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Abstract
Fractures of the capitellum and trochlea account for a small proportion of elbow trauma. Clinicians need to be vigilant in their assessment as they are commonly associated with other injuries about the elbow. To optimize outcomes, the goals of management include a stable, anatomic reduction and early range of motion. Closed reduction of noncomminuted fractures may be successful but requires close follow-up. Open reduction and internal fixation is the preferred management of displaced capitellum-trochlear fractures. Elbow stiffness is the most commonly reported complication in operatively treated fractures. Arthroscopic-assisted reduction and internal fixation and arthroplasty are evolving management options.
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Affiliation(s)
- Michael J Carroll
- Division of Orthopedic Surgery, Roth|McFarlane Hand & Upper Limb Centre, St. Joseph's Health Center, Western University, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada
| | - George S Athwal
- Division of Orthopedic Surgery, Roth|McFarlane Hand & Upper Limb Centre, St. Joseph's Health Center, Western University, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada
| | - Graham J W King
- Division of Orthopedic Surgery, Roth|McFarlane Hand & Upper Limb Centre, St. Joseph's Health Center, Western University, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada
| | - Kenneth J Faber
- Division of Orthopedic Surgery, Roth|McFarlane Hand & Upper Limb Centre, St. Joseph's Health Center, Western University, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada.
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152
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Pooley J, Salvador Carreno J. Total elbow joint replacement for fractures in the elderly--Functional and radiological outcomes. Injury 2015; 46 Suppl 5:S37-42. [PMID: 26362422 DOI: 10.1016/j.injury.2015.08.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM The purpose of this paper was to review the literature on the treatment of intra-articular fractures of the distal humerus in the elderly in order to evaluate the place for total elbow replacement (TER) in the light of our experience over the past 15 years. METHODS A review of the records of 11 consecutive patients over the age of 60 years who underwent primary TER for comminuted fractures of the distal humerus between 1997 and 2011 were reviewed and the surviving patients were interviewed. The Scopus database was used to perform a pragmatic review of the literature published between the mid-1990s and the present-day. RESULTS At the time of the most recent follow-up 3.5 years following surgery (range: 2-6 years) 7 patients assessed with the Mayo elbow performance index were classified as excellent, 4 were classified as good. There were no complications requiring further procedures encountered. Five surviving patients remain satisfied with the function of their TER. The number of papers recommending TER for treatment of these fractures continues to increase with time. CONCLUSIONS TER is now the treatment of choice for unreconstructable fractures of the distal humerus in the elderly. This option should therefore be available at the time of surgery for all distal humeral fractures in this patient population. A surgical approach other than olecranon osteotomy, which would preclude TER is therefore required.
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153
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Aitken SA, Jenkins PJ, Rymaszewski L. Revisiting the 'bag of bones': functional outcome after the conservative management of a fracture of the distal humerus. Bone Joint J 2015. [PMID: 26224833 DOI: 10.1302/0301-620x.97b8.35410] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The best method of managing a fracture of the distal humerus in a frail low-demand patient with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for patients in whom open reduction and internal fixation (ORIF) is not possible. Conservative methods of treatment, including the 'bag of bones' technique (acceptance of displacement of the bony fragments and early mobilisation), are now rarely considered as they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with a fracture of the distal humerus who had been treated conservatively at our hospital between March 2008 and December 2013, and assessed their short- and medium-term functional outcome. In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to 80) at six weeks after injury to 67 points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30 points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of fracture union at one year was 53%. The mortality at five years approached 40%. Conservative management of a fracture of the distal humerus in a low-demand patient only gives a modest functional result, but avoids the substantial surgical risks associated with primary ORIF or TEA.
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Affiliation(s)
- S A Aitken
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - P J Jenkins
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK
| | - L Rymaszewski
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK
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154
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Nestorson J, Ekholm C, Etzner M, Adolfsson L. Hemiarthroplasty for irreparable distal humeral fractures. Bone Joint J 2015; 97-B:1377-84. [DOI: 10.1302/0301-620x.97b10.35421] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients. Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty. Cite this article: Bone Joint J 2015;97-B:1377–84.
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Affiliation(s)
| | - C. Ekholm
- Gothenburg University Institute of Clinical
Sciences at Sahlgrenska Academy, Gothenburg, Sweden
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155
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Somford MP, van Deurzen DFP, Ostendorf M, Eygendaal D, van den Bekerom MPJ. Quality of research and quality of reporting in elbow surgery trials. J Shoulder Elbow Surg 2015; 24:1619-26. [PMID: 25958211 DOI: 10.1016/j.jse.2015.03.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 03/12/2015] [Accepted: 03/18/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Randomized controlled trials (RCTs) are high in the hierarchy of scientific evidence, but possible sources of bias should be identified or even excluded. This systematic review assessed the methodologic quality and the quality of reporting of the RCTs on the treatment of elbow pathology. METHODS A systematic review of RCTs was performed on the treatment of elbow pathology. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for relevant trials. Thirty-five of the initial 540 articles being an (pseudo) RCT on invasive treatment of elbow pathology in humans were included. These were scored with the use of an adapted Checklists to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). To assess quality of reporting, points were administered to the articles based on the results from CLEAR-NPT list. The highest possible score for quality is 26 points. RESULTS The average quality score was 18.1 points (range, 10-25 points). The mean scores were 19.5 for trials published in the American Journal of Sports Medicine, 19.8 for those published in the Journal of Bone and Joint Surgery, and 20.3 for those published in the Journal of Shoulder and Elbow Surgery. CONCLUSIONS The most important finding was that the overall quality and the quality of reporting has not improved over the years and that the overall quality of the selected studies and the quality of reporting in these trials is not related to the journal they are published in.
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Affiliation(s)
- Matthijs P Somford
- Department of Orthopedic Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Derek F P van Deurzen
- Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Marieke Ostendorf
- Department of Orthopedic Surgery, St Maartenskliniek Woerden, Woerden, The Netherlands
| | - Denise Eygendaal
- Upper Limb Unit, Department of Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands
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156
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Dachs RP, Vrettos BC, Chivers DA, Du Plessis JP, Roche SJ. Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty. J Hand Surg Am 2015; 40:1832-7. [PMID: 26254945 DOI: 10.1016/j.jhsa.2015.06.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/19/2015] [Accepted: 06/19/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE Ulnar nerve (UN) lesions are a significant complication after total elbow arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a center, which routinely performs an in situ release of the nerve without transposition, were investigated. METHODS Eighty-three primary TEAs were retrospectively reviewed for the intraoperative management of the UN and presence of postoperative UN symptoms. RESULTS Three patients had documented preoperative UN symptoms. One patient had a prior UN transposition. The nerve was transposed at the time of TEA in 4 of the remaining 82 elbows (5%). The indication for transposition in all cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. Of the 4 patients who underwent UN transposition, 2 had postoperative UN symptoms. Both were neuropraxias, which resolved in the early postoperative period. The remaining 78 TEAs received an in situ release of the nerve. The incidence of postoperative UN symptoms in the in situ release group was 5% (4 of 78). Two patients had resolution of symptoms, whereas 2 continued to experience significant UN symptoms requiring subsequent transposition. Seven patients had preoperative flexion of less than 100°. Of these, 2 had a UN transposition at the time of TEA. Of the remaining 5 elbows with preoperative flexion less than 100°, 2 had postoperative UN symptoms after in situ release, with 1 requiring subsequent UN transposition. CONCLUSIONS A 3% incidence of significant UN complications after TEA compares favorably with systematic reviews. We do not believe that transposition, which adds to the handling of the nerve and increases surgical time, is routinely indicated and should rather be reserved for cases with marked limitation of preoperative elbow flexion or when intraoperative assessment by the surgeon deems it necessary. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Robert P Dachs
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Basil C Vrettos
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - David A Chivers
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Jean-Pierre Du Plessis
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Stephen J Roche
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
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157
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Heijink A, Wagener ML, de Vos MJ, Eygendaal D. Distal humerus prosthetic hemiarthroplasty: midterm results. Strategies Trauma Limb Reconstr 2015; 10:101-8. [PMID: 26311568 PMCID: PMC4570889 DOI: 10.1007/s11751-015-0229-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 08/19/2015] [Indexed: 11/23/2022] Open
Abstract
Treatment of comminuted distal humeral fractures remains challenging. Open reduction–internal fixation remains the preferred treatment, but is not always feasible. In selected cases with non-reconstructable or highly comminuted fractures, total elbow arthroplasty has been used, however, also with relatively high complication and failure rates. Distal humerus prosthetic hemiarthroplasty (DHA) may be an alternative in these cases. The purpose of this study was to report the midterm results of six patients that were treated by DHA for acute and salvage treatment of non-reconstructable fractures of the distal humerus. All six patients were treated by DHA for acute and salvage treatment of non-reconstructable fractures of the distal humerus. Medical records were reviewed, and each patient was seen in the office. Mean follow-up was 54 months (range 21–76 months). Implant survival was 100 %. Three were pain free and three had mild or moderate residual pain. Average flexion–extension arc was 95.8° (range 70°–115°) and average pronation–supination arc was 165° (range 150°–180°). In three, there was some degree of instability, which was symptomatic in one. One had motoric and sensory sequelae of a partially recovered traumatic ulnar nerve lesion. According to the Mayo Elbow Performance Score, there were three excellent, one good and two poor results. Four were satisfied with the final result, and two were not. In this case series of six patients with DHA for non-reconstructable distal humerus fractures, favorable midterm follow-up results were seen; however, complications were also observed.
