Total elbow arthroplasty for non-rheumatoid patients with a fracture of the distal humerus

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.

Implant survival of total elbow arthroplasty: analysis of 514 cases from the Dutch Arthroplasty Registry

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions.

Distal humerus hemiarthroplasty for trauma: a systematic review of the outcomes and complications

BACKGROUND

In patients with distal humerus fractures that are unreconstructible, total elbow arthroplasty is an established alternative to open reduction-internal fixation. Distal humerus hemiarthroplasty is a further alternative to avoid the significant lifestyle limitations associated with total elbow arthroplasty. Distal humerus hemiarthroplasty is an increasingly popular treatment option for unreconstructible distal humeral fractures not amenable to reconstruction. The aim of this systematic review was to assess the literature regarding the functional outcomes and complications of the use of distal humerus hemiarthroplasty for acute trauma.

METHODS

A systematic review of the PubMed, Embase, and Scopus databases was performed. The search terms included "distal humerus fracture" OR "elbow fracture" AND "hemiarthroplasty" OR "arthroplasty" OR "replacement." Studies were limited to those published in the English language with reported functional outcome measures and complications. Patient demographic characteristics, implant systems, clinical outcomes (range of motion and functional outcome scores), and complications were extracted.

RESULTS

Thirteen studies with a total of 207 patients met the inclusion criteria. The average age ranged from 44 to 79 years, with the mean length of follow-up ranging from 11 to 82 months postoperatively. A mean range-of-motion arc ≥ 93° was achieved in all studies, with 11 of 13 studies achieving mean functional range of motion ≥ 100°. All studies reported good to excellent mean outcome scores. Heterotopic ossification, ulnar cartilage wear, stiffness, and ulnar neuropathy were the most commonly encountered complications. The reoperation rate and revision rate were 17% and 3%, respectively.

CONCLUSIONS

Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected. Long-term outcome data and the use of distal humerus hemiarthroplasty in younger patients are yet to be fully defined.

Does preservation of columns affect the medium-term outcome in distal humerus hemiarthroplasty for acute unreconstructable fractures?

BACKGROUND

We assessed distal humeral column preservation effects on clinical, radiographic and patient reported outcomes following distal humerus hemiarthroplasty for acute unreconstructable fractures.

METHODS

Thirty-seven consecutive patients (mean age, 75; range, 29-93 years) with an average follow-up of 61 months (range, 24-105 months) after distal humerus hemiarthroplasty using a triceps preserving approach were studied. QuickDASH and Oxford Elbow Score assessed patient reported outcomes. Clinical and radiographic assessments comprised range of motion, grip strength, instability, implant loosening, chondral wear, heterotopic ossification and condylar union.

RESULTS

Average QuickDASH was 14.9 (range, 0-63) and Oxford Elbow Score 40.35 (range, 25-48). Mean flexion arc was 108°, extension deficit 17° and pronosupination arc 155°. Average operative sided grip strength was 31.05 kg versus 31.13 kg contralaterally. Column preservation had no statistically significant effect on QuickDASH (p = 0.75), Oxford Elbow Score (p = 0.78), flexion-extension (p = 0.87), pronosupination (p = 0.78) or grip strength (p = 0.87). No progressive radiographic loosening or symptomatic chondral wear occurred. All fixed columns united. Three cases of immediate post-operative laxity fully resolved on elbow mobilisation. Four post-operative complications required further surgery: one ulnar neuropathy, one heterotopic ossification, one wound breakdown and one traumatic dislocation.

CONCLUSION

Medium-term outcome of distal humerus hemiarthroplasty for acute unreconstructable distal humeral fractures is reliable irrespective of condylar preservation.

Temporary spanning plate across the elbow for complex fractures of the distal humerus

BACKGROUND

Open reduction internal fixation (ORIF) is the gold standard management of fractures of the distal humerus. Stable fixation to allow early mobilization is not always possible in cases with comminuted fracture patterns and bone loss, with a high failure rate. We propose augmentation of internal fixation in these unstable situations with a spanning plate across the elbow to protect the fixation construct temporarily until bone union.

METHODS

Eighteen patients with complex distal humeral fractures were managed with standard ORIF technique augmented with a temporary plate spanning across the elbow as an internal fixator. Cases included were either very distal, comminuted (6 cases) or insufficiency fractures (4 cases) or revision fixation cases (8 cases). The temporary spanning plate was removed as soon as signs of early radiographic union were detected.

RESULTS

Seventeen patients were available for final follow up at a mean 28.3 months. The spanning plate was removed after 3.4 months on average. At the final follow-up, the mean elbow total arc of motion was 86.3°. The mean Mayo Elbow Performance Score (MEPS) was 80, and the mean Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score was 27.

