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

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.

Minimum four-year clinical outcomes after on-table reconstruction technique for Dubberley type III in coronal shear fractures of the capitellum and trochlea: a report of 10 patients

PURPOSE

Comminuted coronal shear fractures of the distal humerus represent rare injuries and are difficult to treat, especially comminuted capitellum and trochlear fractures (Dubberley Type III). The on-table reconstruction technique of comminuted articular fractures may be an option, although it has not been reported in the coronal shear fracture of the distal humerus. The aim of the present case series is to determine the functional and radiological outcomes of on-table reconstructed Dubberley III fractures.

METHODS

A retrospective review was conducted of 10 patients with Dubberley type III fractures in coronal shear fractures of the capitellum and trochlea who underwent an 'on-table' reconstruction technique between January 2009 and October 2019. All patients were evaluated using the disabilities of the arm, shoulder, and hand (DASH) score, American Shoulder and Elbow Surgeons(ASES) score, Mayo Elbow Score Performance Index (MEPI) score and at least 4 years later.

RESULTS

All cases achieved union. At the final follow-up, the mean range of elbow motion was 11.5°of flexion contracture and 131.9° of further flexion. The mean DASH score was 21.2 (5.7) points (range 13.3-32.5). The mean ASES score was 88.6 ± 7.4 (range, 77 to 100). The mean MEPI score was 87 (10) points (range 70-100). In complication, partial osteonecrosis of capitellum is developed in one patient. One patient had heterotopic ossification without functional impairment.

CONCLUSION

The on-table reconstruction technique can be a reliable option in the surgical treatment of complex distal humerus fractures. This technique allows anatomical reduction of comminuted capitellum and trochlea, with a low risk of avascular necrosis over 4 years of follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective 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.

The "Bag of Bones" Treatment of Comminuted Intra-articular Distal Humerus Fractures in the Elderly

BACKGROUND

Extensively comminuted intra-articular distal humerus fractures in the elderly present a challenging therapeutic dilemma. The purpose of this study was to investigate the results of nonoperative treatment of these fractures in a select subset of patients.

METHODS

Patients treated with nonoperative management for a comminuted intra-articular distal humerus fracture between 2007 and 2018 were reviewed. Patients were administered 3 elbow-specific functional outcomes instruments.

RESULTS

A total of 8 patients (2 men, 6 women) were treated with brief immobilization followed by early range of motion. All had fractures with extensive comminution of the articular surface such that open reduction and internal fixation was not feasible. Average age was 70 years. At an average of 33 months postinjury, average flexion was 124°, and extension was -27°, with full forearm rotation. No patients required pain medications at the latest follow-up. At 33 months of follow-up, the average Mayo Elbow Performance Score was 92/100 (100 optimal), Oxford Elbow Score was 43/48 (48 optimal), and Quick Disabilities of the Arm, Shoulder, and Hand Score was 10/100 (0 optimal). All patients were satisfied with the nonsurgical treatment that they received.

CONCLUSIONS

Nonoperative treatment for comminuted intra-articular distal humerus fractures results in acceptable functional outcome in elderly patients and should be considered when the fracture is not amenable to internal fixation and in lower-demand patients with higher surgical risk.

Risk Factors for Non-Union after Open Reduction and Internal Fixation in Patients with Distal Humerus Fractures

BACKGROUND

Only a few studies have reported on the risk factors for non-union after open reduction and internal fixation (ORIF) in distal humerus fractures.

METHODS

We retrospectively reviewed 155 patients who underwent ORIF for distal humerus fractures from January 2008 to June 2020. Various patient factors, including body mass index (BMI), diabetes mellitus (DM), and combined fracture, as well as surgical factors, including fixation methods (e.g., orthogonal plate/parallel plate/single plate/tension bend wiring [TBW]) and combined fracture operations, were evaluated as risk factors for non-unions.