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Affiliation(s)
- Andras Heijink
- Department of Orthopaedic Surgery, Academic Medical Center (AMC), Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands.
| | - Marc L Wagener
- Department of Orthopaedic Surgery, St. Radboud University Hospital, Nijmegen, The Netherlands
| | - Maarten J de Vos
- Department of Orthopaedic Surgery, Tergooi Hospitals, Hilversum, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
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158
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Phadnis J, Banerjee S, Watts AC, Little N, Hearnden A, Patel VR. Elbow hemiarthroplasty using a "triceps-on" approach for the management of acute distal humeral fractures. J Shoulder Elbow Surg 2015; 24:1178-86. [PMID: 26117619 DOI: 10.1016/j.jse.2015.04.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/08/2015] [Accepted: 04/11/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty is an established option for the primary treatment of acute distal humeral fractures, but there are sparse data regarding elbow hemiarthroplasty (EHA) as an alternative. We present the outcome of EHA performed with a modular anatomic prosthesis and a "triceps-on" surgical technique. METHODS Eighteen consecutive patients underwent EHA for an acute fracture. Two patients died, leaving a study group of 16 patients with minimum 2-year follow-up. Clinical evaluation included range of motion; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder, and Hand score; and Oxford Elbow Score. Radiographic assessment looked at alignment, evidence of loosening, ulnar and radial head wear, heterotopic ossification, and whether healing of the condyles had occurred. RESULTS Mean follow-up was 35 months (24-79 months). The mean scores were as follows: Mayo Elbow Performance Score, 89.6; shortened Disabilities of the Arm, Shoulder, and Hand score, 11.2; and Oxford Elbow Score, 43.7. The mean flexion and pronation-supination arcs were 116° and 172° respectively. Radial head wear was absent in 13 patients and mild in 3. Ulnar wear was absent in 6 patients, mild in 8, and moderate in 2. Wear was not associated with greater pain or inferior functional scores. There was no sign of aseptic loosening, and complete condylar bone union occurred in 15 elbows. There was 1 complication, a transient ulnar nerve neurapraxia that resolved without intervention. CONCLUSION EHA with a modular anatomic implant using a triceps-on approach is a reliable technique for the management of acute unreconstructible distal humeral fractures in older patients.
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Affiliation(s)
| | | | | | - Nicholas Little
- Department of Orthopaedic, Epsom and St Helier University Hospitals NHS Trust, Epsom, Surrey, UK
| | | | - Vipul R Patel
- Department of Orthopaedic, Epsom and St Helier University Hospitals NHS Trust, Epsom, Surrey, UK
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159
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Desloges W, Faber KJ, King GJW, Athwal GS. Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients. J Shoulder Elbow Surg 2015; 24:1187-96. [PMID: 26189804 DOI: 10.1016/j.jse.2015.05.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 05/03/2015] [Accepted: 05/04/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is scant contemporary literature describing the outcomes of nonoperative management of distal humeral fractures. The aim of this study was to report the functional and radiographic outcomes after nonoperative management of distal humeral fractures. METHODS Between 2007 and 2013, 32 low-demand, medically unwell, or older patients with distal humeral fractures were treated nonoperatively. At the time of this study, 8 patients had died of unrelated causes, and 5 patients were lost to follow-up. The remaining 19 patients, with a mean age of 77 years, were available for a comprehensive assessment. RESULTS At a mean of 27 ± 14 months of follow-up, 68% (13 of 19) of patients reported good to excellent subjective outcomes. Outcomes in 2 patients were classified as poor, one of whom underwent total elbow arthroplasty as a result. Overall, the mean score on the Patient Rated Elbow Evaluation was 16 ± 23 and the Mayo Elbow Performance Index was 90 ± 11. When the injured was compared with the uninjured side, extension (22° ± 11° vs 8° ± 12°; P = .025) and flexion (128° ± 16° vs 142° ± 7°; P = .002) were significantly worse in the injured elbows. The fracture union rate was 81% (22 of 27) at a mean radiographic follow-up of 12 months. CONCLUSIONS Satisfactory outcomes were observed after the nonoperative management of selected distal humeral fractures in lower-demand, medically unwell, or older patients. Fracture union can be expected in most patients. In the uncommon instance when an unsatisfactory outcome occurs, successful salvage can be achieved with conversion to a total elbow arthroplasty.
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Affiliation(s)
- William Desloges
- Division of Orthopedic Surgery, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Centre, University of Western Ontario, London, ON, Canada
| | - Kenneth J Faber
- Division of Orthopedic Surgery, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Centre, University of Western Ontario, London, ON, Canada
| | - Graham J W King
- Division of Orthopedic Surgery, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Centre, University of Western Ontario, London, ON, Canada
| | - George S Athwal
- Division of Orthopedic Surgery, Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Centre, University of Western Ontario, London, ON, Canada.
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160
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Herzberg G, Burnier M, Marc A, Izem Y. Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fracture in the Independent Elderly. J Wrist Surg 2015; 4:156-63. [PMID: 26261739 PMCID: PMC4530175 DOI: 10.1055/s-0035-1558841] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Volar plating for acute distal radius fractures (DRF) in the elderly has been recommended. Some studies have suggested that open reduction with internal fixation (ORIF) in this situation results in frequent complications. Our purposes were to provide a definition of irreparable DRF in independent elderly patients and to review the results of a preliminary retrospective series of wrist hemiarthroplasty (WHA) in this patient population. Materials Between 2011 and 2014, 11 consecutive independent elderly patients (12 wrists) with irreparable intra-articular DRF were treated with primary WHA at the acute stage. A resection of the ulnar head was associated in nine wrists. A total of 11 wrists with more than 2 years of follow-up form the basis of this paper. Description of Technique The approach was dorsal longitudinal. An osteotome longitudinally entered the dorsal aspect of the fracture medial to the Lister tubercle. Two thick osteoperiosteal flaps were elevated radially and ulnarly in a fashion similar to opening a book. The distal radius articular surface was excised. The implant was pressed into the radial canal with attention to restoring distal radius length. The two osteoperiosteal flaps were brought back together and sutured so as to close, again like a book, the osseous and soft tissues around the implant. Results At mean follow-up of 30 months, average visual analog scale (VAS) pain was 1/10. Mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) score was 32, and mean Patient-Rated Wrist Evaluation (PRWE) score was 24. Mean forearm rotation arc was 151°. Mean active flexion-extension arc was 60°. Mean active extension was 34°. Mean grip strength was 14 kg (64% of contralateral wrist). Mean Lyon wrist score was 73%. Bone healing around the implants was satisfactory in all but one case. Conclusions Out data suggest that treatment of irreparable DRF in the independent elderly patient with a bone-preserving WHA may be a viable option. Longer-term follow-up and comparative studies are needed to confirm the validity of this concept.
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Affiliation(s)
| | | | - Antoine Marc
- Wrist Surgery Unit, Herriot Hospital, Lyon, France
| | - Yadar Izem
- Wrist Surgery Unit, Herriot Hospital, Lyon, France
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161
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Yari SS, Bowers NL, Craig MA, Reichel LM. Management of distal humeral coronal shear fractures. World J Clin Cases 2015; 3:405-417. [PMID: 25984515 PMCID: PMC4419104 DOI: 10.12998/wjcc.v3.i5.405] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/15/2015] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
Coronal shear fractures of the distal humerus are rare, complex fractures that can be technically challenging to manage. They usually result from a low-energy fall and direct compression of the distal humerus by the radial head in a hyper-extended or semi-flexed elbow or from spontaneous reduction of a posterolateral subluxation or dislocation. Due to the small number of soft tissue attachments at this site, almost all of these fractures are displaced. The incidence of distal humeral coronal shear fractures is higher among women because of the higher rate of osteoporosis in women and the difference in carrying angle between men and women. Distal humeral coronal shear fractures may occur in isolation, may be part of a complex elbow injury, or may be associated with injuries proximal or distal to the elbow. An associated lateral collateral ligament injury is seen in up to 40% and an associated radial head fracture is seen in up to 30% of these fractures. Given the complex nature of distal humeral coronal shear fractures, there is preference for operative management. Operative fixation leads to stable anatomic reduction, restores articular congruity, and allows initiation of early range-of-motion movements in the majority of cases. Several surgical exposure and fixation techniques are available to reconstruct the articular surface following distal humeral coronal shear fractures. The lateral extensile approach and fixation with countersunk headless compression screws placed in an anterior-to-posterior fashion are commonly used. We have found a two-incision approach (direct anterior and lateral) that results in less soft tissue dissection and better outcomes than the lateral extensile approach in our experience. Stiffness, pain, articular incongruity, arthritis, and ulnohumeral instability may result if reduction is non-anatomic or if fixation fails.
