A multicenter, prospective, randomized, controlled trial of open reduction--internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients

Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly: A multi-center retrospective study (TRON study)

Background

Distal humerus fracture in the elderly is a challenging fracture for orthopedic surgeons. Non-union is one of the serious complications of distal humerus fracture after surgery. This retrospective multicenter study aimed to estimate the incidence of distal humeral non-union after open reduction and internal fixation, determine factors related to non-union, and compare the postoperative results of cases with non-union to cases with the union.

Methods

Among 423 patients diagnosed with distal humeral fracture and who were treated by surgical therapy in 2010-2020 from our database called TRON. Only 190 subjects met the inclusion criteria. We performed a logistic regression analysis with the presence of non-union as the response variable to examine risk factors. We compare the Mayo Elbow Performance Scores of cases with non-union to cases with the union.

Results

Non-union occurred after surgery in 15 patients (7.9%). The logistic regression analysis showed that body mass index<20 kg/m2 and ≥25 kg/m2, and ≤3 screws in the articular segment were significant explanatory factors for non-union (odds ratio 10.4 and 47.8, respectively). The Mayo Elbow Performance Scores were significantly worse in patients with non-union.

Discussion

Low and high body mass index and three or fewer screws in the articular segment might be risk factors for non-union of distal humerus fracture in the elderly. Non-union is associated with poor clinical outcomes.

Total Elbow Arthroplasty Versus Open Reduction and Internal Fixation for Distal Humerus Fractures: A Propensity Score Matched Analysis of 30-Day Postoperative Complications

Introduction

Open reduction and internal fixation (ORIF) is an established surgical procedure for distal humeral fractures; however, total elbow arthroplasty (TEA) has become an increasingly popular alternative for elderly patients with these injuries. Using a large sample of recent patient data, this study compares the rates of short-term complications between ORIF and TEA and evaluates complication risk factors.

Methods

Patients who underwent primary TEA or ORIF from 2012 to 2021 were identified by Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared.

Results

A total of 1539 patients were identified, with 1365 (88.7%) and 174 (11.3%) undergoing ORIF and TEA, respectively. Patients undergoing TEA were older on average (ORIF: 56.2 ± 19.8 years, TEA: 74.3 ± 11.0 years, P < .001). 348 patients were included in the matched analysis, with 174 patients in each group. TEA was associated with an increased risk for postoperative transfusion (OR = 6.808, 95% CI = 1.355 - 34.199, P = .020). There were no significant differences in any adverse event (AAE) between procedures (P = .259). A multivariate analysis indicated age was the only independent risk factor for the development of AAE across both groups (OR = 1.068, 95% CI = 1.011 - 1.128, P = .018).

Conclusion

The risk of short-term complications within 30-days of ORIF or TEA procedures are similar when patient characteristics are controlled. TEA, however, was found to increase the risk of postoperative transfusions. Risks associated with increasing patient age should be considered prior to either procedure. These findings suggest that long-term functional outcomes can be prioritized in the management of distal humerus fractures.

Articular fracture of the distal humerus classified Dubberley 2b: Case report of two patients and review of the literature

Articular fractures of the distal humerus are rare, and even rarer are fractures involving the trochlea and capitellum in a single fragment, with no associated comminution. These fractures are classified as 2a according to the Dubberley classification and are rarely described in the literature. Two cases of Dubberley 2a fractures were treated at our hospital. The first case, involving a 68-year-old patient, was treated with a medial and a lateral approach, combined with posteroanterior fixation using 3 Herbert screws. In the 2nd case, a 16-year-old male was treated with a single lateral approach, permitting fixation with two Herbert screws. One of the two screws is inserted into the bone at the edge of the cartilage, with an anteroposterior trajectory that leaves the cartilage intact. We opted mainly for posteroanterior screw fixation in subchondral bone, which is less damaging to articular cartilage and soft tissues and has already demonstrated its reliability. No associated lesions were found, and no complications were encountered. Results were excellent, with Mayo Elbow Performance Index (MEPI) scores of 95 and 100 respectively. Herbert screw fixation therefore appears to be an option of choice for these fractures, although comparative studies are needed to evaluate the different treatments available.