RESULTS

Among the patient factors, BMI (25.0 ± 3.4 vs. 22.7 ± 3.4, p = 0.032), DM (5/13 [38.5%] vs. 20/142 [14.1%], p = 0.038) and combined fracture (5/13 [38.5%] vs. 16/142 [11.3%], p = 0.018) were significantly different between groups with non-union and union. Among the surgical factors, combined fracture operation (5 [38.5%] vs. 9 [6.3%], p = 0.002) and the fixation method (3 [23.1%]/1 [7.7%]/4 [30.8%]/5 [38.5%] vs. 84 [59.2%]/7 [4.9%]/40 [28.2%]/11 [7.7%], p = 0.005) showed a significant difference between groups with non-union and union. Multivariate regression analysis showed that combined fracture operation (OR 10.467; 95% CI 1.880-58.257; p = 0.007) and TBW (OR 9.176; 95% CI 1.474-57.135; p = 0.018) among the fixation methods posed as a significant risk factor for non-union.

CONCLUSIONS

The risk of non-union increased in patients who underwent surgery for another fracture combined with distal humerus fracture and in patients who underwent ORIF with TBW.

Bilateral triceps tendon approach is flexible and efficient in the treatment of type C distal humerus fractures

PURPOSE

The purpose of this study was to assess and compare elbow range of motion, triceps extension strength and functional results of type C (AO/OTA) distal humerus fractures treated with bilateral triceps tendon (BTT) approach and olecranon osteotomy (OO). At the same time, we are also trying to know whether BTT approach can provide sufficient vision for comminuted intra-articular fractures of the distal humerus, and whether it is convenient to convert to the treatment to total elbow arthroplasty (TEA) or OO.

METHODS

Patients treated with OO and BTT approaches for type C distal humerus fractures between July 2014 and December 2017 were retrospectively reviewed. Inclusion criteria include: (1) patients' age were more than 18 years old, (2) follow-up was no less than 6 months, and (3) patients were diagnosed with type C fractures (based on the AO/OTA classification). Exclusion criteria include: (1) open fractures (Gustillo type 2 or type 3), (2) treated by other approaches, and (3) presented with combined injuries of ipsilateral upper extremities, such as ulnar nerve. Elbow range of motion and triceps extension strength testing were completely valuated, when the fractures had healed. Assessment of functional results using the Mayo elbow performance score and complications were conducted in final follow-up. The data were compared using the two tailed Student's t-test. All data were presented as mean ± standard deviation.

RESULTS

Eighty-six patients of type C distal humerus fractures, treated by OO and BTT approach were retrospectively reviewed between July 2014 and December 2017. Fifty-five distal humerus fractures (23 males and 32 females, mean age 52.7 years) treated by BTT approach or OO were included in this study. There were 10 fractures of type C1, 16 type C2 and 29 type C3 according to the AO/OTA classification. Patients were divided into two surgical approach groups chosen by the operators: BTT group (28 patients) and OO group (27 patients). And the mean follow-up time of all patients was 15.6 months (range, 6-36 months). Three cases in BTT group were converted to TEA, and one converted to OO. Only one case in BTT group presented poor articular reduction with a step more than 2 mm. There were not significantly different in functional outcomes according to the Mayo elbow performance score, operation time and extension flexion motion are values between BTT group and OO group (p > 0.05). Complications and reoperation rate were also similar in the two groups. Triceps manual muscle testing were no significant difference in the two groups, even subdivided in elder patients (aged >60 years old).

CONCLUSION

BTT is a safe approach to achieve similar functional result comparing with OO. BTT were not suitable for every case with severe comminuted pattern, but it avoids the potential complications related to OO, and has no complications concerning with triceps tendon. It is convenient for open reduction internal fixation and flexible to be converted to OO, as well as available to be converted to TEA in elder patients.

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.

Outcomes and complications of distal humeral hemiarthroplasty for distal humeral fractures - A systematic review

BACKGROUND

Distal humeral hemiarthroplasty has been performed for a variety of indications with the most common being management of distal humeral fractures. This systematic review evaluates the outcomes and complications of distal humeral hemiarthroplasty for this pathology.

METHODS

We searched PubMed, EMBASE, and MEDLINE for studies reporting indications and outcomes of patients undergoing distal humeral hemiarthroplasty. Study screening, risk of bias assessment, and data extraction were performed. Summery statistics were provided.

