Complex fractures of the distal humerus in the elderly: is primary total elbow arthroplasty a valid treatment alternative? A series of 20 cases

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.

Distal humerus fracture in older patients: ORIF vs. total elbow arthroplasty

Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion.

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.

Elbow arthroplasty is safe for the management of simple open distal humeral fractures

BACKGROUND

Elbow arthroplasty (EA) is an established technique for the treatment of select distal humeral fractures, yet little data exists regarding the safety and outcome of EA in the presence of an open distal humeral fracture where the risk of periprosthetic infection is an even greater concern. We hypothesized that EA does not carry an increased risk of infection or other postoperative complications when performed for simple open distal humeral fractures.

METHODS

Seventeen patients underwent total EA (n = 9) or hemiarthroplasty (n = 8) for an open distal humeral fracture. The open fracture component was classified according to the Orthopaedic Trauma Society system as "simple" or "complex." Outcome measures collected included the Mayo Elbow Performance Score (MEPS), range of motion, complications, and reoperations. Patients who underwent primary débridement and implantation were compared with those who underwent preliminary débridement procedures and subsequent staged arthroplasty. A systematic review of the existing literature was performed to analyze other reported cases and contextualize our findings.

RESULTS

The mean follow-up was 46 months (range, 12-138 months). All fractures were multifragmentary and intra-articular. Sixteen patients had a "simple" open fracture and 1 had a "complex" fracture. The overall mean MEPS was 83 (range, 30-100; standard deviation ± 17), with a mean flexion-extension arc of 96°. Patients who underwent primary débridement and implantation demonstrated a higher mean flexion arc (116° vs. 79°, P = .02) than those who underwent staged arthroplasty. The mean MEPS was not significantly different between the groups (90 vs. 78, P = .12). Complications included asymptomatic ulna component loosening (n = 1), joint instability (n = 1), and symptomatic heterotopic ossification (n = 3). There were no deep or superficial infections recorded.

CONCLUSION

EA is safe and effective when performed for simple open distal humeral fractures. Primary débridement and implantation may offer functional benefits over a staged approach.

Hemiarthroplasty or total elbow arthroplasty for unreconstructable distal humeral fractures in patients aged over 65 years : a systematic review and meta-analysis of patient outcomes and complications

AIMS

Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?

METHODS

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on PROMs, ROM, and complications. PROMs and ROM results were reported descriptively and a meta-analysis of complications was conducted. Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROSPERO (CRD42021228329).

RESULTS

A total of 29 studies met the inclusion and exclusion criteria. The mean Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score was 19.6 (SD 7.5) for HA and 38 (SD 11.9) for TEA and the mean abbreviated version of DASH was 17.2 (SD 13.2) for HA and 24.9 (SD 4.8) for TEA. The Mayo Elbow Performance Score was the most commonly reported PROM across included studies, with a mean of 87 (SD 5.3) in HA and 88.3 (SD 5) in TEA. High complication rates were seen in both HA (22% (95% confidence interval (CI) 5 to 44)) and TEA (21% (95% CI 13 to 30), but no statistically significant difference identified.

CONCLUSION

This systematic review has indicated PROMs and ROM mostly favouring HA, but with a similarly high complication rate in the two procedures. However, due to the small sample size and heterogeneity between studies, strength of evidence for these findings is low. We propose further research in the form of a national randomized controlled trial. Cite this article: Bone Joint J 2022;104-B(5):559-566.

Total elbow arthroplasty in elderly trauma patients: adding a new perspective for functional evaluation

PURPOSE

Total elbow arthroplasty (TEA) has evolved over the last years, with satisfactory early results, mainly not only in degenerative arthritis, but also increasingly after trauma. Outcome studies in recently published papers are mainly based on the range of motion (ROM), complication rate as well as patient-reported outcome scales and questionnaires. The purpose of this study was to add a new perspective with the "Purdue Pegboard" skill tests in a homogenous set of elderly trauma patients to contribute to a more precise objective outcome measurement in this specific population.

METHODS

A retrospective review was performed on a consecutive cohort of all patients with age above 60 years that received TEA after trauma. Data from follow-up examinations over a standardized time-schedule within 2 years after TEA were included. Mayo Elbow Performance Score (MEPS), "Disability of Arm, Shoulder and Hand" (DASH) Questionnaire, ROM as well as test-scores using the Pegboard test were evaluated.

RESULTS

Mean age was 76.0 years ± 10.3. Indications for TEA were posttraumatic arthrosis in 68.8% (n = 11) and extensive fractures that could not be reconstructed surgically in 31.3% (n = 5). The mean score of MEPS was 82.81 ± 16.63 and 29.18 ± 12.01 in the DASH. ROM presented with a mean of 109.7° ± 15.4. Patients demonstrated good, but marginally reduced test scores in the Pegboard skill tests in comparison with the healthy reference population. No relevant differences between the arm with and the arm without TEA (0.3 ± 3.6; p = 0.715) were noted after 2 years.

