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

Biomechanical Design Optimization of Distal Humerus Fracture Plates: A Review

The goal of this article was to review studies on distal humerus fracture plates (DHFPs) to understand the biomechanical influence of systematically changing the plate or screw variables. The problem is that DHFPs are commonly used surgically, although complications can still occur, and it is unclear if implant configurations are always optimized using biomechanical criteria. A systematic search of the PubMed database was conducted to identify English-language biomechanical optimization studies of DHFPs that parametrically altered plate and/or screw variables to analyze their influence on engineering performance. Intraarticular and extraarticular fracture (EAF) data were separated and organized under commonly used biomechanical outcome metrics. The results identified 52 eligible DHFP studies, which evaluated various plate and screw variables. The most common plate variables evaluated were geometry, hole type, number, and position. Fewer studies assessed screw variables, with number and angle being the most common. However, no studies examined nonmetallic materials for plates or screws, which may be of interest in future research. Also, articles used various combinations of biomechanical outcome metrics, such as interfragmentary fracture motion, bone, plate, or screw stress, number of loading cycles to failure, and overall stiffness (Os) or failure strength (Fs). However, no study evaluated the bone stress under the plate to examine bone "stress shielding," which may impact bone health clinically. Surgeons treating intraarticular and extraarticular distal humerus fractures should seriously consider two precontoured, long, thick, locked, and parallel plates that are secured by long, thick, and plate-to-plate screws that are located at staggered levels along the proximal parts of the plates, as well as an extra transfracture plate screw. Also, research engineers could improve new studies by perusing recommendations in future work (e.g., studying alternative nonmetallic materials or "stress shielding"), clinical ramifications (e.g., benefits of locked plates), and study quality (e.g., experimental validation of computational studies).

A novel configuration for the fixation of intra-articular C2.3 distal humerus fractures with the potential for minimally invasive surgery: a biomechanical evaluation and finite element analysis

BACKGROUND

Distal humerus fractures are a challenge to treat, and the current standard of care, open reduction internal fixation with a double-plate, has a high rate of complications. We proposed a novel internal fixation configuration, lateral intramedullary nail and medial plate (LINMP) and verified its rigidity through biomechanical tests and finite element analysis.

METHODS

The study involved biomechanical testing of 30 synthetic humerus models to compare 2 different fixation systems for an AO 13C-2.3 type fracture. The orthogonal double-plate (ODP) group and the LINMP group were compared through biomechanical testing to measure stiffness and failure load fewer than 3 working conditions. Based on the results, we optimized the intramedullary nail by eliminating the holes at the distal end of the nail and incorporating a 2-hole external locking plate. The Finite element analysis was also conducted to further compare the modified LINMP configuration with the previous 2 fixation configurations.

RESULTS

In biomechanical tests, the ODP group exhibited lower stiffness under bending and compression forces compared to the LINMP group, but higher stiffness and failure loads under torsion force. In finite element analysis, the modified LINMP reduces the maximum stress of the fixation structure without significantly reducing the stiffness under bending stress and axial compression conditions. In torsion stress conditions, the modified LINMP enhances both the maximum stress and the stiffness, although it remains marginally inferior to the ODP structure.

CONCLUSION

Our study demonstrates that the innovative LINMP presents comparable or slightly superior concerning bending and axial loading compared to orthogonal double-plate osteosynthesis for distal humeral intra-articular fractures, which might become a minimally invasive option for these fractures.

Mid-term results of total elbow arthroplasties in the treatment of geriatric distal humerus fractures

BACKGROUND

While double plate fixation is the gold standard treatment for distal humerus fractures in the general population, it is the source of many complications in the elderly. Total elbow arthroplasty (TEA) has been proposed as an alternative treatment, with satisfactory short-term functional outcomes. However, little is known about the longevity of the implant and the mid- and long-term complications of this procedure.

MATERIALS AND METHODS

A total of 58 TEAs were performed in 57 patients with comminuted distal humerus fractures between September 2008 and September 2019. All patients were clinically (ranges of motion, Mayo Elbow Performance Score [MEPS] and Disabilities of the Arm, Shoulder and Hand [QuickDASH] functional scores) and radiographically assessed. The minimum follow-up was 2years, and the mean follow-up was 4.7years.