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162
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Complications associated with hinged external fixation for chronic elbow dislocations. J Hand Surg Am 2015; 40:730-7. [PMID: 25721235 DOI: 10.1016/j.jhsa.2014.12.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the outcomes of patients who underwent application of hinged external fixators for chronic elbow fracture-dislocations. We hypothesized that patients treated for this injury pattern can achieve satisfactory outcomes but encounter many complications and require numerous additional procedures. METHODS We performed a retrospective review of 7 patients who were surgically treated with application of a hinged external fixator for chronic ulnohumeral elbow fracture-dislocation. Patients were included only if they had complete ulnohumeral dislocation of greater than 1 month's duration. Demographics, injury pattern, and range of motion were documented. Preoperative and postoperative range of motion was recorded and any treatment complications or additional surgeries were noted. RESULTS The interval between the initial injury and index procedure averaged 8 months. All patients underwent initial treatment with open reduction internal fixation. Average arc of ulnohumeral motion improved from 26° (range, 0° to 60°) to 120° (range, 100° to 145°). Overall, 4 of 7 patients developed at least one complication during treatment. Three patients required additional procedures aside from removal of the hinged external fixator. These 3 patients underwent a total of 13 additional procedures. CONCLUSIONS Although patients can achieve good outcomes, realistic expectations should be set. Patients should be aware that surgery can be associated with a high risk of complications, potential treatment failure, and a need for additional surgical procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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163
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Dachs RP, Fleming MA, Chivers DA, Carrara HR, Du Plessis JP, Vrettos BC, Roche SJ. Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches. J Shoulder Elbow Surg 2015; 24:339-47. [PMID: 25591460 DOI: 10.1016/j.jse.2014.11.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 11/03/2014] [Accepted: 11/09/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty (TEA) is associated with high complication rates compared with other large-joint arthroplasties. The frequency and type of complication may differ, depending on the surgical approach. A comparison of outcomes with triceps-off and triceps-on approaches was investigated. METHODS Seventy-three patients underwent 83 primary TEAs between 2003 and 2012. Forty-six elbows had a triceps-off approach, and 37 had a triceps-on approach. Results were reviewed at a mean of 4.2 years. Cementing technique was graded according to Morrey's criteria, and clinical outcomes were assessed by means of the Mayo Elbow Performance Score. RESULTS There was no statistically significant difference between the triceps-off and triceps-on groups with regard to the patient's age, gender, preoperative Mayo Elbow Performance Score or range of motion, or previous surgery on the affected elbow. Among patients who underwent a TEA for an inflammatory arthropathy, there was a significant difference in outcome between groups with regard to final flexion, extension, arc of motion, and pronation. Cementing technique in the triceps-off group was adequate in 70%. In the triceps-on group, cementing technique was adequate in 92%. The complication rate in the triceps-off group was 32.6% and included 7 triceps ruptures. Three patients who had attempted repairs of the triceps rupture developed deep infections requiring multiple further surgeries. The complication rate in the triceps-on group was 8.1%. CONCLUSION A triceps-on approach in TEA results in consistently good clinical outcomes with no risk of triceps rupture, and the approach does not compromise the cement mantle. We believe that this approach will reduce complication rates in TEA.
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Affiliation(s)
- Robert P Dachs
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa.
| | - Mark A Fleming
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
| | - David A Chivers
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
| | - Henri R Carrara
- Department of Medical Statistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Basil C Vrettos
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
| | - Stephen J Roche
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
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164
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Sela Y, Baratz ME. Distal humerus fractures in the elderly population. J Hand Surg Am 2015; 40:599-601. [PMID: 25661293 DOI: 10.1016/j.jhsa.2014.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 11/24/2014] [Accepted: 12/08/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Yaron Sela
- Orthopaedic Specialists, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mark E Baratz
- Orthopaedic Specialists, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Crisscross-type screw fixation for transcondylar fractures of distal humerus in elderly patients. Arch Orthop Trauma Surg 2015; 135:1-7. [PMID: 25416098 DOI: 10.1007/s00402-014-2116-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION This study presents the outcomes of low transcondylar fractures of the distal humerus treated by closed reduction and internal fixation with two screws in a crisscross orientation. MATERIALS AND METHODS Between 2003 and 2009, ten consecutive elderly patients (1 man and 9 women) with transcondylar fractures of distal humerus (AO 13A2.3) were included in this study. The average age at the time of injury was 72 years (range 63-82). All were closed injuries without nerve injury. The mechanism of the injuries was low-energy fall or slip. Six patients had medical or other systemic diseases. SURGICAL TECHNIQUE After a closed reduction of the fracture fragments, two guide wires were inserted in a crisscross orientation; one from the lower lateral edge of the capitellum to the medial cortex of the distal humerus, and the other from the lower medial edge of the trochlea to the lateral cortex of the distal humerus. After drilling, fully threaded cannulated screws (4.5 mm in diameter) were inserted along the each guide wire. Functional outcome was assessed with Mayo Elbow Performance scores. RESULTS The mean operation time was 55 min (range 40-100 min). The average follow-up duration was 26.8 months (range 24-35 months). The mean Mayo Elbow Performance scores were 93.8 (range 90-99). The elbow extension-flexion arc was 12(o)-125(o). The mean pronation-supination angle was 74(o)-72(o). CONCLUSION In geriatric patients with transcondylar fractures of the distal humerus, a crisscross fixation with two cannulated screws provides satisfactory results that allow a nearly full range of elbow motion with minimal surgical morbidity.
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Arthroplasty compared to internal fixation by locking plate osteosynthesis in comminuted fractures of the distal humerus. INTERNATIONAL ORTHOPAEDICS 2014; 39:747-54. [DOI: 10.1007/s00264-014-2635-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/04/2014] [Indexed: 11/25/2022]
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Kozánek M, Bartoníček J, Chase SM, Jupiter JB. Treatment of distal humerus fractures in adults: a historical perspective. J Hand Surg Am 2014; 39:2481-5. [PMID: 25442772 DOI: 10.1016/j.jhsa.2014.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 08/03/2014] [Accepted: 08/05/2014] [Indexed: 02/02/2023]
Abstract
Nonsurgical treatment was the mainstay of management of distal humerus fractures for centuries and nonunions and malunions were common. The 19th century featured the recognition of distinct injury patterns. With advances in radiology, anesthesia, antisepsis, and hardware technology, surgical treatment is now generally preferred, yet loss of elbow joint mobility can still be a vexing problem.
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Affiliation(s)
- Michal Kozánek
- Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Combined Orthopaedic Residency Program, Boston, MA; Department of Orthopaedic Trauma of 1(st) Faculty of Medicine of Charles University and Central Military Hospital, Prague, Czech Republic; Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Jan Bartoníček
- Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Combined Orthopaedic Residency Program, Boston, MA; Department of Orthopaedic Trauma of 1(st) Faculty of Medicine of Charles University and Central Military Hospital, Prague, Czech Republic; Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Samantha M Chase
- Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Combined Orthopaedic Residency Program, Boston, MA; Department of Orthopaedic Trauma of 1(st) Faculty of Medicine of Charles University and Central Military Hospital, Prague, Czech Republic; Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Jesse B Jupiter
- Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Combined Orthopaedic Residency Program, Boston, MA; Department of Orthopaedic Trauma of 1(st) Faculty of Medicine of Charles University and Central Military Hospital, Prague, Czech Republic; Faculty of Medicine, Comenius University, Bratislava, Slovakia.
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168
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Linn MS, Gardner MJ, McAndrew CM, Gallagher B, Ricci WM. Is primary total elbow arthroplasty safe for the treatment of open intra-articular distal humerus fractures? Injury 2014; 45:1747-51. [PMID: 25192866 PMCID: PMC4321717 DOI: 10.1016/j.injury.2014.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/14/2014] [Accepted: 07/17/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures. METHODS Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit. RESULTS Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21° (range 5-30°) to 113° flexion (range 90-130°). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits. CONCLUSIONS TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.
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169
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Mansat P, Bonnevialle N, Rongières M, Bonnevialle P. The role of total elbow arthroplasty in traumatology. Orthop Traumatol Surg Res 2014; 100:S293-8. [PMID: 25164351 DOI: 10.1016/j.otsr.2014.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/26/2014] [Indexed: 02/02/2023]
Abstract
UNLABELLED Fractures of the distal humerus account for 5% of osteoporotic fractures in subjects older than 60 years. A history of osteoporosis, co-morbidities, and joint comminution make their management difficult. The therapeutic options are limited to functional treatments, osteosynthesis, or either partial or total arthroplasty. Functional treatment of distal humerus fractures in the elderly subject provide inconsistent results, often with persistence of pain with a stiff or unstable elbow. Osteosynthesis remains the reference treatment for these fractures, following the principle of stable and rigid osteosynthesis allowing early mobilization. However, joint comminution and a history of osteoporosis occasionally make it impossible to meet this objective, with a considerable rate of complications and surgical revisions. Total elbow arthroplasty remains an alternative to osteosynthesis with very satisfactory immediate results restoring a painless, stable, and functional elbow. These results seem reproducible and sustainable over time. The complication rate is not uncommon with an approximately 10% surgical revision rate. Elbow hemiarthroplasty remains to be validated in this indication. LEVEL OF EVIDENCE V.