CONCLUSION

In the elderly trauma patient with complex fractures of the elbow, TEA is a good alternative to joint reconstruction using various osteosynthesis techniques. TEA is able to avoid revision surgery after open reduction and internal fixation of complex fractures. In cases of failed reconstruction, it is also a viable secondary procedure in posttraumatic arthrosis. Good outcomes in functionality and dexterity can be achieved. Skill tests like the Purdue Pegboard could add a valuable perspective in assessing functional outcomes after TEA.

Coronal Shear Fractures of the Distal Humerus

Coronal shear fractures of the distal humerus are rare, frequently comminuted, and are without consensus for treatment. The aim of this paper is to review the current concepts on the diagnosis, classification, treatment options, surgical approaches, and complications of capitellar and trochlear fractures. Computed Tomography (CT) scans, along with the Dubberley classification, are extremely helpful in the decision-making process. Most of the fractures necessitate open reduction and internal fixation, although elbow arthroplasty is an option for comminuted fractures in the elderly low-demand patient. Stiffness is the most common complication after fixation, although reoperation is infrequent.

Good functional outcomes after open reduction and internal fixation for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in patients aged over 45 years

BACKGROUND

The purpose of this study was to report the functional outcomes and complications after open reduction and internal fixation (ORIF) for Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type 13-C2 and -C3 acute distal humeral fractures with minimum 2-year follow-up. Our hypothesis was that ORIF would provide functional outcomes that are comparable to those of total elbow arthroplasty and elbow hemiarthroplasty reported in the literature.

MATERIALS AND METHODS

During a 6-year period, 23 patients aged > 45 years were treated with double plating for AO/OTA type 13-C2 or -C3 fractures. The mean age was 62 years (range, 46-80 years). The Oxford Elbow Score was used as the primary outcome; the Mayo Elbow Performance Score, pain severity score (on a visual analog scale), range of motion, reoperations, and complications were used as secondary outcomes.

RESULTS

The median Oxford Elbow Score was 42 (range, 25-48), where a score of 48 represents a normal elbow; 20 patients achieved good to excellent outcomes, and 3 achieved fair outcomes. The median Mayo Elbow Performance Score was 85 (range, 60-100), where a score of 100 represents a normal elbow; 18 patients achieved good to excellent outcomes, and 5 achieved fair outcomes. The median visual analog scale score was 2 (range, 0-5). The median flexion-extension and supination-pronation arcs were 120° (range, 70°-155°) and 160° (range, 75°-170°), respectively. Eight complications were recorded in 7 patients; 4 of them required reoperation because of fracture pseudarthrosis or elbow stiffness. Ten patients were working at the time of trauma, and nine of them returned to the same occupation. Our results are comparable to the results of previously published studies regarding the outcome of ORIF, elbow hemiarthroplasty, or total elbow arthroplasty for AO/OTA type 13-C fractures.

CONCLUSION

ORIF is a reliable treatment option for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in middle-aged and elderly patients, despite the considerable rate of complications. Good to excellent results can be obtained in most patients.

A systematic review of the complications of contemporary total elbow arthroplasty

BACKGROUND

Total elbow arthroplasty is a low volume procedure. We aimed to evaluate complication rates and cumulative percentages associated with the most frequently used contemporary implants and for the commonest indications.

METHODS

A systematic literature search of all studies reporting complications following total elbow arthroplasty with 12-month minimum follow-up was undertaken. Quality of studies was assessed with the Methodological-Index-for-Non-Randomised-studies criteria. British NJR data identified the most common UK prostheses and indications. The complication rates for all undesirable events contributing to patient outcome were extracted and cumulative percentages were calculated.

RESULTS

One hundred seventeen studies were screened, 12 studies included, totalling 815 procedures. Mean follow-up was 3.8 years. The overall complication cumulative percentage was 60.7%, significantly higher than that seen in other joint arthroplasty, including a 6.5% deep infection rate. Nerve injury was comparable between implants at around 4.1%. Radiographic loosening had a cumulative rate of 17.2%. Revision for symptomatic aseptic loosening was 6.3%.

CONCLUSIONS

This is the largest systematic review of the complications of total elbow arthroplasty. Surgeons should be aware of differing complications related to their implant of choice, each having its own specific complication. Trauma as an indication appears to have an increased complication rates compared to inflammatory arthropathy. There is a lack of literature regarding the independent results of osteoarthritis as a specific indication for total elbow arthroplasty.

