferior compared with primary procedures. The OES contributes to the evaluations of the outcome after TEA surgery with a nuanced picture of the patient's perception.

Total elbow arthroplasty in distal humeral nonunion: clinical and radiographic evaluation after a minimum follow-up of three years

BACKGROUND

Total elbow arthroplasties (TEAs) are usually indicated in chronic inflammatory arthropathies. This procedure has also recently been used in complex distal humeral fractures and nonunions in selected patients. This study analyzed the clinical and radiographic outcomes in patients treated for nonunions around the elbow region with a minimum follow-up of 3 years.

METHODS

Between May 2002 and June 2012, 20 patients affected with distal humeral nonunions were treated with TEA. All patients were assessed clinically using the Mayo Elbow Performance Score and radiographically to evaluate the positioning of the prosthetic components and signs of loosening. Statistical analyses were performed to investigate the presence of clinical and radiographic variables as predictive factors of poor functional outcomes.

RESULTS

The Mayo Elbow Performance Score of the affected arm improved significantly between the preoperative period and follow-up. Results were good or excellent in 90% of the patients even if a high rate of complications (30%) was encountered. The development of complications after surgery and stages II, III, and IV radiolucency, according to the Morrey criteria, were predictive factors of poor outcomes.

CONCLUSIONS

According to the satisfactory results observed in this study, TEA could be indicated in selected patients aged older than 70 years with low functional demands and affected with distal humeral nonunions in which obtaining a stable fixation is difficult.

Total Elbow Arthroplasty for Distal Humerus Fractures

Total elbow arthroplasty is a good treatment alternative for selected patients with distal humerus fractures. Its attractiveness is related to several factors, including the possibility of performing the procedure; leaving the extensor mechanism intact; faster, easier rehabilitation compared with internal fixation; and overall good outcomes reported in terms of both pain relief and function. Implant failure leading to revision surgery does happen, and patients must comply with certain limitations to extend the longevity of their implant. Development of high-performance implants may allow expanding the indications of elbow arthroplasty for fractures.

Peri-implant failure in dual plating of the distal humerus-A biomechanical analysis with regard to screw and plate positioning

PURPOSE

The aim of this biomechanical study was to analyse the influence of plate and screw positioning on peri-implant failure in dual plate osteosynthesis. We hypothesized that screw positioning rather than plate configuration influences the risk of peri-implant fractures.

METHODS

Twenty macerated humerus specimens were available. 5 groups of 4 were built according to specimen size. Locking dual plates (Medartis, Switzerland) were randomly applied to the distal humerus of the specimens in 4 types of configuration: Bending forces were applied using a universal testing machine until peri-implant fracture occurred.

RESULTS

Mean failure loads for respective configuration types were as follows: P1: 428.7 (±84.2) N, A1: 410.0 (±54.7) N, A0: 297.8 (±48.3) N, P0: 261.0 (±65.0) N. Configurations with positioning of the most proximal screws at different levels (P1, A1) reached significantly higher failure loads when compared to screw placement at the same level (P0, A0) (0.01≤p≤0.03). Altering the plate configuration did not significantly influence failure loads (0.34≤p≤0.58).

CONCLUSIONS

The results of this study suggest that placement of the most proximal screws rather than the configuration of the plates is critical regarding the predetermined risk of peri-implant failure in dual plate osteosynthesis of the distal humerus. Varying levels of the outermost screws of corresponding double plates seem to be crucial to avoid complications related to the osteosynthesis.