RESULTS

We included 11 studies (N = 163) in this review. In all studies, the indication for distal humeral hemiarthroplasty was the presence of an intraarticular, comminuted, unreconstructable fracture. The mean post-operative MEPS, FullDASH, and QuickDASH (SD) scores were 83.6 (6.1) points, 25.4 (10.3), and 15.7 (7.4) points, respectively. The mean post-operative range of motion (SD) was 106° (11°) in the flexion and extension arc and 153° (19°) in the protonation and supination arc. The overall rate of adverse events and complication was 63%. The rate for major complications was 11%. The mean total revision rate was 4% (0% to 15) and total re-operation rate was 29% (0% to 88%).

CONCLUSION

Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates.

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.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

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.

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.

A Limited Fixation, Olecranon Sparing Approach, for Management of Geriatric Intra-Articular Distal Humerus Fractures

Purpose

We propose that geriatric comminuted intra-articular distal humerus fractures can be effectively treated with a limited fixation approach aimed at achieving varus/valgus stability with columnar fixation, but allowing intra-articular comminution to heal by secondary congruency against an intact olecranon, thus avoiding an olecranon osteotomy.

Methods

Fifty-six elderly patients with AO 13-C type fractures, who underwent surgical fixation with ≥12-months of follow-up were retrospectively reviewed. Thirty patients were treated with intra-articular open reduction internal fixation (ORIF) with an olecranon osteotomy and 26 patients were treated with our limited fixation (L-ORIF) approach. Outcomes were range of motion (ROM), complications, additional surgery, and patient-reported outcome measures (PROMIS).

Results

At final follow-up, the average elbow ROM was 97° (40°-155°) in the ORIF group and 86.5° (20°-145°) in the L-ORIF group. There was a trend toward more complications and additional surgery in the ORIF group. PROMIS scores for pain were 53.1 and 52.14, and PROMIS functional scores were 41.7 and 41.4 in the ORIF and L-ORIF group respectively. No differences in outcomes were statistically significant.

Conclusion

A limited fixation technique based on achieving varus/valgus stability with columnar fixation, demonstrated equivalent outcomes in elderly patients with intra-articular distal humerus fractures when compared to intra-articular ORIF with an olecranon osteotomy.

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.

Primary Total Elbow Replacement for Treatment of Complex Distal Humerus Fracture: Outcomes of Short-term Follow-up

Background

High complication rate after open reduction and internal fixation can lead to use of primary total elbow replacement (TER) in treatment of complex distal humerus fractures in elderly patients. The purpose of this study was to investigate the short-term outcomes and complications after primary TER in patients with complex distal humerus fracture.

Methods

Nine patients with acute complex distal humerus fracture were treated by primary TER using the semiconstrained Coonrad-Morrey prosthesis. The mean age of patients was 72.7 years (range, 63–85 years). Clinical and radiographic outcomes were evaluated over a mean follow-up of 29.0 months (range, 12–65 months) using visual analog scale (VAS) score for pain; Mayo elbow performance score (MEPS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; and serial plain radiographs. Complications were also evaluated.

Results

At the final follow-up, mean VAS, MEPS, and Quick-DASH scores were 1.2, 80.5, and 20, respectively. The mean range of motion was 127.7º of flexion, 13.8º of extension, 73.3º of pronation, and 74.4º of supination. There was no evidence of bushing wear or high-grade implant loosening on serial plain radiographs. Three complications (33.3%) comprising two periprosthetic fractures and one ulnar neuropathy were observed.

Conclusions

Primary TER for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes. However, surgeons should consider the high complication rate after primary TER.

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.

