Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature

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

INTRODUCTION

Distal humerus fractures are fairly rare. But as our population ages, these fractures become more complex and the choice of treatment more delicate. Poor bone quality results in many technical problems and the fixation hardware stability remains at risk. The goal of this study was to evaluate the functional recovery and morbidity of complex distal humerus fractures in elderly patients when treated with elbow prosthesis.

HYPOTHESIS

Good functional recovery can be achieved with a total joint replacement.

PATIENTS AND METHODS

This series consisted of 20 patients (18 women and two men) having an average age of 80years (range 65-93, median 80). Based on the AO classification, there were two Type A2 fractures, two Type B fractures, 15 Type C fractures and one fracture that could not be classified because of previous rheumatoid disease history at this elbow. Two fractures were open. In two cases, the olecranon was also fractured. Treatment consisted of the implantation of a Coonrad-Morrey, hinge-type total elbow prosthesis (Zimmer(®), Warsaw, IN, USA). The Mayo Clinic surgical approach was used 17 times and the transolecranon approach was used three times. Primary arthroplasty was performed in 19 cases and the surgery was performed after six weeks of conservative treatment (diagnostic delay) in one case. Unrestricted motion was allowed after surgery, but a maximum of 0.5kg could be carried during the first 3months; this was subsequently increased to 2.5kg.

RESULTS

Fifteen of the 20 patients were available for reevaluation with an average follow-up of 3.6years (range 1.7-5.5, median 3.4). Four patients had died and one was lost to follow-up. The average range of motion was 97° (range 60-130°), comprising an average flexion of 130° (range 110-140°) and average loss of extension of 33° (range 0-80°). Pronation and supination were normal. The average Mayo Elbow Performance Score (MEPS) was 83 (range 60-100, median 80). X-rays revealed seven cases of radiolucent lines, with two being progressive. There was no visible wear of the polyethylene bushings at the hinge. Six patients had moderate periarticular heterotopic ossification. The two cases of olecranon osteotomy and one case of olecranon fracture had healed. There were no surgical site infections but two cases of ulnar compression, one of which required neurolysis. There was one case of humeral component loosening after 6years, but the implant was not changed.

DISCUSSION

The clinical range of motion results were comparable to published data. The functional scores were slightly lower, mainly because of the pain factor. The initial results were encouraging and consistent with published data as long as the indications were well-chosen. Based on this retrospective study, total elbow arthroplasty can be a valid alternative in the surgeon's treatment armamentarium for complex distal humerus fractures in elderly patients who have moderate functional demands. Our results support our hypothesis, since we found good functional recovery without associated morbidity.

LEVEL OF EVIDENCE

Level IV retrospective study without comparator.

Distal humerus fractures in the elderly: osteosynthesis or endoprosthesis? Review of the literature

Fractures of the distal humerus in adults are rare but challenging for the orthopaedic trauma surgeon. The bimodal distribution reflects the trauma mechanism. While distal humerus fractures are caused by high-energy traumata in young male adults, a fall from a standing height is the most common reason for humerus fractures among elderly females. As a rule, fractures of the distal humerus are treated surgically. In young patients, open reduction and internal fixation (ORIF) with anatomic locking plates are the gold standard. In elderly patients, reconstruction is not always possible, and total elbow arthroplasty (TEA) becomes necessary. The present article provides an overview of the current diagnostic and treatment recommendations. The current literature is reviewed and the results discussed.

Fragility fractures of the distal humerus

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.

Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up

BACKGROUND

The LCP Distal Humerus Plate (DHP) system represents an angular stable fixation system consisting of 2 anatomically pre-shaped orthogonal plates intended for the treatment of fractures of the distal humerus. The purpose of this retrospective study was to evaluate the clinical and radiologic outcome after a minimum follow-up of 2 years after open reduction and fixation of distal humeral fractures with this device.

METHODS

Twenty-two consecutive patients with distal humeral fractures were treated with the DHP system between January 2004 and June 2006. Of these, 16 could be clinically and radiologically evaluated after a mean follow-up of 30.5 months. Follow-up included anteroposterior and lateral radiographs; assessment of range of motion; pain according to a VAS; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score.

RESULTS

All fractures showed satisfactory articular reduction. One patient showed preoperative sensory ulnar neuropathy, which recovered incompletely, and two patients showed sensory ulnar neuropathy postoperatively, requiring revision surgery in one patient. Mean range of motion was as follows: flexion, 129°; extension, -16°; pronation, 82°; and supination, 71°. The mean visual analog scale score was 1 point; the mean Disabilities of the Arm, Shoulder and Hand score, 23.3 points; and the mean Mayo Elbow Performance Score, 84.7 points.

CONCLUSION

The DHP system represents a valuable tool to perform internal fixation of complex fractures of the distal humerus. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, even in elderly patients with potentially reduced bone mass. The multiple angular stable point fixation also of small distal fragments seems to be effective in the application of this system.

Innovative techniques for the osteosynthesis of distal humeral fractures

Adequate restoration of the mechanical alignment, anatomic reduction of the articular surface, and stable fixation allowing early motion of the elbow joint are the primary goals in the treatment of distal humeral fractures. The purpose of our study is the comparison of the effectiveness between distal humeral locking compression plates (LCP) and conventional reconstruction and one third tubular plates. Between January 2008 and January 2009, 11 consecutive patients (4 men and 7 women) with distal humeral fractures were treated with plates in our hospital; eight patients were treated with LCP distal humeral plates and three cases were fixed with a combination of 1/3 tubular plates and reconstruction plates. They were all followed up for 12 months using the functional score of Cassebaum and radiologically with standard X-rays. Good to excellent results were obtained in 6/11 patients with a mean range of motion of 115°. At this small cohort of patients no significant differences between the two fixation methods was identified regarding clinical outcome, complications and function of the affected limb.