CONCLUSION

Spanning the elbow temporarily with a plate in adjunct to standard ORIF technique is both simple and effective in achieving fracture stability and union and minimizes failure rates after fixation of comminuted, very distal fractures, osteoporotic cases, or revision fixation cases with bone loss.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

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.

Triceps Insufficiency After Total Elbow Arthroplasty: A Systematic Review

BACKGROUND

The incidence of triceps insufficiency after total elbow arthroplasty (TEA) varies in the literature, and a consensus on treatment strategy is lacking. We review the incidence, the risk factors, the clinical presentation, and the diagnosis and treatment of triceps insufficiency after TEA. Based on this information, we have formulated recommendations for clinical practice.

METHODS

We performed a systematic review of the literature from January 2003 to April 2020 to identify studies that investigated triceps function following TEA by searching the PubMed, Cochrane, and Embase databases. Eligible studies (1) reported on triceps function following primary or revision TEA for every indication, regardless of technique (e.g., bone grafts), (2) included ≥6 adult patients, (3) had the full-text article available, and (4) had a minimum follow-up of 1 year.

RESULTS

Eighty studies with a total of 4,825 TEAs were included. The quality was low in 15 studies, moderate in 64 studies, and high in 1 study. The mean incidence of triceps insufficiency was 4.5%. The rates were highest in patients after revision TEA (22%), in those with posttraumatic arthritis as an indication for surgery (10.2%), and after a triceps-reflecting approach (4.9%). Most studies used the Medical Research Council scale to score triceps function, although cutoff points and the definition of triceps insufficiency differed among studies. Surgical treatment showed favorable results with anconeus tendon transfer and Achilles allograft repair when compared with direct repair.

CONCLUSIONS

The incidence of triceps insufficiency varies greatly, probably due to a lack of consensus on the definition of the term. Therefore, we recommend the guidelines for clinical practice that are presented in this article. These guidelines assist clinicians in providing the best possible treatment strategy for their patients and help researchers optimize their future study designs in order to compare outcomes.

LEVEL OF EVIDENCE

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

Outcomes following revision of the revision total elbow arthroplasty

BACKGROUND

There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure.

METHODS

We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification.

RESULTS

We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases.

CONCLUSIONS

RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System

PURPOSE

Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system.

METHODS

All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated.

RESULTS

A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively.

CONCLUSIONS

This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Load bearing performance of mechanical joints inspired by elbow of quadrupedal mammals

One of the biggest issues of the mechanical cylindrical joints is related to premature wear appearing. Application of bioinspiration principles in an engineering context taking advantage of smart solutions offered by nature in terms of kinematic joints could be a way of solving those problems. This work is focussed on joints of one degrees of freedom in rotation (revolute or ginglymus joints in biological terms), as this is one of the most common type of mechanical joints. This type of joints can be found in the elbow of some quadrupedal mammals. The articular morphology of the elbow of these animals differs in the presence/absence of a trochlear sulcus. In this study, bio-inspired mechanical joints based on these morphologies (with/without trochlear sulcus) were designed and numerically tested. Their load bearing performance was numerically analysed. This was done through contact simulations using the finite element method under different external loading conditions (axial load, radial load and turnover moment). Results showed that the tested morphologies behave differently in transmission of external mechanical loads. It was found that bio-inspired joints without trochlea sulcus showed to be more specialized in the bearing of turnover moments. Bio-inspired joints with trochlea sulcus are more suitable for supporting combined loads (axial and radial load and turnover moments). Learning about the natural rules of mechanical design can provide new insights to improve the design of current mechanical joints.

Long-term outcomes of total elbow arthroplasty: a systematic review of studies at 10-year follow-up

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the functional outcomes, dislocation, and revision rates following total elbow arthroplasty (TEA) at a minimum 10 years' mean follow-up.

MATERIALS AND METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and Cochrane Library databases. Studies were only included if they focused on outcomes post-TEA at a minimum 10 years' mean follow-up.

RESULTS

Our search found 23 studies including 1429 elbows (60.4% linked TEA) that met our inclusion criteria. There were 1276 patients (79.0% female), with an average age of 64.7 years (19-93) and a mean follow-up of 137.2 months (120-216). At final follow-up, the mean Mayo Elbow Performance Score, Oxford Elbow Score, and Quick Disabilities of the Arm, Shoulder, and Hand scores were 89.1 (35-100), 64.4 (16-48), and 39.2 (3-93), respectively, and 63.3% of patients reported having no pain. The rates of aseptic loosening, infection, implant dislocation, and nerve injury were 12.9%, 3.3%, 4.2%, and 2.1%, respectively. The overall complication and revision rates were 16.3% and 14.6%, respectively.