RESULTS

The overall complication rate was 20.7%, with ulnar nerve damage, complex regional pain syndrome, and severe stiffness being the main complications. The mean MEPS was 85.3, and the mean QuickDASH was 28.1. The mean flexion was 122°, and the mean extension was -23.5°. There were no prosthetic revisions. Of these patients, 17% had radiolucent lines, and 13% had bushing wear at the last follow-up.

DISCUSSION

TEA is an effective technique for treating comminuted distal humerus fractures in the geriatric population. The prosthesis's mid-term survivorship was highly satisfactory, with a complication rate that remained low and was generally lower than that of osteosynthesis, with identical functional outcomes. TEAs are indicated in elderly patients, for whom maintaining the fullest possible autonomy is paramount. Our findings suggest that TEAs have sufficient longevity to guarantee a functional, pain-free elbow with no need for reoperation.

LEVEL OF EVIDENCE

IV; case series.

A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options

Background

Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management.

Methods

A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates.

Results

Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)).

Discussion

Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Weak Points of Double-Plate Stabilization Used in the Treatment of Distal Humerus Fracture through Finite Element Analysis

BACKGROUND

Multi-comminuted, intra-articular fractures of the distal humerus still pose a challenge to modern orthopedics due to unsatisfactory treatment results and a high percentage (over 50%) of postoperative complications. When surgical treatment is chosen, such fractures are fixed using two plates with locking screws, which can be used in three spatial configurations: either parallel or one of two perpendicular variants (posterolateral and posteromedial). The evaluation of the fracture healing conditions for these plate configurations is unambiguous. The contradictions between the conclusions of biomechanical studies and clinical observations were the motivation to undertake a more in-depth biomechanical analysis aiming to indicate the weak points of two-plate fracture stabilization.

METHODS

Research was conducted using the finite element method based on an experimentally validated model. Three variants of distal humerus fracture (Y, λ, and H) were fixed using three different plate configurations (parallel, posterolateral, and posteromedial), and they were analyzed under six loading conditions, covering the whole range of flexion in the elbow joint (0-145°). A joint reaction force equal to 150 N was assumed, which corresponds with holding a weight of 1 kg in the hand. The biomechanical conditions of bone union were assessed based on the interfragmentary movement (IFM) and using criteria formulated by Steiner et al. Results: The IFMs were established for particular regions of all of the analyzed types of fracture, with distinction to the normal and tangential components. In general, the tangential component of IFM was greater than normal. A strong influence of the elbow joint's angular position on the IFM was observed, with excessive values occurring for flexion angles greater than 90°. In most cases, the smallest IFM values were obtained for the parallel plaiting, while the greatest values were obtained for the posteromedial plating. Based on IFM values, fracture healing conditions in particular cases (fracture type, plate configuration, loading condition, and fracture gap localization) were classified into one of four groups: optimal bone union (OPT), probable union (PU), probable non-union (PNU), and non-union (NU).

CONCLUSIONS

No plating configuration is able to ensure distal humerus fracture union when the full elbow flexion is allowed while holding a weight of 1 kg in the hand. However, flexion in the range of 0-90° with such loadings is acceptable when using parallel plating, which is a positive finding in the context of the early rehabilitation process. In general, parallel plating ensures better conditions for fracture healing than perpendicular plate configurations, especially the posteromedial version.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial

BACKGROUND

Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.

MATERIAL AND METHODS

This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength.

RESULTS

Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group.

CONCLUSION

In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Clinical outcomes of capitellar fractures with posterior comminution treated with Herbert screws combined with metacarpal locking plates

BACKGROUND

The treatment of Dubberley type B capitellar fractures, which are frequently complicated, is widely debated. This study aimed to investigate the prognostic factors and clinical outcomes of Dubberley type B capitellar fractures treated with Herbert screws combined with posterior buttress plates.

METHODS

Seven men and nine women (aged 30-68 years) with Dubberley type B capitellar fractures were operated on with Herbert screws combined with posterior buttress plates. The patients were classified into Dubberley types IB (seven), IIB (four), and IIIB (five). Complications and bone union were observed, and functional outcomes were evaluated by the Mayo Elbow Performance Index (MEPI).