Distal Humerus Fractures Managed With Elbow Hemiarthroplasty

Background

Distal humerus fractures not amenable to open reduction internal fixation (ORIF) present a unique dilemma, especially for patients that weight bear through assistive devices. The one accepted operative treatment for irreparable distal humerus fractures is total elbow arthroplasty (TEA). However, TEA commonly requires lifetime weight lifting restrictions and has limited long term results. Elbow hemiarthroplasty (EHA) represents an alternative treatment modality. This study reviews patients treated with EHA permitted to weight bear postoperatively.

Methods

Twelve patients underwent EHA for comminuted distal humerus fractures deemed non-reconstructable by ORIF. Patient survey data was collected retrospectively. All patients were allowed to weight bear as tolerated through the operative extremity. Outcome measures included Patient rated elbow evaluation (PREE), Mayo elbow performance score (MEPS), and whether revision surgery was required.

Results

The average MEPS score was 76.1 indicating fair outcomes and the average PREE score was 41. One patient required revision. Average follow up was 44.1 months. Three patients required an assistive device prior to injury.

Discussion

EHA serves as a viable option for non-reconstructable distal humerus fractures. EHA does not require a weight lifting restriction, which is a benefit over TEA. Overall, patients reported preserved functional capabilities but did report moderate pain. EHA demonstrated durability, although one patient required revision.

Conclusion

With growing interest in use of EHA, further studies are required to evaluate EHA as a superior treatment for patients with nonreconstructable traumatic distal humerus fractures; however, this study does support use in elderly patients with intermediate follow up.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complications and functional outcomes after transolecranon distal humerus fracture

BACKGROUND

Transolecranon distal humerus fractures are uncommon injuries. This is the first multipatient case series to describe outcomes and complications following transolecranon distal humerus fractures in the adult population.

METHOD

Design: retrospective; setting: single level 1 trauma center; patients/participants: 16 patients; intervention: surgical management of transolecranon distal humerus fracture; main outcome measurement: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after a minimum of 12 months.

RESULTS

A total of 16 patients with open (n = 12) or closed (n = 4) transolecranon distal humerus fractures were identified. Nine female and 7 male patients with a mean age of 47 years were included. Mechanisms of injury included motor vehicle collisions (n = 3), motorcycle crashes (n = 4), ground-level falls (n = 3), falls from height (n = 4), train collision (n = 1), and an industrial accident (n = 1). Seven patients (44%) presented with nerve injury. Patients underwent open reduction with internal fixation (n = 15), external fixation (n = 6), or both (n = 5). Additional surgeries were ultimately required in 11 patients (69%), with a mean of 3 surgeries to manage each patient's elbow injuries. All patients returned for at least 3 clinical follow-up visits; mean clinical follow-up was 15.8 months and mean radiographic follow-up was 12.3 months. Complications were observed in 15 patients (94%). Eleven patients (69%) had limited range of motion with a flexion arc of less than 100° at their last clinic visit. Seven patients (44%) developed deep wound infections requiring repeat débridement and intravenous antibiotics. Implant removal was performed in 10 patients (62.5%) because of infection (n = 5), symptomatic hardware (n = 4), or device failure (n = 1). Heterotopic ossification was seen in 8 patients (50%) and post-traumatic arthrosis in 4 (25%). Two patients (12.5%) required flap reconstruction for soft tissue defects. Nonunion occurred in 7 patients (44%). DASH scores were obtained for 10 patients (62.5%) at a mean of 3.8 years after injury. The mean DASH score was 40.2, ranging from 4.2 to 76.5. Among respondents, 7 (70%) were able to resume working, with an average DASH work module score of 25.

CONCLUSION

Management of transolecranon distal humerus fractures remain a challenge for orthopedic surgeons. Complication rates, including deep infection and nonunion, are high, with frequent long-term functional limitations posed to the patient, as evidenced by DASH scores.

Indications and outcome in total elbow arthroplasty: A systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

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.

Good outcome after elbow hemiarthroplasty in active patients with an acute intra-articular distal humeral fracture

BACKGROUND

This study reported the clinical outcomes and complications after elbow hemiarthroplasty (EHA) for acute distal humeral fractures Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type C2 and C3.

METHOD

During a 6-year period, 24 active patients with acute intra-articular and multifragmentary distal humeral fractures were treated with an EHA by 1 of 4 experienced elbow surgeons. Mean age was 65 years (range, 47-80 years). Median follow-up time was 20 months (range, 12-70 months).

RESULTS

The median Oxford Elbow Score was 40 points (range, 17-48 points), where 48 points represents a normal elbow. Outcomes were "good to excellent results" in 21 patients, "fair" in 2 patients, and "poor" in 1 patient. The median Mayo Elbow Performance Score was 85 points (range, 50-100 points), where 100 points represents a normal elbow. Outcomes were "good to excellent" in 19 patients, "fair" in 4 patients, and "poor" in 1 patient. The median pain severity score was 2 (range, 0-7) in a scale from 0 to 10 where 0 represents a pain-free elbow. The median flexion/extension and supination/pronation arcs were 110° (range, 60°-140°) and 160° (range, 115°-180°), respectively. Complications were recorded in 7 patients, and 3 of them underwent reoperation because of stiffness, which was treated with open release.