DISCUSSION AND CONCLUSION

Our systematic review established that TEA offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term.

Results of Linked Convertible Total Elbow Arthroplasty for the Management of Distal Humeral Fractures in the Elderly

PURPOSE

Total elbow arthroplasty (TEA) is increasingly used for the management of comminuted distal humeral fractures in elderly patients. There are limited data on the outcome of modern elbow arthroplasty designs in larger patient cohorts. The aim of the current study was to review the outcomes and complications using a cemented convertible TEA system in a linked configuration in patients with distal humeral fractures.

METHODS

Patients with distal humeral fractures treated with TEA and a minimum of 2 years' follow-up were reviewed. Demographic information, patient-reported outcome, functional and radiographic outcome assessments, and complications were reported.

RESULTS

Forty patients met inclusion criteria; 35 were female. Median follow-up was 4 years (range, 2-13 years). Average age of patients at the index procedure was 79 ± 9 years. All implants were linked. Range of motion was: extension 16° ± 13°, flexion 127° ± 14°, supination 79° ± 11°, and pronation 73° ± 20°. Patient-reported outcome scores were: Patient-Rated Elbow Evaluation 37 ± 35, Quick-Disabilities of the Arm, Shoulder, and Hand 31 ± 31, and Mayo Elbow Performance Index 90 ± 18. Seven patients had heterotopic ossification. Lucent lines were noted predominantly in humeral implant zone V. No lucent lines were noted around the ulnar component in any radiographic zone. Complications occurred in 9 patients (22%) and 2 revisions were performed: one for infection and one for a late periprosthetic fracture.

CONCLUSIONS

Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores. No implant-related complications of this convertible implant system were encountered, but longer-term follow-up is needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Total elbow arthroplasty for acute distal humeral fractures with humeral condyle resection or retention: a long-term follow-up study

Background

Open reduction and internal fixation is the gold standard for the operative treatment of intra-articular distal humeral fractures. However, in elderly patients the approach involves a high rate of complications. We reviewed the long-term outcomes of 13 primary total elbow arthroplasties (TEAs) performed to treat acute fractures in non-rheumatoid patients who at the time of trauma were aged less than 70 years. The aim of the study was to establish whether condyle retention enhances hinge stability and influences outcomes in these patients, who are younger than those who typically undergo TEA.

Methods

In 13 consecutive patients with acute distal humeral fractures aged 61-67 years, a linked semi-constrained Coonrad-Morrey prosthesis was implanted. The medial and lateral condylar bone fragments were resected (7 patients) or stabilized to the diaphysis using k-wires or plates (6 patients).

Results

At a mean follow-up of 12 years, the mean Mayo Elbow Performance Score was 88 and patient satisfaction was 85%. Nine patients (70%) did not require surgical revision. All revisions involved the group managed by condyle resection.

Discussion

TEA can be considered in elderly subjects with acute distal humeral fracture. In our patients, resection of the medial and lateral condyle fragments did not influence outcomes, although clinical observation suggested that it involves greater mechanical stress on the hinge, heightening the long-term risk of bushing wear. Condyle fixation with plates or k-wires seems to afford longer implant survival and is recommended in younger patients with higher functional demands.

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.

Thirty-day readmissions and reoperations after total elbow arthroplasty: a national database study

BACKGROUND

The purpose of this study was to determine the rate of short-term complications after total elbow arthroplasty (TEA) and identify predictors of readmission and reoperation. We hypothesized that TEA performed for acute elbow trauma would have higher rates of 30-day readmission and reoperation than TEA performed for osteoarthritis (OA).

METHODS

Using the National Surgical Quality Improvement Program for the years 2011-2017, we identified patients undergoing TEA for fracture, OA, or inflammatory arthritis. Patient demographic characteristics, comorbidities, reoperations, and readmissions within 30 days of surgery were analyzed. Potential predictors of reoperation and readmission in the model included age, sex, race, body mass index (BMI), diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, smoking, bleeding disorders, American Society of Anesthesiologists classification, wound classification, operative time, and indication for surgery.