RESULTS

All patients were followed up for a mean period of 23.5 months (12-30 months). All fractures healed in 8-14 weeks (mean, 10.5 weeks). No cases of non-union, elbow instability, or avascular necrosis occurred. Degenerative arthritis occurred in 7 (44%) and heterotopic ossification in 11 (69%) patients. The median MEPI score was 92.5 (interquartile range, 85-100) points, with 11 reporting excellent, 3 good, and 2 fair outcomes. The MEPI scores of type IIIB fractures were significantly lower than those of types IB and IIB fractures, while the MEPI scores of type IB and IIB fractures did not differ significantly.

CONCLUSIONS

Dubberley type IIIB capitellar fractures with multiple articular fragments have a poorer prognosis than type IB and IIB fractures. However, Herbert screw fixation combined with posterior metacarpal locking plates is feasible, providing satisfactory recovery of elbow joint function.

On the importance of accurate elasto-plastic material properties in simulating plate osteosynthesis failure

Background: Plate osteosynthesis is a widely used technique for bone fracture fixation; however, complications such as plate bending remain a significant clinical concern. A better understanding of the failure mechanisms behind plate osteosynthesis is crucial for improving treatment outcomes. This study aimed to develop finite element (FE) models to predict plate bending failure and validate these against in vitro experiments using literature-based and experimentally determined implant material properties. Methods: Plate fixations of seven cadaveric tibia shaft fractures were tested to failure in a biomechanical setup with various implant configurations. FE models of the bone-implant constructs were developed from computed tomography (CT) scans. Elasto-plastic implant material properties were assigned using either literature data or the experimentally derived data. The predictive capability of these two FE modelling approaches was assessed based on the experimental ground truth. Results: The FE simulations provided quantitatively correct prediction of the in vitro cadaveric experiments in terms of construct stiffness [concordance correlation coefficient (CCC) = 0.97, standard error of estimate (SEE) = 23.66, relative standard error (RSE) = 10.3%], yield load (CCC = 0.97, SEE = 41.21N, RSE = 7.7%), and maximum force (CCC = 0.96, SEE = 35.04, RSE = 9.3%), when including the experimentally determined material properties. Literature-based properties led to inferior accuracies for both stiffness (CCC = 0.92, SEE = 27.62, RSE = 19.6%), yield load (CCC = 0.83, SEE = 46.53N, RSE = 21.4%), and maximum force (CCC = 0.86, SEE = 57.71, RSE = 14.4%). Conclusion: The validated FE model allows for accurate prediction of plate osteosynthesis construct behaviour beyond the elastic regime but only when using experimentally determined implant material properties. Literature-based material properties led to inferior predictability. These validated models have the potential to be utilized for assessing the loads leading to plastic deformation in vivo, as well as aiding in preoperative planning and postoperative rehabilitation protocols.

Linking the distal humerus columns in articular fracture fixation

INTRODUCTION

Concerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture.

MATERIALS AND METHODS

Ten matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths.

RESULTS

Mean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94).

DISCUSSION

Our results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments.

Widening Access: Sterile Tourniquets for Surgery to the Distal Humerus

Purpose of the study The use of tourniquets during surgery of the distal humerus can improve visibility and reduce surgical time. However, the available operating field can be limited due to the size and placement of the tourniquet. This proof-of-concept study aimed to determine if sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus. Methods Volunteers (n = 5) were positioned to simulate access to the distal humerus. The distance from the posterior corner of the acromion to the tip of the olecranon was measured. Participants were draped according to the standard protocol for the use of a non-sterile or sterile tourniquet for distal humerus and humeral shaft fractures. Two non-sterile pneumatic tourniquets (standard and narrow) and two sterile tourniquets (pneumatic and elastic exsanguination) were tested. The surgical field was measured from the sterile drape or tourniquet proximally to the tip of the olecranon. A one-way repeated measures ANOVA was conducted to examine the effect of each tourniquet on the surgical field. Results The sterile elastic exsanguination tourniquet had the largest available field with a mean of 24.4 cm (71% of arm available for incision after application), followed by the sterile pneumatic tourniquet of 20.0 cm (58%), narrow non-sterile pneumatic of 19.2 cm (55%), and standard non-sterile pneumatic of 17.0 cm (49%). Repeated measures ANOVA determined that mean surgical field length is statistically significant between tourniquet devices (F (1.729, 6.914) = 21.783, p = .001). The surgical field length was statistically significantly increased from a non-sterile standard tourniquet to a sterile elastic tourniquet (7.4 (95% CI, 2.9-11.9) cm, p = .008) but not the other two tourniquet devices tested. Conclusion The use of certain types of sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus, specifically the sterile elastic exsanguination tourniquet providing a statistically significant mean gain of 7.4 cm from the non-sterile tourniquets. These findings suggest that the use of sterile tourniquets should be considered more frequently in surgery of the distal humerus, and a sterile exsanguinating tourniquet could be considered for midshaft humeral fractures, facilitating safer exposure of the radial nerve and reduced blood loss.