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Affiliation(s)
- P Mansat
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France.
| | - N Bonnevialle
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France
| | - M Rongières
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France
| | - P Bonnevialle
- Départementd'orthopédie-traumatologie, hôpital Riquet, centre hospitalier universitaire de Toulouse, place du Dr Baylac, 31059 Toulouse, France
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Giannicola G, Scacchi M, Polimanti D, Cinotti G. Discovery elbow system: 2- to 5-year results in distal humerus fractures and posttraumatic conditions: a prospective study on 24 patients. J Hand Surg Am 2014; 39:1746-56. [PMID: 25063393 DOI: 10.1016/j.jhsa.2014.05.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To prospectively evaluate preliminary results of the Discovery Elbow System (DES) used for acute distal humerus fractures and posttraumatic conditions. METHODS We analyzed 24 patients (9 men and 15 women), with a mean age of 69 years (range, 45-89 y). Ten had comminuted distal humerus fractures (group I), and 14 had severe post-traumatic arthritis, chronic instability, or nonunion (group II). Clinical and radiographic evaluations were performed. The preoperative (group II) and postoperative (both groups) evaluations were assessed with the Mayo Elbow Performance Score and Mayo Elbow Performance Index, the Quick Disabilities of the Arm, Shoulder, and Hand score, and the modified American Shoulder and Elbow Surgeons score. Patient satisfaction was evaluated on a 4-point scale. RESULTS Mean follow-up was 41 months (range, 29-63 mo). At the last evaluation, average flexion, extension, pronation, and supination were 136°, 17°, 80°, and 83°, respectively. The average Mayo Elbow Performance Score, Quick Disabilities of the Arm, Shoulder, and Hand score, and the modified American Shoulder and Elbow Surgeons score were 96, 20, and 84, respectively, and without significant intergroup differences. According to the Mayo Elbow Performance Index, there were 20 excellent, 3 good, and 1 fair result. Twenty patients were very satisfied or satisfied with the outcome. A significant increase in the functional scores was observed in group II compared with preoperative results. Radiological evaluation showed 1 patient with progressive radiolucency and 1 with a nonprogressive radiolucency at the final follow-up. No mechanical failures were observed. Two transient ulnar neuropathies, 1 wound infection, and 1 epicondyle fracture were observed. CONCLUSIONS The DES yielded promising 2- to 5-year results in the treatment of acute fractures and posttraumatic conditions regarding pain relief, functional improvement, and patient satisfaction, achieving excellent results in most cases. The DES may represent an effective linked-implant option for total elbow replacement in such patients. However, long-term studies are needed. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Giuseppe Giannicola
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - Marco Scacchi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - David Polimanti
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Gianluca Cinotti
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, Rome, Italy
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172
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Leigey DF, Farrell DJ, Siska PA, Tarkin IS. Bicolumnar 90-90 plating of low-energy distal humeral fractures in the elderly patient. Geriatr Orthop Surg Rehabil 2014; 5:122-6. [PMID: 25360342 PMCID: PMC4212421 DOI: 10.1177/2151458514526882] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Fragility fractures of the distal humerus in elderly patients, especially the low transcondylar fracture pattern, can be difficult to optimally manage. Although the fractures are typically low energy resulting in either extra-articular or simple intra-articular patterns, gaining fixation into the distal fragments can be difficult with open reduction internal fixation (ORIF) using traditional 90-90 or parallel plating techniques. Anatomy preserving reconstruction with ORIF is preferred over total elbow arthroplasty (TEA) if possible. In this study, 15 patients were managed with a bicolumnar 90-90 plating construct as a novel method of enhancing distal fixation in these fractures. Fourteen patients went on to radiographic union at an average of 77 days after surgery with an average arc of motion of 105°. One patient was lost to follow-up. Bicolumnar 90-90 plating of distal humerus fractures in elderly patients may represent a viable alternative to traditional ORIF or TEA.
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Affiliation(s)
- Daniel F. Leigey
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana J. Farrell
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter A. Siska
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ivan S. Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for the Treatment of Geriatric Distal Humerus Fractures: A Systematic Review and Meta-Analysis. J Orthop Trauma 2014; 28:481-8. [PMID: 24375273 DOI: 10.1097/bot.0000000000000050] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this systematic review and meta-analysis was to pool and analyze outcomes and complication rates in elderly patients with intraarticular distal humerus fractures being treated with either total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) with locking plates. DATA SOURCES PubMed, Embase, and the Cochrane databases were used. The search included publications up to June 2013. Article selection was independently performed by 2 authors and disagreements were resolved by consensus. STUDY SELECTION Studies meeting criteria for inclusion were observational cohort studies or randomized controlled trials evaluating functional and radiographic outcomes and complications in elderly patients treated for distal humerus fractures with either primary TEA or ORIF with locking plates. Studies with mean age <60 years, indications for TEA other than acute fracture, and those including nonlocked plates were excluded. DATA EXTRACTION Standardized data extraction was performed. A quality assessment tool was used to evaluate individual study methodology. DATA SYNTHESIS Descriptive statistics for functional outcomes were reported. Meta-analysis and regression analysis were performed for complication rates. CONCLUSIONS A systematic review and meta-analysis revealed that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion. Although there was a trend toward a higher rate of major complications and reoperation after ORIF, this was not statistically significant. The quality of study methodology was generally weak. Ongoing research including prospective trials and cost analysis is indicated to better define the roles of ORIF versus TEA in the management of these injuries.
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174
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Sørensen BW, Brorson S, Olsen BS. Primary total elbow arthroplasty in complex fractures of the distal humerus. World J Orthop 2014; 5:368-372. [PMID: 25035841 PMCID: PMC4095031 DOI: 10.5312/wjo.v5.i3.368] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus.
METHODS: A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo.
RESULTS: Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt.
CONCLUSION: Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.
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175
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Zhang C, Zhong B, Luo CF. Comparing approaches to expose type C fractures of the distal humerus for ORIF in elderly patients: six years clinical experience with both the triceps-sparing approach and olecranon osteotomy. Arch Orthop Trauma Surg 2014; 134:803-11. [PMID: 24777538 DOI: 10.1007/s00402-014-1983-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although open reduction and internal fixation (ORIF) is a standard fracture treatment method, the optimal way to expose a fracture prior to ORIF is debated. We compared the effects of two exposure methods, the triceps-sparing approach and olecranon osteotomy, on the functional outcomes of ORIF-treated type C distal humerus fractures in elderly people. METHODS From January 2006 to January 2011, 75 elderly patients with type C distal humerus fractures were treated with ORIF, and we retrospectively reviewed their medical records, radiographs, and follow-up charts to identify any complications. Patients' Mayo Elbow Performance Score (MEPS) and range of motion were determined at their final clinic visit. RESULTS Sixty-seven patients (89 %) attended the final visit. Of these patients, 36 received olecranon osteotomy and 31 received the triceps-sparing approach. For patients with type C1 and C2 fractures, we observed reductions in procedure times, blood loss, complication rates, and MEPS outcomes (all P < 0.01) with the triceps-sparing approach compared with olecranon osteotomy. Except for MEPS outcomes, all of these approach-related improvements were also statistically significantly for type C3 fractures (all P < 0.01). Overall, we did not observe any cases of fracture nonunion, implantation breakage or loosening, or elbow stiffening in our series. CONCLUSIONS In our study, we found better functional outcomes for type C1 and C2 distal humerus fractures that were exposed using the triceps-sparing approach rather than olecranon osteotomy. Even for the most complex type of fracture, C3 fractures, similar recoveries in elbow function were achieved using either approach. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Chi Zhang
- Orthopaedic Department, Shanghai Jiaotong University Affiliated No 6th People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China
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Lapner M, Willing R, Johnson JA, King GJW. The effect of distal humeral hemiarthroplasty on articular contact of the elbow. Clin Biomech (Bristol, Avon) 2014; 29:537-44. [PMID: 24780463 DOI: 10.1016/j.clinbiomech.2014.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 03/25/2014] [Accepted: 03/25/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hemiarthroplasty is a treatment option for selected distal humerus fractures. The purpose of this study was to determine the effect of distal humeral hemiarthroplasty and implant size on elbow articular contact. We hypothesized that implants of varying sizes produce different contact patterns compared with the native elbow. METHODS Eight cadaveric arms were tested in an elbow simulator and the kinematics recorded. Three-dimensional reconstructions of bones and cartilage were generated from computed-tomography images to determine contact patterns. The native articulation was compared to optimal, oversized, and undersized implants (Latitude Anatomic Hemiarthroplasty). Changes in contact patterns relative to the native articulation were measured using total contact area and contact patch agreement scores, defined as the sum of distance between contact patches×area, indicating how well contact patches agree with the native contact pattern. FINDINGS The native articulation had significantly lower ulnohumeral contact patch agreement scores compared to all tested implants (P<0.05). Mean ulnohumeral and radiocapitellar contact area decreased an average 44% (P=0.03) and 4% (P=0.07) following placement of an optimally sized implant. There was no effect of implant size on contact area or contact patch agreement score (P>0.05). INTERPRETATION Shape differences of elbow implants relative to the native joint may be responsible for altered contact patterns and could be improved with design modifications. These changes may predispose the elbow to arthritis. The lack of influence of implant size suggests that implant shape and materials may be more important than implant sizing during surgery.