RESULTS

A total of 414 patients underwent TEA from 2011-2017. Of these patients, 40.6% underwent TEA for fracture; 37.0%, for OA; and 22.7%, for inflammatory arthritis. The overall rate of unplanned readmissions was 5.1% (21 patients). The rate of unplanned reoperations was 2.4% (10 patients). Infection was the most common reason for both unplanned readmissions and reoperations. The rates of reoperations and readmissions were not significantly associated with any of the 3 operative indications: fracture, OA, or inflammatory arthritis. Multiple logistic regression analysis found increased BMI to be associated with lower odds of an unplanned readmission (odds ratio [OR], 0.883; 95% confidence interval [CI], 0.798-0.963; P = .0035) and found wound classification ≥ 3 to be associated with increased odds of an unplanned reoperation (OR, 16.531; 95% CI, 1.300-167.960; P = .0144) and total local complications (OR, 17.587; 95% CI, 2.207-132.019; P = .0057). Patients who were not functionally independent were more likely to experience local complications (OR, 4.181; 95% CI, 0.983-15.664; P = .0309) than were functionally independent patients.

CONCLUSIONS

The 30-day unplanned reoperation rate after TEA was 2.4%, and the unplanned readmission rate was 5.1%. Low BMI was predictive of readmission. Wounds classified as contaminated or dirty were predictive of reoperation. Dependent functional status and contaminated wounds were predictive of local complications. The indication for TEA (fracture vs. OA vs. inflammatory arthritis) was not found to be a risk factor for reoperation or readmission after TEA.

Skinny wire and locking plate fixation for comminuted intra-articular distal humerus fractures: a technical trick and case series

Introduction

Intra-articular distal humerus fractures present a challenge to orthopedic surgeons. Stable fixation is difficult to achieve in fractures with articular and metaphyseal comminution and osteoporotic bone. Hence, these fractures are more commonly being managed with total elbow arthroplasty. We describe a novel surgical technique that confers stable fixation, allowing for early range of motion resulting in a high rate of union, a functional range of motion, and excellent patient reported outcome scores without the activity restrictions of total elbow arthroplasty.

Methods

Retrospective case series of 30 patients with AO/OTA type B and C intra-articular distal humerus fractures who underwent ORIF from 2014-2019 utilizing a novel surgical technique that focuses on reconstructing a comminuted articular surface through meticulous, transverse fixation of the tiny articular fragments with long, thin Kirchner wires, which are then bent over and trapped under locking compression plates to create a fixed angle support to the metadiaphysis.

Results

Patient mean age of 59 (19-90) years and 61% were female. Median follow up was 1.2 years. Twenty-seven (87%) were type C fractures and 3 (13%) were type B. Five patients (16%) suffered a concurrent ipsilateral upper extremity injury and four (13%) had an open fracture. Two were polytrauma patients. All fractures healed with an average time to union of 11 weeks. Over 80% patients reported no or mild pain at final follow up. Mean arc of elbow motion was 102 degrees, mean QuickDASH score 25.2. Post-operative complications included ulnar nerve paresthesias (38%), wound infection (3.2%), heterotopic ossification (3.2%), and olecranon nonunion (3.2%). Eight patients underwent secondary procedures: 7 (23%) removal hardware, 3(9.6%) capsular release, 2 (6.4%) ulnar nerve transpositions, and 1 (3.2%) total elbow arthroplasty.

Conclusion

We describe a novel surgical technique that we believe results in strong, stable fixation of complex intra-articular distal humerus fractures irrespective of bone quality. In our series, all fractures healed and post-operatively patients reported low levels of pain, achieved excellent elbow range of motion, high patient reported outcome scores. Patients should be counseled about high rates of post-operative ulnar nerve paresthesias that can be expected to improve over time and high reoperation rates for symptomatic hardware.

Survival and outcome of total elbow arthroplasty for distal humeral fracture at long term follow-up

Background Total elbow arthroplasty is an accepted procedure for the treatment of acute comminuted distal humeral fractures in elderly. Few long-term outcomes are available. The purpose of this study was to examine long-term clinical and radiological outcomes of prosthesis performed (January 2002-June 2015) for complex intra- fractures of the distal humerus (AO/C) in patients older than 65 years with low functional demands. Materials and Methods Further inclusion criteria were: the availability of a clinical and radiological follow-up of minimum 5 years and pattern of closed fracture. Demographic data and characteristics of patients were collected. All patients were clinically and radiographically assessed after 2 and 5 years from surgery. Results Twelve patients were included with complete available data. The mean follow-up was 7.6 years. Five patients reported a worsening of the elbow functionality through the follow-ups. Five subjects had complications. There were no cases of revision surgery. The quality of fixation showed a progressive worsening with increase of radiolucency both on humeral and ulnar side. The recorded MEPS showed no correlation with the grade of periprosthetic osteolysis. Polyethylene bushing wear was scored of grade 2 in one subject who had showed type 4 Morrey radiolucency. Discussion and Conclusions Total elbow arthroplasty is an effective and reliable procedure for comminuted fractures of the distal humerus in elderly, although the incidence of complications can not be considered as negligible. For the majority of these patients, a well-performed implant will give them a well-functioning elbow for their remaining life.