Combined Medial and Lateral Approach Versus Paratricipital Approach in Open Reduction and Internal Fixation for Type C Distal Humerus Fracture: A Randomized Controlled Study

OBJECTIVE

Olecranon osteotomy and paratricipital approaches were widely used in the treatment of type C distal humerus fracture but some disadvantages exist, so a combined medial and lateral approach was designed. The objective of this study was to investigate and compare the clinical outcomes of combined medial and lateral approach with the paratricipital approach in open reduction and internal fixation of type C distal humerus fractures.

METHODS

From May 2018 to April 2020, 37 patients with type C distal humerus fracture who accepted open reduction and internal fixation in our hospital were enrolled in this study. All cases were randomly divided into two groups according to the surgical approach: combined medial and lateral approach group (19 cases), paratricipital approach group (18 cases). All of the patients received open reduction and double vertical plates fixation. The operation and follow-up indexes, including operation time, blood loss, incision length, triceps muscle strength, flexion-extension arc of elbow and forearm rotation arc, were recorded and compared. Caja score was used to assess the quality of fractures reduction. Mayo Elbow Performance Score (MEPS) was used to evaluate the elbow function in the follow-up. Complications such as incision infection, ulnar nerve injury, degenerative osteoarthritis, and heterotopic ossification were analyzed.

RESULTS

The differences in age, gender, and AO classification of fractures between two groups were not statistically significant (p > 0.05). The sum of medial and lateral incision length of combined approach group was longer than the midline incision of paratricipital approach group (15.4 ± 0.8 vs. 14.6 ± 0.8, p < 0.05), but there was no significant difference in operation time (103.5 ± 10.2 vs. 106.0 ± 8.8, p > 0.05), blood loss (71.3 ± 24.5 vs. 72.8 ± 24.6, p > 0.05), and Caja score (16.05 ± 5.67 vs. 15.56 ± 5.66, p > 0.05). During the follow-up, the MEPS of combined approach group was higher than that of paratricipital approach group at 3 months postoperatively (80.5 ± 5.7 vs. 68.9 ± 8.1, p < 0.05), but there was no significant difference in MEPS at 6 months postoperatively (83.9 ± 6.6 vs. 79.7 ± 7.0, p > 0.05) and at the last follow-up (86.8 ± 7.1 vs. 86.9 ± 7.7, p > 0.05) between the two groups. There was no significant difference in triceps muscle strength (p > 0.05), flexion-extension arc (126.8 ± 5.3 vs. 128.9 ± 6.0, p > 0.05), and forearm rotation arc (163.2 ± 5.3 vs. 163.6 ± 4.8, p > 0.05) at the last follow-up. Although the incidence of complication of combined approach group (15.8%) was lower than that of paratricipital approach group (22.2%), the difference was not statistically significant (p > 0.05).

CONCLUSIONS

The combined medial and lateral approach was an effective and safe way of open reduction and internal fixation for type C distal humerus fractures. Compared with the paratricipital approach, the combined medial and lateral approach could restore the elbow function more quickly postoperatively, and the long-term results were comparable.