Risk of conversion to total knee arthroplasty after surgically treated tibial plateau fractures: an observational cohort study of 439 patients

BACKGROUND AND PURPOSE

We aimed to assess joint failure rate, i.e., subsequent conversion to TKA after surgical treatment of a tibial plateau fracture (TPF). Secondary aims were to explore the association between joint failure and fracture type, and to determine the risk of failure associated with inadequate joint surface reduction.

METHODS

We included all patients ≥ 18 years of age with a surgically treated TPF, treated at Uppsala University Hospital between 2002 and 2015. All fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Traumatology Association (AO/OTA) classification. Postoperative radiographs were evaluated to determine the quality of joint surface inadequate reduction, defined as an articular step-off ≥ 2 mm. The study cohort was linked with the Swedish Arthroplasty Register (SAR) for information on subsequent total knee arthroplasty (TKA).

RESULTS

439 patients (57% women) with a mean age of 55 years (SD 17) were included. According to the AO/OTA classification, the fracture distribution was B1: 4.8%, B2: 10%, B3: 47%, C1: 12%, C2: 6.4%, and C3: 19%. 23 patients (5.2%) were converted to a TKA within 2 years of initial surgery, and 34 patients (7.7%) had been converted by the end of follow-up (16 years). AO/OTA type B3 and C3 had a 6.8 (95% confidence interval [CI] 1.6-29) times greater risk of joint failure compared with B1-2 and C1-C2 at 2 years' follow-up. Inadequate joint surface reduction led to an 8.4 (CI 3.6-20) times greater risk of conversion to TKA at 2 years' follow-up.

CONCLUSION

Overall, 5.2% were converted to a TKA within 2 years. Fracture types AO/OTA B3 and C3 with a comminuted articular surface and inadequate joint surface reduction were strongly associated with joint failure.

Top fifty cited articles on humeral fractures

Background

Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature.

Methods

The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables.

Results

Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01).

Conclusion

The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.

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.

The Top 100 Classical and Contemporary Papers on Elbow Surgery: A Trend Analysis of Elbow Surgery Literature

INTRODUCTION

Bibliometric analyses provide an aggregate of the most frequently cited literature in a given field. The purpose of this study was to analyze the top 100 most-cited classical and contemporary papers relating to elbow surgery to serve as a reference for surgeons and trainees for educational and research purposes.

METHODS

A search was conducted for all papers containing the term "elbow" in the categories Orthopedics, Surgery, and Sports Science in the Clarivate Web of Science. Classical papers were those published from 1980 to 2009, and contemporary papers were those published from 2010 to 2019. Articles were assessed by country of origin, authors and their credentials, parent journal, level of evidence, and topic.

RESULTS

Citation frequency ranged from 86 to 867. Among the classical group, there were more level IV papers compared with level I papers; however, the opposite was true in the contemporary group. The most common topic in the classical group was elbow anatomy and function, and the most common topic in the contemporary group was lateral epicondylitis and medial epicondylitis and associated therapies.

DISCUSSION

This bibliometric analysis serves to help guide surgeons and trainees on the highly cited articles and important topics in elbow surgery, demonstrating a shift to prospective randomized controlled trials in recent years.

LEVEL OF EVIDENCE

Level V (Systematic Review with Level V as Lowest LOE).

Distal humeral hemiarthroplasty compared to total elbow replacement for distal humeral fractures: a registry analysis of 906 procedures

BACKGROUND

Total elbow replacement (TER) is an accepted treatment for complex intra-articular distal humerus fractures in elderly patients. Distal humeral hemiarthroplasty (HA) is also a potential surgical option for unreconstructable fractures and avoids the concerns regarding mechanical wear and functional restrictions associated with TER. In the current literature, there are limited data available to compare the revision rates of HA and TER for the treatment of fracture. We used data from a large national arthroplasty registry to compare the outcome of HA and TER undertaken for fracture/dislocation and to assess the impact of demographics and implant choice on revision rates.