Prevention and management of early treatment failures in elbow injuries

The appropriate management of early treatment failures in patients with elbow injuries requires the identification of the cause of failure. In this work, six types of elbow injury are considered: (i) identification of early failed reduction of a dislocation or fracture-dislocation of the elbow should lead to a repeat reduction procedure, testing for elbow instability, and ligament repair, followed by the use of a hinged external fixator to allow early mobilisation. Differentiating an isolated dislocation from a dislocation combined with a fracture of the coracoid process is crucial. Re-implantation of the coronoid process allows repair of the ligaments and restoration of stability in the sagittal plane; (ii) early secondary displacement of a distal humeral fracture after internal fixation is usually due to insufficient fixation confined to a single humeral pillar. If both humeral pillars are fractured, then both must be repaired; (iii) early treatment failure of an intra-articular distal humeral fracture in an elderly patient with bone loss warrants distal humeral hemiarthroplasty or total elbow arthroplasty; (iv) in fractures of the olecranon, treatment failures are due to insufficient fixation or to a mistaken diagnosis of trans-olecranon fracture-dislocation; (v) in fractures of the radial head, causes of early revision include excessive tilting of the head in radial neck fractures, with secondary displacement due to insufficient internal fixation, and adverse effects on the wrist of radial head resection performed without assessing the ulnar variance. In patients with radial head fractures, no treatment decisions can be made before performing an anteroposterior radiograph of the wrist; (vii) in fracture-dislocations of both the radius and ulna, accurate reduction of the ulnar fracture is a pre-requisite to proper reduction of the radio-humeral and proximal radio-ulnar joints. An early postoperative assessment, within 10 days after surgery, is of paramount importance to re-evaluate the initial treatment and, if needed, to introduce modifications. Early failure of the initial treatment of an elbow injury should lead to the prompt implementation of corrective measures: follow-up anteroposterior and lateral radiographs must be obtained on day 8 to ensure the diagnosis of initial treatment failure and to allow the institution of an appropriate management strategy; the dogma stating that the elbow should never be immobilised remains valid, and every effort should be made to ensure that mobilisation starts as early as possible.

[Treatment of severe distal humeral bone defects with three-dimensional printing technology]

Objective

To explore the application of three-dimensional (3D) printing technology in precise and individualized surgical treatment of severe distal humeral bone defect.

Methods

Five patients with severe distal humeral bone defects were treated with customized 3D printing prostheses between December 2010 and December 2015. There were 4 males and 1 female, with an age of 23-57 years (mean, 35 years); and the length of the bone defect was 5-12 cm (mean, 8 cm). The cause of injury was mechanical injury in 2 cases and strangulation in 3 cases. All of them were the open fracture of Gustilo type Ⅲ. There were 2 cases of radial fracture, 1 case of cubital nerve injury, and 3 cases of radial nerve injury. The time from injury to one-stage operation was 6-18 hours (mean, 10 hours). The operation time, intraoperative blood loss, and intraoperative fluoroscopy were recorded. During follow-up, the anteroposterior and lateral X-ray films of the elbow joints were performed to identify whether there was prosthesis loosening; Mayo Elbow Performance Score (MEPS) and upper extremity Enneking score were used to evaluate limb function.

Results

The operation time was 140-190 minutes (mean, 165 minutes). The intraoperative blood loss was 310-490 mL (mean, 415 mL). The intraoperative fluoroscopy was 1-3 times (mean, 1.6 times). Five patients were followed up 14-38 months (mean, 21 months). The wound exudate occurred in 1 case and cured after anti-inflammatory local dressing change; the subcutaneous hematoma occurred in 1 case, and improved after color Doppler ultrasound guided puncture and drainage. The MEPS scores and the Enneking scores were all significantly improved when compared with preoperative ones ( P<0.05). Except MEPS score between 6 and 12 months after operation had no significant difference ( P>0.05), there were significant differences in MEPS scores and Enneking scores between the other time points ( P<0.05). During the follow-up, no prosthetic loosening or joint dislocation occurred.

Conclusion

3D printing technology can achieve personalized treatment of severe distal humeral bone defects, obtain relatively good elbow joint function, and has less postoperative complications and satisfactory effectiveness.

Operative Distal Humerus Fractures in Older Patients: Predictors for Early Complications Based on a National Database

BACKGROUND

Open reduction internal fixation (ORIF) and total elbow arthroplasty (TEA) have both been utilized in the treatment of distal humerus fractures in patients over 65 years of age. Comparisons of early complications between these procedures have not been well described.

QUESTIONS/PURPOSES

The purpose of this study is to evaluate complication rates in the treatment of distal humerus fractures in elderly patients and to utilize prediction models to identify risk factors associated with postoperative complications. Additionally, to compare ORIF and TEA treatment.

METHODS

A retrospective case series was performed by querying the National Surgical Quality Improvement Program for both ORIF and TEA performed for distal humerus fractures in patients over the age of 65 years between 2005 and 2014. We examined both preoperative risk factors and complications within 30 days in these three groups.