Wound Complications Following Olecranon Fracture Fixation: Implant and Soft Tissue Considerations

BACKGROUND

The aim of this multicenter, retrospective, case-control series was to investigate patient- and treatment-specific factors associated with wound breakdown following olecranon fracture fixation.  Methods: We identified patients at our two participating academic centers who were operatively treated for olecranon fractures and those who subsequently underwent a re-operation secondary to postoperative wound breakdown. Demographic and historical information was collected, including BMI and Charlson comorbidity index (CCI) scores. The primary outcome measure was the standardized radiographic measurement of plate prominence and soft tissue thickness posterior to the plate tip.  Results: We identified 32 patients who underwent internal fixation and subsequent wound breakdown. This was compared to a cohort of 35 matched controls that did not have wound issues. Cases with wound breakdown were of higher energy, nine being open cases compared to two in the control group (p<0.05). No differences were identified in plate prominence, soft tissue thickness, and plate type.  Conclusions: Wound breakdown following olecranon fracture fixation is more commonly seen in high-energy open injuries. Plate prominence, soft tissue thickness, and patient-specific factors do not correlate with wound breakdown. Further investigation into the factors influencing plate placement and how they may contribute to wound complications is needed.

Bicolumnar 90-90 Locking Plate Fixation Through a Posterior Approach for the Treatment of Low Distal Humeral Fracture in Elderly Patients

Background and objective Treating transcondylar humeral fractures in elderly individuals remains a challenge in trauma surgery, with plate fixation being one potential treatment method. This retrospective study was conducted to assess the effectiveness of plate fixing through a posterior approach in elderly individuals suffering from distal humeral fractures. Methods This retrospective study involved 28 older participants aged ≥65 years with low transcondylar fractures of the humerus (AO/OTA 13A2-3 fractures). We used the 90-90 orthogonal method for treatment. The inclusion criteria were as follows: (1) low transcondylar type of distal humeral fractures (13A2-3 according to the AO/OTA classification system), (2) patients aged ≥65 years, and (3) a follow-up period of at least 12 months. The exclusion criteria were as follows: polytrauma, pathological injuries, chronic elbow osteoarthritis or degenerative arthropathy, and fractures impacting the articular surface of the distal humeral. Clinical outcomes were assessed in terms of the visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), and range of motion (ROM) of the elbow joint. Results The mean age of the patients was 72.25 years (range: 65-81 years), of which 14 (50%) were female and 14 (50%) were male. The mean VAS score for pain was 2.7 (range: 0-6). The mean angle of flexion was 130.6^o (range: 115-140^o), and the mean angle of the extension was -27.7 (range: -21 to -34). Regarding MEPS, 23 patients had an excellent score, four patients had a good score, and one patient had a poor score. There were four complications (two major and two minor) in the patients involved in the study. Conclusion Based on our findings, 90-90 plate fixation for low distal humeral fractures is associated with a high union rate and satisfactory clinical outcomes. Although we found complications in four patients, their healing was not affected. Therefore, we concluded that through improved monitoring and care, we could overcome such complications, and they did not affect the healing of the bone.

Massive bone defects due to infection at the surgical site associated with a distal humeral fracture that was treated using fibula autograft: a case report

Distal humerus fractures comprise between 2 and 5% of all fractures, and approximately one-third of all humerus fractures are of this type. In the present report, the authors described the massive bone defects due to infection at the surgical site associated with a distal humeral fracture that was treated using fibula autograft.

Case presentation

A 28-year-old female patient experienced a fall from a height of 4 m and was referred to Poursina Educational and Medical Center. Clinical examinations and radiological imaging showed an open fracture of the right distal humerus. In the postoperative 50-day follow-up, the complication of infection at the surgical site causes bone loss of up to 8 cm. The posterior triceps-split approach (Campbell) to the distal humerus was used in this surgery. To evaluate the quality of surgery, standard radiographs of anteroposterior and lateral of the elbow joint and humeral shaft were performed after surgery.

Clinical discussion

At 5 months postoperatively, the patient's initial results are good, and the range of motion of the elbow joint is ~10-120°.

Conclusion

Based on the results of the present study, fibular transplantation in distal humerus fractures is considered one of the bone treatment options for repair.

Controversies in the Management of Bicolumnar Fractures of the Distal Humerus

Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

Clinical comparison of double-plate fixation by the perpendicular plate method versus parallel plate method for distal humeral fracture: a multicenter (TRON group) study

INTRODUCTION

Double-plating methods are popular, with perpendicular and parallel plate methods being widely used surgical method for the rigid fixation of distal humeral fracture (DHF). However, which plate method is better for DHF remains controversial. The aim of this study was to compare patient outcomes including the incidences of complications and reoperation between the two plate methods.