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Affiliation(s)
- Michael Lapner
- Division of Orthopedic Surgery, Sturgeon Hospital, University of Alberta, 201 Boudreau Rd, St. Albert, Alberta T8N 6C4, Canada
| | - Ryan Willing
- Mechanical Engineering Department, Thomas J. Watson School of Engineering & Applied Science, Binghamton University - SUNY, P.O. Box 6000, Binghamton, NY 13902-6000, USA
| | - James A Johnson
- Biomedical Engineering, Department of Surgery, Roth
- McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St. Joseph's Health Centre, 268 Grosvenor St., London, Ontario N6A 4L6, Canada; Department of Mechanical and Materials Engineering, Western University, Roth
- McFarlane Hand and Upper Limb Centre Bioengineering Laboratory, St. Joseph's Health Centre, 268 Grosvenor St., London, Ontario N6A 4L6, Canada
| | - Graham J W King
- Western University, Roth
- McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, 268 Grosvenor St., Room D0-202, London, Ontario N6A 4L6, Canada.
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Flinkkilä T, Toimela J, Sirniö K, Leppilahti J. Results of parallel plate fixation of comminuted intra-articular distal humeral fractures. J Shoulder Elbow Surg 2014; 23:701-7. [PMID: 24745319 DOI: 10.1016/j.jse.2014.01.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/29/2013] [Accepted: 01/12/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study investigated the results of parallel plate fixation of comminuted distal humeral fractures in a consecutive series of patients. METHODS Parallel plate fixation was used in 47 patients (30 women), mean age 60 years (range 18-98 years), with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C distal humeral fractures during 2007 to 2011. Medical records and radiographs were retrospectively assessed. Thirty-five patients completed Disabilities of Arm, Shoulder and Hand (DASH) outcome measure and the RAND Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey. Twenty-seven patients underwent clinical examination, Mayo Elbow Performance Score (MEPS) rating, and radiography after 3.9 years (range, 1.6-7.9 years) of follow-up. RESULTS The mean flexion arc was lower on the affected side vs the unaffected elbow (123° vs 140°, P = .03). The mean MEPS was 88; the result was excellent in 14, good in 8, fair in 3, and poor in 2 patients. DASH results indicated slight impairment of upper extremity function compared with the reference value (26 vs 10, P = .001). RAND SF-36 scores indicated normal quality of life compared with reference values from the Finnish population. Forty-four fractures united uneventfully. One case each of nonunion and malunion occurred. One olecranon osteotomy failed to unite. There were 3 cases of infection. Prominent hardware was a common late problem, and plates often required removal. The complication rate was 7 of 47 (15%); 4 of these patients (9%) required reoperation. The hardware removal rate was 13 of 47 (28%). CONCLUSION Parallel plate fixation is an effective method to treat comminuted distal humeral fractures. Good elbow function can be restored in most cases with minor impairments that do not worsen quality of life.
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Affiliation(s)
- Tapio Flinkkilä
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland.
| | - Juhana Toimela
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Kai Sirniö
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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A prospective multicenter clinical study of the Discovery elbow. J Shoulder Elbow Surg 2014; 23:e95-e107. [PMID: 24745320 DOI: 10.1016/j.jse.2013.12.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/20/2013] [Accepted: 12/25/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Semiconstrained total elbow arthroplasty is used to improve elbow function and reduce pain. Although effective, high complication rates exist, with the polyethylene bushing especially susceptible to failure. The Discovery Elbow System (Biomet Inc, Warsaw, IN, USA) contains a spherical bearing designed to minimize polyethylene wear. This prospective, multicenter clinical study investigated the 4-year (mean) outcomes of this elbow. METHODS From 2002 to 2009, 92 patients (71 women, 21 men; mean age, 63.9 years; range, 33.4-88.7 years) received 99 Discovery elbows at 4 centers. The study cohort was limited to 46 elbows with complete preoperative and minimum 2-year clinical (modified American Shoulder and Elbow Surgeons elbow score) and radiographic follow-up. RESULTS Mean follow-up was 4.1 years (range, 2-5.9 years). All American Shoulder and Elbow Surgeons elbow score components improved significantly (P < .001). Mean flexion-extension arcs increased from 81° to 121° and pronation-supination arcs from 134° to 163° (P < .001). Loose locking screws in 2 elbows (first-generation screws), a loose polyethylene bearing in 1 (history of falls), and a condyle/bearing in 1 (deep infection) were exchanged. Among the 46 elbows, gross survivorship was humeral/ulnar components, 100%; condyles, 97.8%; bearings, 95.7%; and screws, 95.7%. One humeral component (2.2%) was radiographically loose but not revised. An additional elbow (elbow 47) that did not meet the criteria for inclusion (<2 years of follow-up) was revised due to a loose humeral component and was reported separately. CONCLUSION The Discovery elbow increased function and decreased pain with high survivorship at a mean of 4.1 years.
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179
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Simone JP, Streubel PN, Sanchez-Sotelo J, Morrey BF. Low transcondylar fractures of the distal humerus: results of open reduction and internal fixation. J Shoulder Elbow Surg 2014; 23:573-8. [PMID: 24630549 DOI: 10.1016/j.jse.2013.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/25/2013] [Accepted: 12/03/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study presents the outcomes of low transcondylar fractures of the distal humerus treated by open reduction and internal fixation. METHODS Between 1996 and 2010, 263 distal humeral fractures were managed at our institution. Patients with a true low transcondylar fracture treated by open reduction and internal fixation were included. Fourteen patients form the basis of this study. Fracture fixation was achieved through a triceps-sparing approach, a triceps tongue, or an olecranon osteotomy. Internal fixation was performed with parallel plates, orthogonal plates, a single lateral plate, or a single medial plate. The clinical outcome was measured with pain levels, range of motion, and the Mayo Elbow Performance Score. Radiographs at latest follow-up were assessed for union, delayed union, nonunion, and hardware failure. RESULTS At most recent follow-up, 11 patients had no pain, 2 had mild pain, and 1 had moderate pain. The mean Mayo Elbow Performance Score was 85. The mean arch of motion was 95°. Complications included nonunion, delayed union, wound complications, deep infection, and heterotopic ossification. DISCUSSION Stable internal fixation of low transcondylar fractures is perceived as difficult to achieve because of the very small size of the distal fragment. However, the results of our study indicate that internal fixation of low transcondylar fractures of the distal humerus is associated with a high union rate and satisfactory clinical results. Elbow arthroplasty does not need to be considered for most patients with a low transcondylar distal humeral fracture.
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Affiliation(s)
- Juan P Simone
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Bernard F Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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180
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Gerich TG. [Intra-articular fractures of the distal humerus : aspects of fracture treatment in geriatric patients]. DER ORTHOPADE 2014; 43:347-52. [PMID: 24671347 DOI: 10.1007/s00132-013-2162-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In the context of osteoporotic fractures, injuries to the distal humerus are quite uncommon, meaning that each surgeon will have only limited experience. OBJECTIVE This leads automatically to the question to what extent treatment recommendations can be transferred to the geriatric population. METHODS Looking at the evidence-based literature, recommendations could be limited to three prospective studies. However, this only means that the remaining literature sources do not provide sufficient statistical power to be able to draw conclusions. RESULTS AND DISCUSSION For the population of geriatric patients a thorough compilation of the contemporary literature is advisable. This review article on the currently available literature evaluates and individually discusses the relevant aspects of fracture treatment in order to develop recommendations for routine daily practice.