METHODS

Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from May 2, 2005, to December 31, 2021, included all procedures for primary elbow replacement with primary diagnosis of fracture or dislocation. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazards models.

RESULTS

There were 293 primary HA and 631 primary TER procedures included. The cumulative percentage revision (CPR) rate at 9 years was 9.7% for HA (95% confidence interval [CI] 6.0, 15.7), and 11.9% (95% CI 8.5, 16.6) for TER. When adjusted for age and gender, there was a significantly higher risk of revision after 3 months for TER compared to HA (HR 2.47, 95% CI 1.22, 5.03, P = .012). There was no difference in the rate of revision for patients aged <55 years or ≥75 years when HA and TER procedures were compared. In primary TER procedures, loosening was the most common cause of revision (3.6% of primary TER procedures), and the most common type of revision in primary TER involved revision of the humeral component only (2.6% of TER procedures). TER has a higher rate of first revision for loosening compared to HA (HR 4.21, 95% CI 1.29, 13.73; P = .017). In HA procedures, instability (1.7%) was the most common cause for revision. The addition of an ulna component was the most common type of revision (2.4% of all HA procedures).

CONCLUSION

For the treatment of distal humerus fractures, HA had a lower revision rate than TER after 3 months when adjusted for age and gender. Age <55 or ≥75 years was not a risk factor for revision when HA was compared to TER. Loosening leading to revision is more prevalent in TER and increases with time. In HA, the most common type of revision involved addition of an ulna component with preservation of the humeral component.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial

BACKGROUND

Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.

MATERIAL AND METHODS

This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength.

RESULTS

Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group.

CONCLUSION

In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series

BACKGROUND

Managing distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock.

METHODS

A consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields.

RESULTS

Five patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures.

CONCLUSIONS

The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.

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.

The Novel Ulnar Nerve Coverage Method Which Has the Potential to Prevent the Postoperative Ulnar Neuropathy after Plate Fixation of Distal Humerus Fractures: Three Case Reports

Introduction

Postoperative ulnar neuropathy is still an unresolved complication in patients undergoing plate fixation of distal humerus fractures. We hypothesized that decreased blood flow to the ulnar nerve due to intraoperative procedures is an important factor in the development of postoperative ulnar neuropathy. We herein report three cases of distal humerus fractures in which the soft tissues surrounding the ulnar nerve were preserved as much as possible and finally not transferred anteriorly. Case Presentation. A 76-year-old woman, 82-year-old woman, and 34-year-old woman underwent plate fixation for distal humerus fractures. None of the patients developed postoperative ulnar neuropathy, and there were no complaints of numbness after postoperative day 1. Nerve conduction studies were performed after 3 months postoperatively and revealed that the motor nerve conduction velocities and compound motor nerve action potentials of the ulnar nerve in two of the three patients were higher than those of the noninjured side. In one of the three patients, these values were slightly lower than those of the noninjured side. All three patients achieved bony union after several months postoperatively.

Conclusions

We obtained good outcomes with the ulnar nerve coverage method for preventing postoperative ulnar neuropathy in patients with distal humerus fractures. Preservation of blood flow to the ulnar nerve was considered important, and anatomical repositioning of the ulnar nerve after plate fixation has the potential to prevent adhesion between the ulnar nerve and the plate.

Incidence and pattern of concurrent capitellum fracture associated with radial head and neck fractures

BACKGROUND

Radial head and neck fracture is a common fracture around the elbow. It is mostly caused by axial or valgus loading after a fall in elbow extension and forearm pronation. When a radial head and neck fracture occurs, the capitellum collides with the radial head and experiences a shear force, leading to capitellum fracture. The primary aim of this study was to evaluate the incidence of concurrent capitellum fracture and analyze its patterns among patients treated for radial head and neck fractures based on computed tomography. Secondary aim is to determine factors associated with concurrent capitellum fractures.

HYPOTHESIS

Capitellum fractures are more common than expected in radial head and neck fractures and show a consistent pattern. With the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture will be shown.