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.

Reoperation Risk After Total Elbow Arthroplasty Versus Open Reduction Internal Fixation for Distal Humerus Fractures in Elderly Patients

OBJECTIVE

To compare reoperation risk after total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF) for intra-articular distal humerus fractures in elderly patients.

DESIGN

Retrospective comparative.

SETTING

Five percent Medicare Part B claims database.

PATIENTS

Patients older than 65 years of age with closed distal humerus fractures undergoing TEA or ORIF from 1996 to 2016.

INTERVENTION

TEA and ORIF.

MAIN OUTCOME MEASURE

Reoperation risk based on multivariate Cox proportional hazards modeling.

RESULTS

A total of 142 TEA and 522 ORIF cases were identified. TEA patients had a greater age and Charlson Comorbidity Index , as well as a higher prevalence of rheumatoid arthritis and osteoporosis than ORIF patients (P < 0.05). Although reoperation risk was lower for TEA than that for ORIF within the entire cohort (11.3% vs. 25.1%; hazard ratio = 0.49; P = 0.014), no significant difference was found for TEA and ORIF performed between 2006 and 2016 (12.6% vs. 18.4%; hazard ratio = 0.73; P = 0.380). The death rate was 65.5% in the TEA group at 3.6 years and 55.7% in the ORIF group at 4.9 years.

CONCLUSIONS

TEA was associated with a decreased reoperation risk compared with ORIF, although this difference did not exist for more recent procedures after popularization of the locking plate technology and half of the reoperations after ORIF were for instrumentation removal. The high death rate within several years of the index procedure may contribute to the low TEA revision rate beyond the short-term when following patients into the medium and long term. Further study comparing TEA and locked plating using prospective, randomized data with long-term follow-up and functional outcomes is warranted.

LEVEL OF EVIDENCE

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

Management of the failed radial head arthroplasty

Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases.

The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis.

The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA.

Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues.

In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint.

Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055

Total Elbow Arthroplasty for Distal Humerus Fractures Provided Similar Outcomes When Performed as a Primary Procedure or After Failed Internal Fixation

OBJECTIVES

To compare clinical and functional outcomes of total elbow arthroplasty (TEA) for distal humerus fractures (DHF) performed either as a primary procedure or after internal fixation.

DESIGN

Retrospective, observational study.

SETTING

Mayo Clinic, Rochester, MN (1998 through 2016).

PATIENTS/PARTICIPANTS

Twenty-two TEA for acute DHF and 66 TEA after previous internal fixation.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures included the Mayo Elbow Performance Score and motion. Reoperation rates and complications were also compared.

RESULTS

The mean time between internal fixation and arthroplasty was 7.3 years, and the main indications for conversion to TEA were nonunion (36%) and posttraumatic osteoarthritis (32%). There were female predominance (70%) and significant differences in age (74 years vs. 60 years, P < 0.0001) and tobacco use (0 vs. 23%; P = 0.02) between the primary and the salvage cohorts, respectively. Cohort demographics were otherwise comparable. TEA provided similar outcomes in both cohorts in terms of the Mayo Elbow Performance Score (acute 85, salvage 81, P = 0.32) and motion (acute 95/82/75 degrees, salvage 112/81/72 degrees in ulnohumeral/pronation/supination, P = 0.07/P = 0.85/P = 0.65). Reoperation rates were also similar (36% acute vs. 39% salvage, P = 1.00). Aseptic loosening (2 acute, 8 salvage) and deep infection (2 acute, 7 salvage) were the most common complications.

CONCLUSIONS

The clinical outcomes and reoperation rates of TEA for DHF seem to be similar when performed as a primary procedure or as salvage after previous internal fixation. The benefit of avoiding elbow arthroplasty in the acute setting needs to be balanced with the potential for 2 surgical procedures if internal fixation was to be unsuccessful.

LEVEL OF EVIDENCE

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

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.

Long-term outcomes of total elbow arthroplasty for distal humeral fracture: results from a prior randomized clinical trial

BACKGROUND

Total elbow arthroplasty (TEA) is a reliable treatment for elderly patients with comminuted intra-articular distal humeral fractures. However, the longevity and long-term complications associated with this procedure are unknown. The objectives of this study were to examine long-term outcomes and implant survival in elderly patients undergoing TEA for fracture.

METHODS

Patients from a previously published randomized controlled trial of 42 patients in which TEA was compared with open reduction-internal fixation (ORIF) were followed up long term. Patients were aged 65 years or older with comminuted intra-articular distal humeral fractures. Outcomes included patient-reported grading of function and pain, revision surgical procedures, and implant survival.