METHODS

We extracted 383 patients with DHF undergoing surgery between 2011 and 2020 from our multicenter database, which is named TRON. We divided the subjects into two groups: perpendicular plating group (Group A) and parallel plating group (Group B). To adjust for baseline differences between the groups, patients were matched for age, sex, olecranon osteotomy, AO type, and type of injury. We assessed the Mayo Elbow Performance Score (MEPS) at 3 and 6 months and the last follow-up month as the clinical outcome. We investigated the incidences of complications and reoperations in both groups.

RESULTS

After matching, each group comprised 50 patients. There was no significant difference between Group A versus Group B in MEPS score at each time point. The incidence of implant removal in Group B was higher than that in Group A (26.5% vs 50%, p = 0.023).

DISCUSSION

Although there were no significant differences in clinical outcomes or complications between the two groups, the incidence of implant removal was higher in Group B than in Group A. In the parallel plate technique, where the plates have to be placed in areas with thin subcutaneous soft tissue, the incidence of implant removal might be high due to the discomfort caused by the implant.

Combined use of minimal screw synthesis and external articulated fixation is effective for the management of supra-intercondyloid humeral fractures in the elderly? A retrospective study

Background

Fractures of the distal humerus are relatively rare and can be a source of disabling outcomes especially if not properly treated. Therefore, the objective of the treatment must be to obtain a stable synthesis that allows early mobilization, avoiding complications such as muscular hypotonotrophy, joint rigidity or delays in consolidation that may be due to prolonged immobilization of this joint. Although ORIF treatment of these fractures may intuitively appear to be the gold standard, there is still no consensus in the literature on which type of treatment is most suitable.

Patients and method

We report in this retrospective case series analysis our experience on 31 elder patients (more than 65 years old), affected by a supra-intercondyloid humerus fracture, treated using a minimal internal fixation with cannulated screws combined with the use of an external articulated elbow fixator. This methodology is less invasive but allows a stable synthesis and an early mobilization.Clinical and radiographic examinations were performed for each patient at 1, 2, 3 and 6 months after surgery. At 6 months the residual joint excursion was evaluated and the data were collected. In addition, at 6 months, each patient underwent three different functional capacity assessment questionnaires: MAYO Elbow Performance score, The Disability of the ARM, Shoulder and Hand Score (QuickDASH) and Oxford Elbow Score.

Results

The healing rate was 100% with no cases of non-union, despite the old age of our patients. The average range of motions obtained at 6 months from the surgery was 111° in flexion-extension and 157° in pronation-supination for the patient with an extra-articular fracture, 88° in flexion-extension and 153° in pronation-supination for the patients with a partial articular fracture and 85° in flexion-extension and 149° in pronation-supination for the patients with a complete articular fracture. Our results in the recovery of an arc of motion in flexion-extension are slightly less performing than the results obtained with an ORIF treatment. Indeed, according to literature the mean postoperative flexion arc in an ORIF treatment of distal humerus fractures in adults is 110°.The functional results obtained were satisfactory, with an average score at 6 months from the surgery of 95/100 (Mayo score) for the patients with an extra-articular fracture, 83.3/100 for the patients with a partial articular fracture and 79/100 for the patients with a complete articular fracture.

Conclusion

The results obtained, in terms of range of motions, function, pain and healing and complications rate lead us to affirm that, in selected patients, this technique can represent a valid treatment and therefore a valid option that could be considered.

Outcomes and complications after open reduction and internal fixation of distal humeral fractures with precontoured locking plates

Objectives

The aim of this study was to evaluate functional and radiographic results after open reduction and internal fixation of distal humeral fractures using precontoured locking plates. Our main hypothesis was that patients older than 65 years have inferior outcomes compared with younger patients.

Methods

All patients treated for a distal humeral fracture with precontoured locking plates between 2006 and 2017 at a level 1 trauma center were identified. Included patients underwent a clinical examination, and new radiographs were obtained. Functional outcomes were evaluated using Quick Disability of the Arm, Shoulder and Hand, Mayo Elbow Performance Score, visual analog scale elbow satisfaction, and range of motion. Complications and reoperations were recorded.