METHODS

A total of 101 patients treated surgically (27 patients) or non-surgically (74 patients) for radial head and neck fractures from January 2017 to December 2020 were retrospectively analyzed. Initial computed tomography was reviewed to identify concurrent capitellum fractures. A fracture was diagnosed when the bone continuity was lost in two consecutive images in any one of the three directions of computed tomography scan images. Seventeen patients with capitellum fractures were classified as group 1 and 84 patients without capitellum fractures as group 2. Each group of patients was assessed using Mason classification, whether fracture extended to the radial neck or not, fracture location, and treatment method. To determine the fracture location, radial head was trisected using three anatomical landmarks: safe zone, posteromedial zone, and anteromedial zone. And it was determined as the location where the fracture was most comminuted.

RESULTS

The average age of the 101 patients was 44.6 years old. There were 54 (53.5%) males and 47 (46.5%) females. Capitellum fracture was accompanied in 17 cases. Its incidence was 16.8%. The rate of accompanying capitellum fracture was 9.5% (6/63) for Mason type 1, 25.0% (6/24) for Mason type 2, and 41.7% (5/12) for Mason type 3. The ratio of radial neck extension of fracture was significantly higher in group 2. There was no isolated radial neck fracture in group 1. However, there were 33 in group 2. After eliminating isolated radial neck fracture patients, significantly more fractures were located in the safety zone in group 1. Group 1 had a significantly higher rate of surgical treatment than group 2 (52.9% (9/17) vs. 21.4% (18/84) p=0.007).

CONCLUSION

For radial head and neck fractures, the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture. When the fracture extended to the radial neck, the comorbidity of the capitellum fracture was decreased. Among radial head fractures, when the fracture was located in the safe zone, the comorbidity of capitellum fracture was increased. The rate of surgical treatment was higher in radial head and neck fracture patients with concurrent capitellum fractures.

LEVEL OF EVIDENCE

IV; diagnostic study.

Outcomes After Acute Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures

Purpose

Compare outcomes of acute versus delayed total elbow arthroplasty (TEA) following distal humerus fractures (DHF).

Methods

This retrospective study included 39 patients who underwent primary TEA with semiconstrained implants for DHF, either within 4 weeks of their injury or after failing initial open reduction and internal fixation (ORIF) or nonsurgical management, between June 1, 2003 and February 1, 2018 with minimum 1-year follow-up. Our outcome measures included QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score, complications, reoperations, and range of motion (ROM). Demographics, clinical variables, and outcomes were compared using the Student's t-test, Mann-Whitney U test, and Fisher's exact test as appropriate. Kaplan-Meier curves for mortality, implant survivorship, and reoperation were created.

Results

Our patients were categorized into acute TEA (n = 22), ORIF to TEA (n = 10), and nonsurgical to TEA (n = 7) treatment groups. Additional analysis was performed comparing acute to delayed TEA, which combined data from failed ORIF and nonsurgical cohorts. The median follow-up, average age, and median Charlson comorbility index were similar between groups. The most common fracture pattern was AO13C. At median follow-up of 5.8 years, QuickDASH differed between cohorts: mean of 31 (SD 19) in acute TEA and 52 (SD 27) in delayed TEA, which further subdivided to 44.2 (SD 25) in failed ORIF and 76 (SD 23) in failed nonsurgical management. Poorer QuickDASH scores at final follow-up were associated with delayed TEA, initial nonsurgical management, and depression. Surgical complications were associated with delayed TEA. Higher Charlson comorbidity index was associated with death. No variables were associated significantly with ROM, revision, or reoperation.

Conclusion

Comminuted DHFs are difficult to treat in the elderly with high rates of complication and poor function after surgery. Our study suggests TEA performed acutely result in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management.

Type of Study/Level of Evidence

Therapeutic, III.