RESULTS

Data were obtained for 40 patients, 15 treated with ORIF and 25 treated with TEA, with a mean follow-up period of 12.5 years for surviving patients and 7.7 years for deceased patients. The reoperation rate was 3 of 25 in the TEA group and 4 of 15 in the ORIF group (P = .39). Of the 25 patients with TEAs, only 1 required (early) revision arthroplasty; 7 were living with their original arthroplasty, and 15 died with a well-functioning implant in situ. Three were lost to follow-up.

CONCLUSIONS

TEA is an effective and reliable procedure for the treatment of comminuted distal humeral fractures in the elderly patient. Our study reveals reliable implant long-term survival, with no patient requiring a late revision. For the majority of these patients, a well-performed TEA will give them a well-functioning elbow for life and will be the last elbow procedure required.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Heterotopic ossification after total elbow arthroplasty: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes after revision total elbow arthroplasty: a systematic review

BACKGROUND

Although revision arthroplasty surgery is a frequently used treatment for failed total elbow arthroplasty (TEA), published results are conflicting. The aim of this systematic review was to provide an overview of the outcomes of revision TEA surgery.

METHODS

A systematic literature search was performed in major databases to find articles relating to outcomes after revision of TEA. Two reviewers independently screened the articles for inclusion, and a third reviewer screened them before final inclusion.

RESULTS

Twenty-one articles containing 532 cases were included. The mean age at revision was 61 years. The mean interval between primary and revision arthroplasty was 77 months, and the average follow-up period was 65 months. Different types of prostheses were included, with 69% of the revision prostheses having linked designs and 31% having unlinked designs. The visual analog scale score, Mayo Elbow Performance Score, Oxford Elbow Score, and range of motion improved significantly after revision surgery. Complications were reported in 232 of 532 cases (44%), leading to reoperations in 22%. After revision with linked prostheses, the Mayo Elbow Performance Score, range of flexion-extension, and pronation improved significantly more than with unlinked designs.

CONCLUSION

Improved functional outcomes can be expected after revision TEA, but the complication rate remains high. Revision TEA should still be considered a salvage procedure for failed TEA. Linked designs for revision TEA result in better outcomes than unlinked designs in the midterm follow-up.

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

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

Triceps on, alignment off? A comparison of total elbow arthroplasty component positioning with a triceps-on and a triceps-off approach

Introduction This retrospective review investigates whether the triceps-on approach obtains alignment of total elbow arthroplasty implants equivalent to a triceps-off approach. Methods The last 30 consecutive total elbow arthroplasties performed by the senior author were reviewed to identify the approach used and pathology treated. Initially, a triceps split and reflection approach was used, then a triceps-preserving approach. Two blinded reviewers measured the component alignment in standardised radiographs. Pearson's correlation coefficient was calculated to investigate inter/intra-observer and error. The two groups were compared using an unpaired Student t-test. Results There were 13 elbows in the triceps-off group and 17 in the triceps-on group. Pearson's coefficient was 0.75 for interobserver error, 0.89 for intra-observer error. There was no statistical difference between the achieved alignment. All ulna components were flexed with a mean angle deviation of 4.5 degrees in the triceps-off group and 5.7 degrees in the triceps on. Two (15%) ulna components in the triceps-off group were placed in over 5 degrees of flexion, compared with seven (44%) in the triceps-on group. Conclusion These results demonstrate no statistical difference in the achieved alignment between the two groups. Surgeons should beware of the tendency to place the ulna component in a flexed position, especially in the triceps-on approach.

Heterotopic ossification following total elbow arthroplasty

Aim

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

Patients and Methods

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

Results

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

Conclusion

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

Long-term results of the lateral resurfacing elbow arthroplasty

Aims

The aim of this study was to report the long-term outcome and implant survival of the lateral resurfacing elbow (LRE) arthroplasty in the treatment of elbow arthritis.

Patients and Methods

We reviewed a consecutive series of 27 patients (30 elbows) who underwent LRE arthroplasty between December 2005 and January 2008. There were 15 women and 12 men, with a mean age of 61 years (25 to 82). The diagnosis was primary hypotrophic osteoarthritis (OA) in 12 patients (14 elbows), post-traumatic osteoarthritis (PTOA) in five (five elbows) and rheumatoid arthritis (RA) in ten patients (11 elbows). The mean clinical outcome scores including the Mayo Elbow Performance Score (MEPS), the American Shoulder and Elbow Surgeons elbow score (ASES-e), the mean range of movement and the radiological outcome were recorded at three, six and 12 months and at a mean final follow-up of 8.3 years (7.3 to 9.4). A one sample t-test comparing pre and postoperative values, and survival analysis using the Kaplan-Meier method were undertaken.