Results

Fifty-seven patients with a median age of 60 years were included in this study. Median Quick Disability of the Arm, Shoulder and Hand was 14, and median Mayo Elbow Performance Score was 85. There was no difference in functional scores in patients younger than 65 years or 65 years or older. However, the median flexion-extension arc was 121 degrees in patients younger than 65 years and 111 degrees in patients 65 years or older (P = 0.01). The overall complication rate was 68%, and 24 patients had at least 1 reoperation. Ulnar neuropathy was the most common complication followed by reduced range of motion.

Conclusions

Operative management of distal humeral fractures with precontoured locking plates provides good functional outcome. The patient-reported outcomes were good, independent of patient age. The implant failure rate is low with precontoured locking plates; however, the complication rate remains high, and reoperations are common.

Level of Evidence

Level 4, retrospective study.

Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review

Background

Distal humerus fractures (DHFs) pose a treatment challenge in elderly patients. We sought to systematically review and report the clinical outcomes of the nonoperative approach (eg, "bag of bones") for the treatment of these injuries and the rate of conversion to delayed surgery.

Methods

A comprehensive review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Studies involving outcomes after nonoperative treatment of DHF in patients >65 years of age were included from 1985 to present. Data regarding patient age, DHF type, nonoperative treatment method, complications, conversion to delayed surgery, range of motion, union rate, and surgeon- and patient-reported outcome measures were extracted.

Results

A total of five studies met inclusion criteria (all level IV evidence), yielding a total of 143 patients (mean age: 73.5 years to 87.4 years) with 7.1 months to 55 months of follow-up. The mean Mayo Elbow Performance Index scores were good to excellent across several studies (range 83-93.1). Multiple studies reported good range of motion (mean arc of motion: 81 to 106 degrees) and low levels of upper extremity disability (mean Quick Disability of the Arm-Shoulder-Hand scores: 31.3 to 38.5) at the final follow-up. The rate of conversion to total elbow arthroplasty and operative fixation ranged from 0% to 7.5% and 0% to 5%, respectively.

Conclusion

Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. This information is important for patient counseling and treatment decision-making.

Long-Term Functional Outcomes and Complications of Intra-Articular (AO type B, C) Distal Humerus Fractures in Adults: A Retrospective Review

Introduction

Treatment of intra-articular fractures of the distal humerus is challenging due to their complexity, comminution, and associated complications. The evolution of surgical approaches and the design of elbow-specific implants over the last decades have failed to improve clinical and radiological outcomes. Studies are sparse regarding the long-term influence of surgical treatment of these types of fractures in the upper limb function. The purpose of the current study was to retrospectively review the long-term functional outcome and complications of all intraarticular (AO type B, C) distal humerus fractures treated surgically in a university hospital during the last 25 years.

Material and methods

The study included patients who were surgically treated for an intra-articular distal humerus fracture between March 1991 and May 2016. Our initial search, using ICD-10 codes, identified 63 patients in the specific time period. Twelve patients had died, nine declined to participate, eight had emigrated, nine could not be located and one patient was excluded as he suffered from quadriplegia unrelated to the initial injury. The remaining 25 patients (mean age at surgery 44.2±19.67) were included in a follow-up study protocol. Functional outcome was evaluated according to Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Pain was assessed using the Numerical Pain Rating Scale (NPRS) and subjects were asked to rate their satisfaction. Perioperative and late complications were recorded as well.

Results

The average follow-up was 158.16 ± 73.73 months. The average score was 89.4 ± 12.36 for MEPS, 42.68 ± 4.03 for OES, and 8.1 ± 15.38 for the QuickDASH. The patient satisfaction was rated 3.8 ± 1.08 on average. The mean flexion of the affected elbow was 137.6 ± 12.68 degrees while extension deficit was present in 14/25 patients, with a mean of 8.6 ± 8.96 degrees. We did not observe any mal- or non-unions. The re-operation rate was 32% primarily due to stiffness and irritation from the hardware. We noticed one spontaneously resolved ulnar nerve palsy, one combined radial, and ulnar nerve palsy after extensive arthrolysis that also resolved two cases of heterotopic ossification, one case of implant failure, and two cases of infection - one superficial, which was managed with antibiotics, and the other was deep managed with surgical drainage.

Conclusions

In our series, we found a satisfying range of motion, good functional outcome, and adequate ability to perform daily activities at a very long follow-up. Posttraumatic arthritis, whenever present, does not seriously affect functional performance.

Level of evidence: IV

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

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