RESULTS

The sample included 216 ORIF and 65 TEA cases. No outcomes examined differed significantly between treatment groups. The most common outcome for both groups was bleeding requiring transfusion (8%). The observed effect size for the association between procedure and the composite morbidity outcome indicated little to no association (phi = 0.004). Furthermore, no presurgery variables were found to be significantly associated with procedure type. The only predictor with a significant independent association with the composite outcome, regardless of procedure type, was ASA class 3/4.

CONCLUSION

Clinical complications were low no matter the type of treatment. Low preoperative hematocrit was a risk factor in both ORIF and TEA.

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.

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.

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.

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.

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.].

The clinical outcome and activity levels of patients under 55 years treated with distal humeral hemiarthroplasty for distal humeral fractures: minimum 2-year follow-up

BACKGROUND

The aim of the present study was to describe the clinical outcomes and activity levels of young patients after distal humeral hemiarthroplasty (DHH).

METHODS

Six patients under 55 years (mean 44 years; range 29 years to 52 years) treated with DHH at a mean postoperative time of 81 months (range 24 months to 133 months) were studied retrospectively. Two other patients had been revised for aseptic loosening and were excluded.

RESULTS

The mean Mayo Elbow Score (MEPS) (88), Subjective Elbow Value (SEV) (89), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) (12) and American Shoulder and Elbow Surgeons (ASES) elbow pain (6), function (23) and satisfaction scores (9) were satisfactory. The mean University of California, Los Angeles (UCLA) activity score was 7.2.

CONCLUSIONS

Although only rarely indicated, DHH has satisfactory clinical outcomes in young patients and allows a higher level of function than is generally advised after total elbow arthroplasty.

Distal humerus fractures: a review of current therapy concepts

Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment.

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.

Total elbow joint replacement for fractures in the elderly--Functional and radiological outcomes

AIM

The purpose of this paper was to review the literature on the treatment of intra-articular fractures of the distal humerus in the elderly in order to evaluate the place for total elbow replacement (TER) in the light of our experience over the past 15 years.

METHODS

A review of the records of 11 consecutive patients over the age of 60 years who underwent primary TER for comminuted fractures of the distal humerus between 1997 and 2011 were reviewed and the surviving patients were interviewed. The Scopus database was used to perform a pragmatic review of the literature published between the mid-1990s and the present-day.

RESULTS

At the time of the most recent follow-up 3.5 years following surgery (range: 2-6 years) 7 patients assessed with the Mayo elbow performance index were classified as excellent, 4 were classified as good. There were no complications requiring further procedures encountered. Five surviving patients remain satisfied with the function of their TER. The number of papers recommending TER for treatment of these fractures continues to increase with time.

CONCLUSIONS

TER is now the treatment of choice for unreconstructable fractures of the distal humerus in the elderly. This option should therefore be available at the time of surgery for all distal humeral fractures in this patient population. A surgical approach other than olecranon osteotomy, which would preclude TER is therefore required.

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

BACKGROUND

Total elbow arthroplasty is an established option for the primary treatment of acute distal humeral fractures, but there are sparse data regarding elbow hemiarthroplasty (EHA) as an alternative. We present the outcome of EHA performed with a modular anatomic prosthesis and a "triceps-on" surgical technique.

METHODS

Eighteen consecutive patients underwent EHA for an acute fracture. Two patients died, leaving a study group of 16 patients with minimum 2-year follow-up. Clinical evaluation included range of motion; Mayo Elbow Performance Score; Quick Disabilities of the Arm, Shoulder, and Hand score; and Oxford Elbow Score. Radiographic assessment looked at alignment, evidence of loosening, ulnar and radial head wear, heterotopic ossification, and whether healing of the condyles had occurred.

RESULTS

Mean follow-up was 35 months (24-79 months). The mean scores were as follows: Mayo Elbow Performance Score, 89.6; shortened Disabilities of the Arm, Shoulder, and Hand score, 11.2; and Oxford Elbow Score, 43.7. The mean flexion and pronation-supination arcs were 116° and 172° respectively. Radial head wear was absent in 13 patients and mild in 3. Ulnar wear was absent in 6 patients, mild in 8, and moderate in 2. Wear was not associated with greater pain or inferior functional scores. There was no sign of aseptic loosening, and complete condylar bone union occurred in 15 elbows. There was 1 complication, a transient ulnar nerve neurapraxia that resolved without intervention.

