Total elbow arthroplasty for distal humerus fractures

Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency in Upper Extremity Surgery

Fragility fractures as a result of osteoporosis, osteopenia, or vitamin D deficiency are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate management and treatment options. A thorough perioperative evaluation can identify causes of low bone mineral density allowing for initiation of appropriate therapy. Surgical treatment of these fractures can be difficult, and techniques should be employed to ensure stable fixation. It is important to understand the potential pitfalls associated with treatment of fragility fractures to prevent avoidable complications. Postoperative management is key to preventing future injuries in this unique patient population.

Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members

INTRODUCTION

Coronal shear fractures of the distal humerus are uncommon injuries representing 6% of distal humeral fractures. There is no univocal consensus about the correct management of this type of fracture. A national survey was conducted to gain more insight into the current classification, diagnosis and treatment of coronal shear fractures in Italy.

MATERIALS AND METHODS

A postal survey was sent to all AO Italian members including residency orthopaedic surgeons. The survey consisted of general questions about personal experience in the management of these fractures: types of classification systems used, surgical approaches, treatment options and rehabilitation programs.

RESULTS

114 orthopaedic surgeons answered a 13-items questionnaire. The most used classification system was AO/OTA (72,8%). Independent screws and if necessary plates were the most answered regarding surgical treatment (81,6%). The most encountered post-surgical complication was stiffening of the elbow (81,6%).

CONCLUSION

An algorithm of treatment has been proposed. To better classify coronal shear fractures, the authors recommended the integration of two classification systems: AO and Dubberley classifications. In the case of posterior wall comminution, a Kocher extensile approach is recommended, otherwise, if a posterior wall is intact, Kocher or Kaplan approach can be used. The posterior transolecranic approach can be reserved to Dubberley type III or AO 13B3.3. The best treatment choice is represented by independent screws and plates placed according to fracture patterns while arthroplasty is indicated when a stable ORIF is not possible. Mobilization is postponed for about 2 weeks.

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

Backgroud

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

Methods

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

Results

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

Conclusions

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

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

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

Surgical Exposures for Total Elbow Arthroplasty

Indications for total elbow arthroplasty (TEA) were traditionally reserved for patients with advanced rheumatoid disease and posttraumatic conditions of the elbow. The indications have expanded for TEA to include patients with acute elbow trauma, dysfunctional instability, and end-stage osteoarthritis. Many of these patients are younger and place a greater demand on their TEA. This evolution of TEA use combined with the concern of soft tissue handling and triceps function has led to increased interest regarding surgical exposure for TEA. Three generalized approaches to TEA are predicated on the handling of the triceps tendon: triceps reflecting, triceps splitting, and triceps sparing. Each of these approaches has its own inherent advantages and disadvantages. As indications grow for TEA and the possibility of revision surgery increases with use in younger, higher demand patients, it is important for treating surgeons to use these various exposures so that they are capable of treating patients in a variety of settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Clinical Outcomes of Semiconstrained Total Elbow Arthroplasty in Patients Who Were Forty Years of Age or Younger

BACKGROUND

Total elbow arthroplasty is not commonly used in young patients with advanced arthritis because of concerns regarding implant loosening and clinical failure. Until now, to our knowledge, there have only been a few studies on the outcome in younger patients undergoing total elbow arthroplasty.

METHODS

Twenty-three elbows in patients forty years of age or younger who underwent total elbow arthroplasty were reviewed retrospectively. There were nine elbows with posttraumatic arthritis and fourteen elbows with nontraumatic arthritis. The mean patient age at the time of the surgical procedure was thirty-three years (range, twenty to forty years), and the mean follow-up duration was 129 months (range, eighty-five to 227 months).

RESULTS

At the time of the latest follow-up, pain during motion decreased from a mean visual analog scale score (and standard deviation) of 5.8 ± 1.8 cm preoperatively to 1.6 ± 1.1 cm postoperatively (p < 0.001), and the mean Mayo Elbow Performance Score increased from 32.0 ± 9.4 points preoperatively to 81.1 ± 13.7 points postoperatively (p < 0.001). The mean subjective patients' satisfaction score was 83.5 ± 11.7 points. The mean flexion-extension arc in the posttraumatic arthritis group increased from 37.8° ± 30.3° preoperatively to 120.6° ± 11.3° at the time of the latest follow-up, whereas that in the nontraumatic arthritis group increased from 24.3° ± 27.6° to 96.4° ± 21.2° (p < 0.001 for both). At the time of the latest follow-up, the loosening rate was 13% and mild-to-moderate bushing wear was observed in four elbows (17%). A revision surgical procedure was performed in five elbows (22%), of which three had revision surgery after fifteen postoperative years. The overall implant survival rates were 95% at the eight-year follow-up and 89% at the fifteen-year follow-up.

CONCLUSIONS

Despite concerns regarding the longevity of total elbow replacements in young patients, long-term follow-up after total elbow arthroplasty showed significant functional improvement and pain relief. Although a desirable range of motion after the surgical procedure was difficult to achieve in patients with preoperative ankylosis, total elbow arthroplasty in selected young patients showed acceptable loosening, reoperation, and implant survival rates.

LEVEL OF EVIDENCE

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

Elbow hemiarthroplasty using a "triceps-on" approach for the management of acute distal humeral fractures

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.

The triceps reflecting approach (Bryan-Morrey) for distal humerus fracture osteosynthesis

Background

“Chevron”-Olecranon osteotomies are commonly used for the approach to intraarticular distal humerus fractures but are often associated with procedure related complications. We studied the triceps reflecting approach (TRA) with preservation of the extensor apparatus as a safe alternative giving a sufficient exposure to the elbow joint and helping to achieve anatomical fracture reduction with the intact olecranon as a template.

Methods

We performed a retrospective review at two trauma centres and identified 31 skeletally mature distal humerus fractures treated with a TRA. 24 of the patients returned to follow-up including history recording, physical examination with functional analysis of the operated vs the normal site with the DASH and Mayo scores, measurement of range of motion, isometric elbow strength measurement and radiographic documentation.

Results

Mean duration of FU was 51 months (24 months-12 years) in 24 patients, 13 female, 11 male with an average age of 57.7 years (range 17-89). AO Classification showed five A2, one B2, two C1, 9 C2 and 7 C3 fractures. Radiologic control showed adequate reduction, distal humeral alignment and fracture healing in all patients. The strength analysis of flexion and extension revealed no statistically relevant loss of strength at last FU. Range of motion was excellent.

Conclusion

The TRA is a valuable option for ORIF in distal intraarticular humerus fractures. It preserves the normal joint anatomy of the olecranon and avoids the potential complications associated with olecranon osteotomy. The clinical outcome parameters of our series revealed excellent maintenance of strength compared to the contralateral side.