Clinical and Radiographic Outcomes of Total Elbow Arthroplasty Using a Semi-constrained Prosthesis with a Triceps-preserving Approach over a Minimum Follow-up Period of 4 Years

OBJECTIVE

Complications related to triceps after total elbow arthroplasty (TEA) have become a major surgical concern. The triceps-preserving approach has the advantage of not disturbing the insertion of triceps but is disadvantaged by the reduced exposure of the elbow joint. The aim of this study was to investigate the clinical and radiological outcomes of TEA with a triceps-preserving approach and to compare the outcomes of TEA to treat arthropathy with that of TEA to treat acute distal humerus fracture.

METHODS

From January 2010 to December 2018, 23 patients undergoing primary TEAs were retrospectively reviewed with a mean follow-up time of 92.6 months (range, 52-136 months). Each TEA was performed using the triceps-preserving approach with a semi-constrained Coonrad-Morrey prosthesis. Patient demographics, range of motion (ROM), pain visual analogue scale (VAS), and triceps strength (Medical Research Council [MRC] scale) were compared before and after surgery. The Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiographic outcome, and complications were evaluated at follow-up.

RESULTS

In total, seven males and 16 females were included in this study, with a mean age of 66.1 years (range:46-85 years). By the last follow-up, pain had been significantly relieved in all patients. The average MEPS in the arthropathy group and fracture group were 90.8 ± 10.3 points (range: 68-98 points) and 91.7 ± 0.4 (range: 76-100 points), respectively. The average DASH of the arthropathy group and fracture group was 37.3 ± 18.8 points (range: 18-52 points) and 38.4 ± 20.1 (range: 16-60 points). At the last follow-up after surgery, the mean flexion arcs in the arthropathy group and fracture group were 100.4° ± 24.1° and 97.8° ± 28.1°, respectively. The mean pro-supination arcs in the arthropathy group and fracture group were 142.4° ± 15.2° and 139.2° ± 17.5°, respectively. There were no significant differences in clinical outcomes between the two groups (P ≥ 0.05). Triceps strength was normal (MRC grade V) in 15 elbows and good in eight elbows. None of the cases experienced weakness of the triceps strength, infection, periprosthetic fractures, or prosthesis breakage.

CONCLUSIONS

The clinical and radiographical outcomes of TEA with the triceps-preserving approach were satisfactory in patients with distal humerus fracture, osteoarthritis and rheumatoid arthritis.

Intraoperative modification of total elbow arthroplasty implants

BACKGROUND

Modification of total elbow arthroplasty (TEA) implants may be necessary in selected patients with substantial anatomic bone deformity or those undergoing revision surgery. The purpose of this study was to investigate the prevalence and consequences of implant modifications during TEA at our institution. We hypothesized that TEA implant modification would be more common in revisions than in primary replacements, and that it would not be associated with worse clinical outcomes or increased rates of radiographic or surgical complications directly related to the implant modification.

METHODS

Elbows that had undergone TEA by any of 3 surgeons at our institution with use of intraoperative implant modification between January 1992 and October 2019 were retrospectively reviewed for the type of modification and complications. Complications were classified as definitely related, probably related, possibly related, or nonrelated to the implant's modification according to the consensus review by the 3 senior surgeons. A survey was sent out to surgeons outside of our institution to investigate whether intraoperative modification to TEA implants is a common clinical practice.

RESULTS

A total of 106 implant components were modified during 94 of 731 TEA procedures (13%) in 84 of 560 patients. Implant modifications were performed in 60 of 285 revision cases (21%) compared with 34 of 446 (8%) primary cases (P < .0001). These included shortening the stem in 40 (44%), bending the stem in 16 (15%), notching the stem in 16 (15%), tapering the stem in 9 (9%), and a combination of 2 or more of these modifications in 19 implants (17%). Among the 55 index surgeries available for complication analysis, 40 complications occurred in 28 index surgeries (11 primary and 17 revisions; 25 patients), making the overall complication rate 51%. Of these 40 complications, 23 were considered independent of any implant modification. Of the remaining 17 complications, 9 were considered nonrelated to the implant modification, 6 were possibly related, and 2 were probably related to the implant modification. Therefore, the complication rate possibly related or probably related to implant modification was 15% (8 of 55). No complication was classified as definitely related to the implant modification. No implant breakage or malfunction occurred after any modification. A total of 442 survey responses were received representing 29 countries, of which 144 surgeons (39%) performed modification to implants during TEA procedures.