CONCLUSION

EHA with a modular anatomic implant using a triceps-on approach is a reliable technique for the management of acute unreconstructible distal humeral fractures in older patients.

Distal humeral hemiarthroplasty: indications, results, and complications. A systematic review

BACKGROUND

Distal humeral hemiarthroplasty (DHH) is a treatment option for unreconstructable intra-articular distal humerus fractures. DHH may also be used in the setting of rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis. DHH has specific advantages over other, more common, treatment modalities: total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF). DHH is especially a reasonable option in younger patients to preserve bone stock, avoid significant weight restrictions, and limit loosening.

METHODS

The literature was reviewed for all cases of DHH for fracture and non-fracture indications between 1947 and 2014. Two hundred thirty-six papers were identified; 4 studies including 17 patients met criteria for non-fracture indications and 13 studies including 116 patients were identified for fracture indications. A systematic review was generated; patient indications, outcomes, and complications were recorded.

RESULTS

For non-fracture indications, good to excellent results were achieved in 76.5 % of patients with a mean arc of motion of 62° at mean follow up of 46.3 months. Half of the patients experienced a complication, most commonly stiffness. Loosening of the prosthesis was not noted in any patient. For fractures, good to excellent results were achieved in 67.4 % of patients with a mean arc of motion of 98.3° at a mean follow up of 42.2 months. One third of the patients experienced a complication but only 1.7 % experienced loosening of the prosthesis.

CONCLUSION

Here, we present the first review of the indications for DHH. DHH is a reasonable treatment option for older patients with unreconstructable intra-articular fractures of the distal humerus as well as younger patients with rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis.

Is primary total elbow arthroplasty safe for the treatment of open intra-articular distal humerus fractures?

OBJECTIVES

Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures.

METHODS

Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit.

RESULTS

Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21° (range 5-30°) to 113° flexion (range 90-130°). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits.

CONCLUSIONS

TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.

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.

Results of parallel plate fixation of comminuted intra-articular distal humeral fractures

BACKGROUND

This study investigated the results of parallel plate fixation of comminuted distal humeral fractures in a consecutive series of patients.

METHODS

Parallel plate fixation was used in 47 patients (30 women), mean age 60 years (range 18-98 years), with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C distal humeral fractures during 2007 to 2011. Medical records and radiographs were retrospectively assessed. Thirty-five patients completed Disabilities of Arm, Shoulder and Hand (DASH) outcome measure and the RAND Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey. Twenty-seven patients underwent clinical examination, Mayo Elbow Performance Score (MEPS) rating, and radiography after 3.9 years (range, 1.6-7.9 years) of follow-up.

RESULTS

The mean flexion arc was lower on the affected side vs the unaffected elbow (123° vs 140°, P = .03). The mean MEPS was 88; the result was excellent in 14, good in 8, fair in 3, and poor in 2 patients. DASH results indicated slight impairment of upper extremity function compared with the reference value (26 vs 10, P = .001). RAND SF-36 scores indicated normal quality of life compared with reference values from the Finnish population. Forty-four fractures united uneventfully. One case each of nonunion and malunion occurred. One olecranon osteotomy failed to unite. There were 3 cases of infection. Prominent hardware was a common late problem, and plates often required removal. The complication rate was 7 of 47 (15%); 4 of these patients (9%) required reoperation. The hardware removal rate was 13 of 47 (28%).

CONCLUSION

Parallel plate fixation is an effective method to treat comminuted distal humeral fractures. Good elbow function can be restored in most cases with minor impairments that do not worsen quality of life.

Reconstruction of traumatic losses of substance at the elbow

Traumatic lesions at the elbow involving great loss of substance are uncommon, but represent a significant problem when such cases are referred to a trauma department. Most of these injuries may cause severe final functional impairment, thereby jeopardising future activities, particularly in cases where treatment was delayed or inappropriate. The timing and method of treatment are critical. The trauma may involve soft tissues only, or bone and joint, or several structures at the same time, which results in combined complex tissue defects. Each type of tissue loss should be managed by choosing the most suitable technique from the armamentarium of reconstructive surgery, taking into account different priorities and the optimum timing (immediate or delayed, one- or two-stages). The authors describe a spectrum of indications and techniques that can be useful tools in managing these injuries.