CONCLUSIONS

EHA provides a good and reliable option in the treatment of an acute intra-articular distal humeral fracture unsuitable for open reduction and internal fixation, especially in active patients.

Heterotopic ossification after total elbow arthroplasty: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Fracture-pattern-related therapy concepts in distal humeral fractures

Around one third of humeral fractures and 2–6% of all fractures occur to the distal part of the humerus. There is a bimodal distribution differentiating between young male patients with high-energy and elderly female patients with low-energy trauma related to osteoporosis. The AO classification and Dubberley subclassification are used in daily routine. Most fractures are diagnosed on radiographs. For further evaluation, three-dimensional computed tomography is recommended, especially for comminuted or complex fractures. Owing to the long immobilization and resultant poor functional outcome, conservative treatment is followed for inoperable patients. The operative approach and osteosynthesis depend on the fracture pattern. In A1 avulsion fractures, open reduction and screw fixation are recommended. In A2/A3 fractures, a triceps-sparing approach following a 90° double-plate construction (radial dorsal/ulnar lateral) with locking plates is favored. Partial articular B1/B2 fractures are exposed via a medial or lateral approach using unilateral locking plates to stabilize the medial/lateral column. Coronal shear fractures (B3) are classified after Dubberley and are treated via an extended Kocher approach and headless compression screws in anteroposterior direction. If there is a further posterior comminution or a lateral column fragment, stabilization is needed for the lateral/medial column with a precontoured locking plate. In solely articular fracture patterns, a dorsal approach with either a 90° or 180° double-plate construction is advised. If a reconstruction is not possible owing to fracture complexity or bone quality, total elbow arthroplasty is a viable option. However, lifelong limitation in weight-bearing up to 5 kg, limited longevity, and the potential for complicated revision surgery should be considered.

Distal Humerus Fractures in the Elderly Population

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

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

INTRODUCTION

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

HYPOTHESIS

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

TYPE OF STUDY

Retrospective non-comparative, single-center.

LEVEL OF EVIDENCE

4.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.].

Comminuted distal humeral fracture treated using the Ilizarov technique in a patient with rheumatoid arthritis and osteoporosis

The goal of treatment for distal humeral fractures in patients with rheumatoid arthritis (RA) is to obtain sufficient bone union and good elbow function. However, treating comminuted distal humeral fractures in patients with RA and osteoporosis is challenging. We present the case of a 58-year-old woman with RA and osteoporosis who suffered a comminuted distal humeral fracture and was successfully treated with the Ilizarov technique. The Ilizarov technique is minimally invasive compared with conventional open surgery, can obtain good stabilization, and allows earlier rehabilitation, even if the fractured bone is severely osteoporotic. The patient exhibited good elbow function and alignment at the final follow-up examination (18 postoperative months). To the best of our knowledge, the present case is the first in which a comminuted distal humeral fracture in a patient with RA and severe osteoporosis was successfully treated with an Ilizarov external fixator.

Total elbow arthroplasty for the treatment of distal humeral fractures

OBJECTIVE

To report the clinical-functional outcomes of the treatment of humeral distal fractures with a total elbow prosthesis.

MATERIAL AND METHODS

This retrospective study was performed in two surgical centres. A total of 23patients were included, with a mean age of 79years, and of which 21 were women. The inclusion criteria were: patients with humeral distal fractures, operated on using a Coonrad-Morrey prosthesis, and with a follow-up of more than one year. According to AO classification, 15fractures were type C3, 7 C2 and 1 A2. All patients were operated on without de-insertion of the extensor mechanism. The mean follow-up was 40 months.

RESULTS

Flexor-extension was 123-17°, with a total mobility arc of 106° (80% of the contralateral side). Pain, according to a visual analogue scale was 1. The Mayo Elbow Performance Index (MEPI) was 83 points. Excellent results were obtained in 8 patients, good in 13, medium in 1, and poor in 1. The mean DASH (disability) score was 24 points.

CONCLUSION

Treatment of humeral distal fractures with total elbow arthroplasty could be a good treatment option, but indications must be limited to patients with complex fractures, poor bone quality, with osteoporosis and low functional demands. In younger patients, the use is limited to serious cases where there is no other treatment option.

LEVEL OF EVIDENCE

Level of Evidence IV.

Total Elbow Arthroplasty for Distal Humerus Fractures

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

Discovery elbow system: 2- to 5-year results in distal humerus fractures and posttraumatic conditions: a prospective study on 24 patients

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.

Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for the Treatment of Geriatric Distal Humerus Fractures: A Systematic Review and Meta-Analysis

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.

Primary total elbow arthroplasty in complex fractures of the distal humerus

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.