Results

A statistically significantly increased outcome score was noted for the whole group at each time interval. This was also significantly increased at each time in each of the subgroups (OA, RA, and PTOA). Implant survivorship was 100%.

Conclusion

We found that the LRE arthroplasty, which was initially developed for younger patients with osteoarthritis, is an effective form of surgical treatment for a wider range of patients with more severe degenerative changes, irrespective of their cause. It is therefore a satisfactory alternative to total elbow arthroplasty (TEA) and has lower rates of complications in the subgroups of patients we have studied. It does not require activities to be restricted to the same extent as following TEA. Based on this experience, we now recommend LRE arthroplasty rather than TEA as the primary form of implant for the treatment of patients with OA of the elbow. Cite this article: Bone Joint J 2018;100-B:338-45.

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.

Open reduction and internal fixation for nonunion of extra-articular distal humeral fractures in patients 70 years and older

HYPOTHESIS

The study purpose was to report the clinical and radiologic outcomes of osteosynthesis by open reduction and internal fixation for nonunion of extra-articular distal humeral fractures in patients aged 70 years or older.

MATERIALS AND METHODS

This retrospective study included 28 patients who received osteosynthesis treatment between March 2010 and December 2015. Primary conservative treatment had failed in all patients. All surgical procedures were performed via the posterior approach without olecranon osteotomy and with the use of double-locking plates for each column.

RESULTS

The mean patient age was 72 years, and surgical procedures were performed a mean of 7.6 months after injury. Preoperatively, extension-flexion was 32° to 101° and forearm pronation-supination was 74° to 47°. The mean visual analog scale score was 4; the mean Mayo Elbow Performance Score was 50; and the mean Disabilities of the Arm, Shoulder and Hand score was 58. All cases showed proper union after a mean of 5.2 months. At the final follow-up examination, the extension-flexion and rotation arcs had improved significantly (to 20° to 124° and to 80° to 66°, respectively; both P < .001), and all clinical scores were satisfactory (visual analog scale score, 1; Mayo Elbow Performance Score, 65; and Disabilities of the Arm, Shoulder and Hand score, 24; all P < .001). Ulnar nerve transposition was performed in 7 patients, and no distinct ulnar nerve symptom was observed in any patient at the final follow-up examination.

CONCLUSIONS

We consider osteosynthesis by open reduction and internal fixation as a recommended option for extra-articular distal humeral fractures in elderly patients aged 70 years or older in whom conservative treatment has failed.

Total elbow arthroplasty under unfavourable soft tissue conditions

PURPOSE

To evaluate the clinical and radiographic outcomes of patients with total elbow arthroplasty (TEA) and soft tissue reconstruction.

METHODS

We investigated six patients who underwent TEA and soft tissue reconstruction (two elbows with 1-stage surgery and four elbows with 2-stage surgery). The mean patient age at the time of the surgical procedure was 43.2 years; the mean follow-up duration was 88.2 months.

RESULTS

The mean pain visual analogue scale (VAS) during motion was improved from 6.3 pre-operatively to 0.7 at the last follow-up. The mean Mayo Elbow Performance Score (MEPS) improved from 26.7 pre-operatively to 81.7 at the last follow-up. The mean flexion-extension arcs of the 1- and 2-stage surgery groups increased from 12.5° and 13.8° pre-operatively to 72.5° and 100° at the last follow-up, respectively. The mean MEPS of the one and two stage surgery groups were 75 and 85, respectively, at the last follow-up. One of the six elbows had loosening on the simple radiograph at the last follow-up, and there were no cases with bushing wear. Three elbows needed additional skin debridement owing to wound complications (2/2 elbows in the 1-stage surgery group and 1/4 elbows in the 2-stage surgery group).

CONCLUSIONS

Under unfavorable soft tissue conditions, performing soft tissue reconstruction with TEA provides satisfactory functional improvement and pain relief. The two stage surgery provided a lower rate of wound complication and better elbow function than the one stage surgery, which led to high patient satisfaction post-operatively.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Distal Humeral Fractures-Current Concepts

Background:

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

Methods:

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

Results:

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

Conclusion:

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

HYPOTHESIS

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

TYPE OF STUDY

Retrospective non-comparative, single-center.

LEVEL OF EVIDENCE

4.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Elbow vascularized composite allotransplantation-surgical anatomy and technique

BACKGROUND

Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA.

METHODS

We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique.

RESULTS

The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs.

CONCLUSIONS

Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.