Radial head, radiocapitellar and total elbow arthroplasties: a review of recent literature

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.

Distal humerus fractures in patients over 65: complications

INTRODUCTION

Fractures of the distal humerus in patients over the age of 65 remain a therapeutic challenge. Treatment options include conservative treatment, internal fixation or total elbow arthroplasty. The complications of these different treatment options were evaluated in a multicentre study.

MATERIALS AND METHODS

Four hundred and ninety-seven medical records were evaluated. A retrospective study was performed in 410 cases: 34 received conservative treatment, 289 internal fixation and 87 underwent total elbow arthroplasty. A prospective study was performed in 87 cases: 22 received conservative treatment, 53 internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated after at least 6 months follow-up.

RESULTS

The rate of complications was 30% in the retrospective study and 29% in the prospective study. The rate of complications in the conservative treatment group was 60%, and the main complication was essentially malunion. The rate of complications was 44% in the internal fixation group and included neuropathies, mechanical failure or wound dehiscence. Although complications only developed in 23% of total elbow arthroplasties, they were often more severe than those following other treatments.

DISCUSSION

Complications develop in one out of three patients over 65 with distal humerus fractures. Three main types of complications were identified. Neuropathies especially of the ulnar nerve, especially during arthroplasty, must always be identified, the nerve requiring isolation and transposition. Bone complications, due principally to mechanical failure, were found following internal fixation. Despite technical progress, care must be taken not to favor excessive utilization of this treatment option in complex fractures on fragile bone. Although there were relatively fewer complications with total elbow arthroplasty they were more difficult to treat. Ossifications were frequent whatever the surgical option and can jeopardize the functional outcome.

Unreconstructable acute distal humeral fractures and their sequelae treated with distal humeral hemiarthroplasty: a two-year to eleven-year follow-up

BACKGROUND

The aim of this study was to describe for the first time the medium to long-term outcome after distal humeral hemiarthroplasty (DHH).

METHODS

Twenty-six patients (mean age, 62; range, 29-92 years) treated with DHH for intra-articular distal humeral fractures and its sequelae were studied retrospectively.

RESULTS

Four patients had died and 4 had been revised to total elbow arthroplasty: 2 for periprosthetic fractures and 2 for primary component loosening (all in prostheses without an anterior flange). Six other complications had occurred: ulnar neuritis, 4; stiffness, 1; and wound necrosis, 1. Seventeen patients underwent assessment at a mean of 80 months after surgery. The mean values of the American Shoulder and Elbow Surgeons (ASES) elbow score (pain, 9.93; function, 25; satisfaction, 9.06); Mayo Elbow Performance Score (90); Quick Disabilities of Arm, Shoulder and Hand (19), and EuroQol EQ5D (Index, 0.84; Visual Analog Scale, 80) outcome measures demonstrated good function and satisfaction with little pain. The mean flexion extension arc was 116°. There was no evidence of instability. Radiologic evidence of ulnar wear was seen in 13 patients and may be related to prosthetic design to some extent. Worse wear was associated with a higher ASES pain score, lower satisfaction score, and lower EuroQoL Visual Analog Scale of quality of life. Degree of wear correlates with time after surgery but not with age at the time of surgery.

CONCLUSION

DHH offers a treatment option for unreconstructable distal humeral fractures and is associated with a good long-term outcome.

LEVEL OF EVIDENCE

Level IV, case series, treatment study.

Update on the state of outcome measurement in total elbow arthroplasty research: identifying a need for consensus

BACKGROUND

There is little consensus for a standard set of metrics to express outcome after total elbow arthroplasty. In order to set the stage for future work toward a core set of measurement tools, our goal was to gather a complete view of the outcomes used in total elbow arthroplasty research, the concepts of their focus, and their quality as measures of the target concept.

METHODS

We reviewed the outcome measures for total elbow arthroplasty presented in the literature from 2004 to 2011 in terms of the instruments used and their concepts of focus. We reviewed the reliability, validity, and responsiveness of the prevailing measurement tools.