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Affiliation(s)
- T G Gerich
- Traumatologie, Centre Hospitalier de Luxembourg, 4, rue Barblé, 1410, Luxembourg, Luxembourg,
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181
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Barthel PY, Mansat P, Sirveaux F, Dap F, Molé D, Dautel G. Is total elbow arthroplasty indicated in the treatment of traumatic sequelae? 19 cases of Coonrad-Morrey(®) reviewed at a mean follow-up of 5.2 years. Orthop Traumatol Surg Res 2014; 100:113-8. [PMID: 24370486 DOI: 10.1016/j.otsr.2013.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 06/20/2013] [Accepted: 10/04/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic sequelae of the elbow are difficult to manage because of bone deformities, changes in joint congruency and bone defects. MATERIALS AND METHODS Total elbow arthroplasty is a therapeutic option when the joint space has disappeared. Nineteen patients underwent semi-constrained Coonrad-Morrey(®) total elbow arthroplasty in 12 cases for post-traumatic elbow arthritis (group 1) and in seven cases for 7 non-union of the distal humerus (group 2). The mean age at surgery was 60 years old (56 in group 1 and 67 in group 2). The mean delay between the initial trauma and arthroplasty was 16 years (group 1) and 22 months (group 2). RESULTS At a mean follow-up of 5.5 years (24-156 months) in group 1, the Quick-DASH score was 34 points with outcomes that were considered to be good to excellent in 75% of the cases according to the Mayo Elbow Performance Score (MEPS). A progressive radiolucency was identified on X-ray in 33% of the cases, and moderate wear of the polyethylene insert in 17%. There were 7 complications (58%) requiring revision in 3 cases (25%). At a mean follow-up of 4.6 years (24-108 months) in group 2, the Quick-DASH score was 39 points with good and excellent results in 86% according to the MEPS. A radiolucency was noted in 28% and moderate wear of the inserts in 14%. There were 2 complications (28%) requiring revision in 1 case (14%). CONCLUSION Semi-constrained total elbow arthroplasties provide recovery of functional range of motion with a stable and pain-free elbow for post-traumatic conditions. The age at surgery is a risk factor for complications. The indication for total elbow arthroplasty in patients under 60 should be carefully considered in relation to alternative treatment options. LEVEL OF EVIDENCE Level IV Retrospective study.
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Affiliation(s)
- P Y Barthel
- Service de chirurgie plastique et reconstructrice de l'appareil locomoteur, Centre chirurgical Emile-Gallé, CHU de Nancy, 54000 Nancy, France.
| | - P Mansat
- Service de Chirurgie orthopédique et traumatologique, CHU Purpan, 31000 Toulouse, France
| | - F Sirveaux
- Service de chirurgie orthopédique et traumatologique, Centre chirurgical Emile-Gallé, 54000 Nancy, France
| | - F Dap
- Service de chirurgie plastique et reconstructrice de l'appareil locomoteur, Centre chirurgical Emile-Gallé, CHU de Nancy, 54000 Nancy, France
| | - D Molé
- Service de chirurgie orthopédique et traumatologique, Centre chirurgical Emile-Gallé, 54000 Nancy, France
| | - G Dautel
- Service de chirurgie plastique et reconstructrice de l'appareil locomoteur, Centre chirurgical Emile-Gallé, CHU de Nancy, 54000 Nancy, France
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182
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Bégué T. Articular fractures of the distal humerus. Orthop Traumatol Surg Res 2014; 100:S55-63. [PMID: 24461911 DOI: 10.1016/j.otsr.2013.11.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 06/13/2013] [Accepted: 11/08/2013] [Indexed: 02/02/2023]
Abstract
Distal humeral fractures represent 2% of all adult elbow fractures. Injury mechanisms include high-energy trauma with skin involvement, and low energy trauma in osteoporotic bone. Treatment goals are anatomical restoration in young, high-demand patients and quick recovery of activities of daily living in the elderly. Complete fractures are relatively easy to diagnose, but partial intra-articular fractures are not. The clinical diagnosis must take into account potential complications such as open injuries and ulnar nerve trauma. Standard X-rays with additional distraction series in the operating room are sufficient in complete articular fracture cases. Partial intra-articular fractures will need CT scan and 3D reconstruction to fully evaluate the involved fragments. SOFCOT, AO/OTA and Dubberley classifications are the most useful for describing fractures and selecting treatment. Surgery is the optimal treatment and planning is based on fracture type. Complete fractures are treated using a posterior approach. Triceps management is a function of fracture lines and type of fixation planned. Constructs using two plates at 90° or 180° are the most stable, with additional frontal screw for intercondylar fractures. Elbow arthroplasty may be indicated in selected patients, having severely communited distal humerus fractures and osteoporotic bone. Open fractures make fixation and wound management more challenging and unfortunately have poorer outcomes. Other complications are elbow stiffness, non-union, malunion and heterotopic ossification.
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Affiliation(s)
- T Bégué
- Service de chirurgie orthopédique et traumatologique, université Paris-Sud, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France.
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Abstract
INTRODUCTION Multifocal humeral fractures are extremely rare. These may affect the neck and the shaft, the shaft alone, or the diaphysis and the distal humerus. There is no classification of these fractures in the literature. MATERIALS AND METHODS From 2004 to 2010, 717 patients with humeral fracture were treated surgically at our department. Thirty-five patients presented with an associated fracture of the proximal and diaphyseal humerus: synthesis was performed with plate and screws in 34 patients, and the remaining patient had an open fracture that was treated with an external fixator. RESULTS Mean follow-up was 3 years and 3 months. A classification is proposed in which type A fractures are those affecting the proximal and the humeral shaft, type B the diaphysis alone, and type C the diaphysis in association with the distal humerus. Type A fractures are then divided into three subgroups: A-I, undisplaced fracture of the proximal humerus and displaced shaft fracture; A-II: displaced fracture of the proximal and humeral shaft; and A-III: multifragmentary fracture affecting the proximal humerus and extending to the diaphysis. DISCUSSION Multifocal humeral fractures are very rare and little described in the literature, both for classification and treatment. The AO classification describes bifocal fracture of the humeral diaphysis, type B and C. The classification suggested in this article mainly concerns fractures involving the proximal and humeral shaft. CONCLUSIONS A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment.
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184
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Abstract
Traumatic lesions at the elbow involving great loss of substance are uncommon, but represent a significant problem when such cases are referred to a trauma department. Most of these injuries may cause severe final functional impairment, thereby jeopardising future activities, particularly in cases where treatment was delayed or inappropriate. The timing and method of treatment are critical. The trauma may involve soft tissues only, or bone and joint, or several structures at the same time, which results in combined complex tissue defects. Each type of tissue loss should be managed by choosing the most suitable technique from the armamentarium of reconstructive surgery, taking into account different priorities and the optimum timing (immediate or delayed, one- or two-stages). The authors describe a spectrum of indications and techniques that can be useful tools in managing these injuries.
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185
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Abstract
The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.
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186
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Serrano-Mateo L, Lopiz Y, León-Serrano C, García-Fernández C, López-Durán-Stern L, Marco F. Results after internal fixation of humerus distal fractures in patients aged over 65 years. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014. [DOI: 10.1016/j.recote.2014.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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187
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Plastaras CT, Chhatre A, Kotcharian AS. Perioperative upper extremity peripheral nerve traction injuries. Orthop Clin North Am 2014; 45:47-53. [PMID: 24267206 DOI: 10.1016/j.ocl.2013.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Peripheral nerve traction injuries may occur after surgical care and can involve any of the upper extremity large peripheral nerves. In this review, injuries after shoulder or elbow surgical intervention are discussed. Understanding the varying mechanisms of injury as well as classification is imperative for preoperative risk stratification as well as management.
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Affiliation(s)
- Christopher T Plastaras
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, 1800 Lombard Street, Philadelphia, PA 19146, USA.
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188
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Puskas GJ, Morrey BF, Sanchez-Sotelo J. Aseptic loosening rate of the humeral stem in the Coonrad-Morrey total elbow arthroplasty. Does size matter? J Shoulder Elbow Surg 2014; 23:76-81. [PMID: 24331123 DOI: 10.1016/j.jse.2013.08.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 08/21/2013] [Accepted: 08/29/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Aseptic implant loosening is one of the most common complications leading to revision surgery in total elbow arthroplasty. Different humeral stem lengths are available with varying designs. In general, the decision of which stem length to use depends on the surgical diagnosis or simply the surgeon preference. Often, the longer stem is used for post-traumatic or revision cases while for rheumatoid patients the shorter stem is preferred. There are no data in the literature to favor one humeral stem size over the other according to the diagnosis. METHODS We analyzed the total elbow joint database of the Coonrad-Morrey design at our institution for aseptic loosening leading to revision and compared the revision rate and the survival of the 4- and 6-inch humeral stems. RESULTS Overall, revision for aseptic humeral loosening is infrequent and occurred in only 16 of 711 total elbow arthroplasties during a mean follow-up of 88 months. There was no significant difference in the revision rate between the 2 stem lengths (1.9% for the 4-inch stems and 2.6% for the 6-inch stem). CONCLUSION Revision rate was correlated to the surgical diagnosis and was significantly higher for post-traumatic patients than for rheumatoid patients (5.1% vs 0.66%, P < .001). Of interest, and possibly not surprising, the mean time to revision was shorter for the 4-inch stems than it was for the 6-inch stems (37 vs 95 months, P = .034).