Non-operative management of distal humerus fractures in the elderly: a review of functional outcomes

Comminuted distal humerus fractures in the elderly have traditionally been managed by ORIF or total elbow arthroplasty (TEA). This poses a treatment dilemma in elderly patients where anaesthetic and surgical risks combine with poor bone and wound healing. We aimed to assess the functional outcomes in patients managed non-operatively, with TEA being used as the salvage procedure. Retrospective analysis of patients over 65 years presenting to our unit between 2005 and 2015 was undertaken. Sixty-two patients were identified, 38 had died, and 5 were lost to follow-up leaving 5 with immediate TEA and 14 non-operatively managed, available for review. Mean follow-up was 55 months (range 17-131). Patient outcomes were measured using VAS scores for pain at rest and during activity, and the Oxford elbow score (OES) for TEA and non-operatively managed patients. Conversion to TEA for non-operative treatment and complications were also recorded. Notes interrogation of patients who had died or were lost to follow-up to ascertain outcomes was undertaken. The mean age at injury was 76 years (range 65-90) of which 79% (11/14) were females. The mean score on the OES was 46.2 (range 29-48). The mean VAS score at rest was 0.4 (range 0-6), and the mean VAS score during activity was 1.3 (range 0-9). 93% (13/14) of patients reported no pain in their injured elbow at rest and 79% (11/14) reported no pain during activity. No patients converted to TEA, and there were no complications. Of deceased patients, notes demonstrated one who had ongoing stiffness after physiotherapy, but no conversions to TEA were undertaken. Those managed primarily with TEA had worse OES (mean 40.8), but slightly better pain scores with means 0.2 at rest and 0.8 at activity. Non-operative management of comminuted distal humerus fractures should be considered for elderly patients, avoiding surgical risks whilst giving satisfactory functional outcomes in this low-demand group.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Inserting the Ulnar Prosthesis into Radius as a Novel Salvage Surgery for Revision Total Elbow Arthroplasty with Massive Bone Defect

Background:

Infection and aseptic loosening are common complications of total elbow arthroplasty (TEA) and often require revision surgery. However, bone defects, along with other complications, bring an extra difficulty to the second surgery, especially for patients with a massive bone defect in the proximal ulna. Several methods including allograft or autograft have been introduced into practice, but none sufficiently solves these problems.

Methods:

We conducted a new surgical method for patients with a massive ulnar bone defect needing revision TEA. During revision arthroplasty, the ulnar prosthesis was inserted into the radius as a salvage procedure. Four consecutive patients received revision arthroplasty with this method between 2013 and 2016. Patients’ data were collected to evaluate the clinical outcome.

Results:

All patients had a Grade III ulnar bone defect. At the last follow-up session, all patients reported a painless, functional elbow joint. Three patients suffered from a periprosthetic infection that was completely cured using the two-stage method. No major complications, including infection, aseptic loosening, or wound problems were found. One patient had a transient ulnar neuritis, and another had a transient radial neuritis. Both patients had full recovery at the last follow-up session.

Conclusions:

Inserting an ulnar prosthesis into the radius is a novel procedure for patients with a massive bone defect due to infection or aseptic loosening. It is a safe, quick, and effective treatment with a promising short-term outcome. This method should be provided as a salvage procedure for patients with a nonreconstructable ulnar bone defect.

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.].

Short-term clinical results of revision elbow arthroplasty using the Latitude total elbow arthroplasty

Aims

Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA.

Patients and Methods

Between 2006 and 2010 we used the Latitude TEA for revision in 18 consecutive elbows (17 patients); mean age 53 years (28 to 80); 14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde TEA in three. Stability, range of movement (ROM), visual analogue score (VAS) for pain and functional scores, Elbow Functional Assessment Scale (EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM) and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed pre-operatively and at each post-operative follow-up visit (six, 12 months and biennially thereafter). Radiographs were analysed for loosening, fractures and dislocation. The mean follow-up was 59 months (26 to 89).

Results

The ROM of the elbow did not improve significantly. The mean EFAS and MAESS scores improved significantly six months post-operatively (18.6 points, standard deviation (sd) 7.7; p = 0.03 and 28.8 points, sd 8.6; p = 0.006, respectively) and continued to improve slightly or reached a plateau. The mean pain scores at rest (Z = -3.2, p = 0.001) and during activity (Z = -3.2, p = 0.001), and stability (Z = -3.0, p = 0.003) improved significantly six months post-operatively. Thereafter scores continued to improve slightly or a plateau was reached. There were no signs of loosening.

Conclusion

Revision surgery using the Latitude TEA results in improvement of functionality, reduced pain and better stability of the elbow. Improvement of ROM of the elbow should not be expected. Cite this article: Bone Joint J 2016;98-B:1086–92.