RESULTS

Of the seventy-two articles identified, 90% (sixty-five) used elbow-specific aggregate outcome measures, which combine concepts, such as physiological variables, with symptom status and functional status. The Mayo Elbow Performance Score, or a variation of that scoring system, was used in fifty-four (75%) of the seventy-two articles. Most outcomes pertained to biological and physiological variables, with fewer outcomes focusing on symptoms, function, or overall health status. A review of the measurement properties of the elbow-specific aggregate outcome measures did not reveal one to be superior.

CONCLUSIONS

Overall, total elbow arthroplasty outcomes are heterogeneous in their reporting and lack standardization. The total elbow arthroplasty literature relies on several physician-derived elbow-specific aggregate measures and focuses primarily on physiological variables. The relative merits of aggregating findings into a single scoring system versus as separate components should be explored further. Finally, consideration should be given to patient-reported outcome measures in total elbow arthroplasty research.

CLINICAL RELEVANCE

This study of the current "state of practice" for outcome measurement in total elbow arthroplasty revealed gaps in the breadth of measurement and a lack of comparability in elbow scoring systems that could hinder our ability to clearly and fully understand outcome after total elbow arthroplasty. Future consensus work could address both concerns and assist in the development of a core set of outcome measures.

Semiconstrained total elbow arthroplasty for posttraumatic arthritis or deformities of the elbow: a prospective study

PURPOSE

To report the short-term results for posttraumatic total elbow arthroplasty.

METHODS

We included patients presenting to our hospital with symptomatic chronic posttraumatic arthritis or deformities of the elbow, aged 55 to 90 years. All patients had reconstruction with a Coonrad-Morrey prosthesis. We performed clinical follow-up after 2, 6, 12, 24, and 36 months, consisting of physical examination, standard radiographs, and calculation of the Mayo elbow performance index.

RESULTS

A total of 17 patients were enrolled in this study and had a mean follow-up of 32 months. Mean preoperative flexion arc was 67° and 105° postoperatively. The mean preoperative Mayo elbow performance index score was 54 (range, 30-80) and improved to a postoperative score of 93 (range, 60-100). We encountered 6 complications in 5 patients. Four complications required surgical intervention and 2 minor complications were treated noninvasively.

CONCLUSIONS

Short-term functional outcomes after total elbow arthroplasty in this prospective cohort of patients with posttraumatic arthritis or deformities of the elbow were good according to mean postoperative measurements.

Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years

INTRODUCTION

Fractures of the distal humerus are often complex and therefore challenging to treat. In elderly patients with decreased bone strength due to osteoporosis, strong fixation is crucial to allow resuming early motion that guarantees a good functional outcome as well as minimising mechanical complications. Locked implants meet these requirements. Here, we report outcomes in a uniform series of patients older than 65 years with distal humerus fractures managed with LCP DHP(®) (Synthès) fixation. Our objective was to evaluate the efficacy and limitations of this technique.

HYPOTHESIS

LCP DHP provides strong fixation of osteoporotic bone and leads to good clinical and radiological outcomes.

MATERIALS AND METHODS

We retrospectively studied 46 consecutive patients (2004-2010) with a mean age of 80 years including 15 with extra-articular and 31 with articular distal humerus fractures. At presentation, 11 complications were noted in nine patients (compound fractures and trauma-related nerve injuries). The transolecranon approach was used in 31 patients. Mean duration of immobilisation was 2.7 weeks in 33 patients.

RESULTS

Forty-three patients were re-evaluated after a mean follow-up of 25 months (range, 10-64 months); two patients died and one was lost to follow-up. Flexion was 127° and loss of extension was 23°, producing an average range of motion of 104°. Functional recovery was highly satisfactory with a Mayo Clinic Performance Score of 87 (70-100) and 95% of good and very good results. Postoperative complications consisted of infection (n=3), metaphyseal non-union (n=2), ulnar nerve injury (n=6), transient radial nerve palsy (n=1), and peri-articular ossification (n=4). Compound fracture and worse AO fracture type were associated with worse functional outcomes.

DISCUSSION

Despite the high complication rate, functional recovery was similar to that reported in previous case series, including after arthroplasty. Furthermore, the rate of mechanical complications was lower. Thus, our working hypothesis was confirmed.

LEVEL OF EVIDENCE

Level IV retrospective non-comparative study.