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Affiliation(s)
| | - Bernard F Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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189
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Ditsios K, Boutsiadis A, Agathangelidis F, Tyllianakis M, Christodoulou A. Elbow Hemiarthroplasty for Late Reconstruction of a Traumatic Elbow Bone Defect in a Young Patient: A Case Report. JBJS Case Connect 2013; 3:e129. [PMID: 29252285 DOI: 10.2106/jbjs.cc.m.00137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Konstantinos Ditsios
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
| | - Achilleas Boutsiadis
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
| | - Filon Agathangelidis
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
| | - Minos Tyllianakis
- Department of Orthopaedic Surgery, Medical School, University of Patras, Rion 26504, Greece.
| | - Anastasios Christodoulou
- First Orthopaedic Department of Aristotelian University of Thessaloniki, "G. Papanikolaou" General Hospital, 57010, Exohi, Thessaloniki, Greece. . . .
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Obert L, Ferrier M, Jacquot A, Mansat P, Sirveaux F, Clavert P, Charissoux JL, Pidhorz L, Fabre T. Distal humerus fractures in patients over 65: complications. Orthop Traumatol Surg Res 2013; 99:909-13. [PMID: 24183745 DOI: 10.1016/j.otsr.2013.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fractures of the distal humerus in patients over the age of 65 remain a therapeutic challenge. Treatment options include conservative treatment, internal fixation or total elbow arthroplasty. The complications of these different treatment options were evaluated in a multicentre study. MATERIALS AND METHODS Four hundred and ninety-seven medical records were evaluated. A retrospective study was performed in 410 cases: 34 received conservative treatment, 289 internal fixation and 87 underwent total elbow arthroplasty. A prospective study was performed in 87 cases: 22 received conservative treatment, 53 internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated after at least 6 months follow-up. RESULTS The rate of complications was 30% in the retrospective study and 29% in the prospective study. The rate of complications in the conservative treatment group was 60%, and the main complication was essentially malunion. The rate of complications was 44% in the internal fixation group and included neuropathies, mechanical failure or wound dehiscence. Although complications only developed in 23% of total elbow arthroplasties, they were often more severe than those following other treatments. DISCUSSION Complications develop in one out of three patients over 65 with distal humerus fractures. Three main types of complications were identified. Neuropathies especially of the ulnar nerve, especially during arthroplasty, must always be identified, the nerve requiring isolation and transposition. Bone complications, due principally to mechanical failure, were found following internal fixation. Despite technical progress, care must be taken not to favor excessive utilization of this treatment option in complex fractures on fragile bone. Although there were relatively fewer complications with total elbow arthroplasty they were more difficult to treat. Ossifications were frequent whatever the surgical option and can jeopardize the functional outcome.
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Affiliation(s)
- L Obert
- Chirurgie orthopédique, traumatologique et plastique, centre hospitalier de Besançon, 2, boulevard Fleming, 25030 Besançon, France.
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191
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Smith GCS, Hughes JS. Unreconstructable acute distal humeral fractures and their sequelae treated with distal humeral hemiarthroplasty: a two-year to eleven-year follow-up. J Shoulder Elbow Surg 2013; 22:1710-23. [PMID: 24054974 DOI: 10.1016/j.jse.2013.06.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/01/2013] [Accepted: 06/09/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to describe for the first time the medium to long-term outcome after distal humeral hemiarthroplasty (DHH). METHODS Twenty-six patients (mean age, 62; range, 29-92 years) treated with DHH for intra-articular distal humeral fractures and its sequelae were studied retrospectively. RESULTS Four patients had died and 4 had been revised to total elbow arthroplasty: 2 for periprosthetic fractures and 2 for primary component loosening (all in prostheses without an anterior flange). Six other complications had occurred: ulnar neuritis, 4; stiffness, 1; and wound necrosis, 1. Seventeen patients underwent assessment at a mean of 80 months after surgery. The mean values of the American Shoulder and Elbow Surgeons (ASES) elbow score (pain, 9.93; function, 25; satisfaction, 9.06); Mayo Elbow Performance Score (90); Quick Disabilities of Arm, Shoulder and Hand (19), and EuroQol EQ5D (Index, 0.84; Visual Analog Scale, 80) outcome measures demonstrated good function and satisfaction with little pain. The mean flexion extension arc was 116°. There was no evidence of instability. Radiologic evidence of ulnar wear was seen in 13 patients and may be related to prosthetic design to some extent. Worse wear was associated with a higher ASES pain score, lower satisfaction score, and lower EuroQoL Visual Analog Scale of quality of life. Degree of wear correlates with time after surgery but not with age at the time of surgery. CONCLUSION DHH offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome. LEVEL OF EVIDENCE Level IV, case series, treatment study.
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Affiliation(s)
- Geoffrey C S Smith
- Sydney Orthopaedic Arthritis and Sports Medicine, Sydney, NSW, Australia.
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192
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Does timing of surgery affect the outcome of open articular distal humerus fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:777-82. [DOI: 10.1007/s00590-013-1358-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
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193
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Serrano-Mateo L, Lopiz Y, León-Serrano C, García-Fernández C, López-Durán-Stern L, Marco F. [Results after internal fixation of humerus distal fractures in patients over than 65 years old]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 58:31-7. [PMID: 24210637 DOI: 10.1016/j.recot.2013.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 06/12/2013] [Accepted: 09/12/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Distal humerus fractures in the elderly frequently associated with poor bone quality and comminution, making it harder to achieve proper osteosynthesis. Our aim is to evaluate the radiological and functional results of open reduction and internal fixation of these fractures. MATERIAL AND METHODS Retrospective study of 26 patients treated by open reduction and internal fixation between the years 2005-2010. Mean follow-up was 42 months. At final follow-up, a radiography evaluation (Knirk and Jupiter score) and clinical examination using Mayo Elbow Performance Score and Quick-Disabilities of the Arm, Shoulder and Hand Score was performed. Mean age of the group was 76.8 years (65-89), with 83% of the patients being female. Sixteen patients suffered type C fractures and 8 type A by AO classification. All underwent posterior surgical approach. RESULTS Mean elbow flexion reached 118.86°, with a mean extension deficit of 25°. More than 3-quarters (79.1%) of the patients showed 0-1 grade degenerative changes on the X-ray films at final follow-up. Functional results reached an average 19.87 points on Quick-Disabilities of the Arm, Shoulder and Hand Score, and 85 points on Mayo Elbow Performance Score scores. Non-union occurred in 2 cases: distal humerus in one patient and olecranon osteotomy in another. Ulnar nerve neuropraxia was recorded in 2 cases, and radial nerve in one. All 3 recovered uneventfully. Revision surgery was required, with 2 patients needing hardware removal and one a new fixation. DISCUSSION Treatment by open reduction and internal fixation with plating in elderly people for type A and C distal humerus fractures gives good functional results regarding this population, and thus scarcely disturbs their quality of life.
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Affiliation(s)
- L Serrano-Mateo
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid. España.
| | - Y Lopiz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid. España
| | - C León-Serrano
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid. España
| | - C García-Fernández
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid. España
| | - L López-Durán-Stern
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid. España
| | - F Marco
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid. España
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194
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Clavert P, Ducrot G, Sirveaux F, Fabre T, Mansat P. Outcomes of distal humerus fractures in patients above 65 years of age treated by plate fixation. Orthop Traumatol Surg Res 2013; 99:771-7. [PMID: 24119369 DOI: 10.1016/j.otsr.2013.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Distal humerus fractures in elderly patients are often complex fractures that are difficult to treat. The goal of this study was to report on the results of a multicentre series of internal fixation of AO type A, B and C distal humerus fractures in elderly patients and to identify the pros and cons of various fixation constructs. PATIENTS AND METHODS Two studies were performed. One was a prospective multicentre study with 53 patients and the other was a retrospective multicentre study with 289 patients, all above 65 years of age and with a recent distal humerus fracture. Patients were evaluated based on clinical criteria (history, health condition, joint range of motion, Mayo Elbow Performance Score) and radiological criteria (fracture type, union of fracture, presence of malunion, hardware condition). RESULTS Based on the MEPS, the clinical and functional results were relatively satisfactory: average of 92 points for type A, 82 points for type B and 88 points for type C. In both series, type B fractures were the most difficult to treat and had less good clinical, functional and radiological outcomes. Most of the complications occurred with type C fractures; these consisted mainly of nerve injuries and fixation failure/non-union. DISCUSSION Although these fractures are difficult to treat and have an appreciable number of complications, the functional recovery was fairly satisfactory. One of the most challenging aspects of surgical treatment is the existence of osteoporosis in these patients. This must be carefully analysed to determine if an indication exists for total elbow arthroplasty. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- P Clavert
- Service d'orthopédie-traumatologie, CHU de Strasbourg, avenue Baumann, 67400 Illkirch, France.
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195
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Mansat P, Nouaille Degorce H, Bonnevialle N, Demezon H, Fabre T. Total elbow arthroplasty for acute distal humeral fractures in patients over 65 years old - results of a multicenter study in 87 patients. Orthop Traumatol Surg Res 2013; 99:779-84. [PMID: 24095596 DOI: 10.1016/j.otsr.2013.08.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fractures of the distal humerus represent 5% of osteoporosis fragility fractures in subjects over the age of 60. Osteoporosis, comorbidities and intra-articular comminution make management of this entity difficult. HYPOTHESIS The hypothesis was that total elbow arthroplasty could be a reliable treatment option in subjects over the age of 65 presenting with a fracture of the distal humerus. MATERIALS AND METHODS Eight-seven patients (80 women and 7 men) mean age 79 years old (65-93) underwent total elbow arthroplasty for the treatment of an AO type A fracture in 9 cases, type B in 8 and type C in 70. RESULTS After a mean follow-up of 37.5 months (6-106) the Mayo Elbow Performance Score MEPS was 86±14, the quick-DASH score was 24±19 and the Katz score was 5±1.5 points. The MEPS was better in patients with a high preoperative Katz score and a history of inflammatory arthritis who were living at home. Fifty-five patients (63%) presented with a pain-free elbow, and 20 (24%) with slight pain. The flexion-extension range of motion was 97±22° and 48% presented with a flexion-extension arc of at least 100°. Function was normal in 69 patients. Complications were identified in 20 cases (23%) and revision surgery was necessary in 8 (9%). Two arthroplasties had to be changed, one for a fracture of the humeral stem component and the other for loosening. Only one infection occurred in this series. CONCLUSION Total elbow arthroplasties provide fractured patients with immediate satisfactory results and a stable, painless and functional elbow. These results seem to be reliable and durable. The rate of complications is low with revision surgery in approximately 10%. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- P Mansat
- Service d'orthopédie-traumatologie, institut de l'appareil locomoteur, CHU Purpan, place du Dr-Baylac, 31059 Toulouse, France.
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196
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Schmidt-Horlohé KH, Bonk A, Wilde P, Becker L, Hoffmann R. Promising results after the treatment of simple and complex distal humerus type C fractures by angular-stable double-plate osteosynthesis. Orthop Traumatol Surg Res 2013; 99:531-41. [PMID: 23755958 DOI: 10.1016/j.otsr.2013.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Revised: 01/22/2013] [Accepted: 02/18/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the functional results and complications following open reduction and internal fixation of distal humerus type C fractures (AO classification) using an anatomically precontoured, angular-stable double-plate system. PATIENTS AND METHODS The study is a retrospective analysis of 45 patients with 46 type C fractures. There was one C1, eight C2 and 31 C3 fractures. Twelve fractures were open (Gustilo classification). Follow-up was performed on 38 patients with 39 fractures (84%) after 14 months (range, 12-22). The mean age was 50 years (range, 14-87). Functional results were evaluated using the Mayo Elbow Performance Score (MEPS); the Disabilities of the Arm, Shoulder and Hand score (DASH); and range-of motion (ROM) measurements. Complications were classified as minor or major, and the postoperative and follow-up X-rays were analyzed. RESULTS Thirty-four fractures were considered stable to allow early physical therapy. With a mean MEPS of 85 points, 36 results (36/39 [92%]) were rated as excellent or good. The mean DASH was 22.5 points, and the ROM for extension-flexion was 105° (range, 50-145). Sixteen major complications (eventually coexistent: 6 × implant failure, 3 × non-union, 6 × stiffness, 2 × necrosis capitulum, 4 × failure olecranon osteotomy refixation) and two minor complications were recorded in 17 patients. These adverse events led to 14 revision surgeries (14/39 [36%]). Except for extension deficit, no statistically significant differences were found between the articular simple and articular complex fractures and when comparing the results between patients with and without a major complication. CONCLUSION The anatomically precontoured and angular-stable double-plate system provides sufficient immediate postoperative stability to allow early physiotherapy, even in C3-type fractures. Excellent or good results could be achieved in the vast majority of patients, independent on having suffered a complication or not. Complication rates were remarkably high, emphasizing the difficulties associated with this rare type of fracture. LEVEL OF EVIDENCE Level IV Retrospective study.
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Affiliation(s)
- K H Schmidt-Horlohé
- Department for Trauma Surgery and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt, Friedberger Landstrasse 430, 60389 Frankfurt, Germany.
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197
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Müller LP, Wegmann K, Burkhart KJ. [Fracture endoprosthesis of distal humerus fractures]. Unfallchirurg 2013; 116:708-15. [PMID: 23934533 DOI: 10.1007/s00113-013-2411-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The treatment of choice for fractures of the distal humerus is double plate osteosynthesis. Due to anatomical preshaped angle stable plates the primary stability and management of soft tissues has been improved. However, osteoporotic comminuted fractures in the elderly are often not amenable to stable osteosynthesis and total elbow arthroplasty has been established as an alternative therapy. Although complication rates have been reduced, complications of total elbow arthroplasty are still much more frequent than in total hip replacement. Furthermore, patients are advised not to exceed a weight bearing of 5 kg. Therefore, the indications for elbow arthroplasty must be evaluated very strictly and should be reserved for comminuted distal humeral fractures in the elderly with poor bone quality that are not amenable to stable osteosynthesis or for simple fractures in cases of preexisting symptomatic osteoarthritis. This article introduces and discusses modern concepts of elbow arthroplasty, such as modular convertible prosthesis systems, hemiarthroplasty and radial head replacement in total elbow arthroplasty.
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Affiliation(s)
- L P Müller
- Unfall-, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Kerpener Straße 62, Köln, Germany.
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Riedel K, Beaton DE. Update on the state of outcome measurement in total elbow arthroplasty research: identifying a need for consensus. J Bone Joint Surg Am 2013; 95:e97 1-8. [PMID: 23864188 DOI: 10.2106/jbjs.k.01420] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is little consensus for a standard set of metrics to express outcome after total elbow arthroplasty. In order to set the stage for future work toward a core set of measurement tools, our goal was to gather a complete view of the outcomes used in total elbow arthroplasty research, the concepts of their focus, and their quality as measures of the target concept. METHODS We reviewed the outcome measures for total elbow arthroplasty presented in the literature from 2004 to 2011 in terms of the instruments used and their concepts of focus. We reviewed the reliability, validity, and responsiveness of the prevailing measurement tools. RESULTS Of the seventy-two articles identified, 90% (sixty-five) used elbow-specific aggregate outcome measures, which combine concepts, such as physiological variables, with symptom status and functional status. The Mayo Elbow Performance Score, or a variation of that scoring system, was used in fifty-four (75%) of the seventy-two articles. Most outcomes pertained to biological and physiological variables, with fewer outcomes focusing on symptoms, function, or overall health status. A review of the measurement properties of the elbow-specific aggregate outcome measures did not reveal one to be superior. CONCLUSIONS Overall, total elbow arthroplasty outcomes are heterogeneous in their reporting and lack standardization. The total elbow arthroplasty literature relies on several physician-derived elbow-specific aggregate measures and focuses primarily on physiological variables. The relative merits of aggregating findings into a single scoring system versus as separate components should be explored further. Finally, consideration should be given to patient-reported outcome measures in total elbow arthroplasty research. CLINICAL RELEVANCE This study of the current "state of practice" for outcome measurement in total elbow arthroplasty revealed gaps in the breadth of measurement and a lack of comparability in elbow scoring systems that could hinder our ability to clearly and fully understand outcome after total elbow arthroplasty. Future consensus work could address both concerns and assist in the development of a core set of outcome measures.
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Affiliation(s)
- Kelly Riedel
- Mobility Clinical Research Unit, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada.
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199
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DeSimone LJ, Sanchez-Sotelo J. Total elbow arthroplasty for distal humerus fractures. Orthop Clin North Am 2013; 44:381-7, ix-x. [PMID: 23827840 DOI: 10.1016/j.ocl.2013.03.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Total elbow arthroplasty has become increasingly popular for the treatment of distal humerus fractures in elderly patients with poor bone quality, comminution, and/or pre-existent elbow abnormalities. The procedure is performed without violating the extensor mechanism; the fractured fragments are exposed and resected on both sides of the triceps, and the components can be implanted through the same exposure. Early outcomes are satisfactory in most elbows and compare favorably with internal fixation in this same group of elderly patients. Advances in elbow arthroplasty for fractures will likely combine refinement of the indications and development of implants with lower rates of failure.
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Affiliation(s)
- Lori J DeSimone
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
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200
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Mora-Navarro N, Sánchez-Sotelo J. [Elbow replacement]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 56:413-20. [PMID: 23594898 DOI: 10.1016/j.recot.2012.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 06/28/2012] [Indexed: 11/16/2022] Open
Abstract
Elbow replacement or arthroplasty is a good therapeutic option for a large percentage of patients with significant joint destruction. However, many orthopaedic surgeons are no familiar with the surgical approaches or techniques associated with elbow replacement implants. Furthermore, the incidence of complications is higher than in other joint replacements, the most important being infections, mechanical failure, cubital neuropathy, and problems with the triceps. For these reasons, the use of bone arthroplasty in Spain may be less than ideal. Although, inflammatory arthritic diseases, such as rheumatoid arthritis, are the most frequent indication for this operation, distal humerus fractures and post-traumatic disease are a growing indication. This work attempts to summarise the most important current concepts associated with elbow replacement.
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Affiliation(s)
- N Mora-Navarro
- Departamento de Cirugía Ortopédica, Clínica Mayo, Rochester, Estados Unidos
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