DISCUSSION

This study confirmed our hypothesis that modification of TEA implants is not uncommon at our institution, particularly in revision arthroplasty. Surgeons should keep in mind that complications possibly related or probably related to implant modification were at minimum 15% and could have been as high as 30% if the patients lost to follow-up had all had complications. Implant modification may be necessary in some cases but should be exercised with thoughtful consideration and caution.

Biomechanical analysis of a novel Y-plate designed for the treatment of extraarticular distal humerus fractures

Adult distal humerus fractures are infrequent, yet they account for one-third of all humerus fractures. For the treatment of comminuted and osteoporotic fractures, locking plates are claimed to be biomechanically superior to alternative internal fixing techniques. Treatment remains difficult despite recent advancements and the use of locking plates due to frequent comminution, low bone quality, and limited healing ability in osteoporotic bone. An optimal design of the newly constructed plate and the control model were selected. The biomechanical characteristics of non-osteoporotic and osteoporotic synthetic bone were compared on six models. The biomechanical properties of the new plate were tested and compared on 54 osteoporotic synthetic humerus models. The control models were reconstructive and parallel LCPs. The tests were carried out under static and dynamic axial, lateral and bending loads. Fracture displacements were measured by optical measuring system Aramis. The test model is significantly stiffer for lateral load (p = 0.0007) and for bending load at the moment of model failure (p = 0.0002), while for axial load the LCP model showed greater stiffness (p = 0.0017). During lateral dynamic loading, all three LCP models broke and there was a significant difference compared to the test model (p = 0.0125). The LCP model is dynamically significantly more durable under axial load, while the largest displacements were recorded with the test model (p = 0.029). The displacements induced by all three loads are within the limits that fulfil the parameters of appropriate biomechanical stability. A novel locking plate for extra-articular distal humerus fractures may provide an alternative to the traditional two-plate.

Coronal Plane Articular Shear Fractures of the Distal Humerus

Coronal plane articular shear fractures of the distal humerus are a rare injury, comprising 6% of distal humerus fractures. The fracture can be easily missed on initial radiographs; therefore, a high index of suspicion is warranted. Radiographically obvious fractures are often more complex than initially appreciated, with plain radiographs often underestimating the extent of posterior comminution and trochlear involvement. Associated bony and ligamentous injuries are common. Anatomic reduction and internal fixation of displaced fractures is the standard of care because poor results have been described with nonsurgical treatment. However, the regional anatomy and the often-limited bone stock can make open reduction and internal fixation challenging. The lateral approach, with headless compression screws placed from anterior to posterior, is commonly used for simpler fracture patterns, but exposure and fixation of trochlea extension can be difficult. In the absence of posterior comminution, the anterolateral approach can enhance trochlea exposure and allow for a better trajectory for screw placement. Posterior comminution often requires locking plate fixation. Better results and lower complication rates have been reported for fractures with less fragmentation of the articular surface and those without posterior comminution. Contracture and symptomatic implants are the most common reasons for revision surgery.

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.

Percent articular exposure of the distal humerus with triceps fascial tongue approach compared with olecranon osteotomy

BACKGROUND

Distal humerus fractures are common and can be difficult to treat. No one approach to the distal humerus has been shown to be superior to another; however, the olecranon osteotomy remains the gold standard for complex, intra-articular fractures. Understanding the percent of articular exposure with approaches to the distal humerus is important for success. The goal of this study is to show the percent of articular exposure of the triceps fascial tongue approach as compared with the olecranon osteotomy.

METHODS

Twelve fresh frozen cadavers were separated randomly into 2 groups of 6 each. The first group of 6 specimens was allocated to the triceps fascial tongue approaches with the collaterals maintained and with the collaterals released off the ulna and elbow dislocated. The second group of 6 was allocated to the triceps fascial tongue approach while maintaining the collaterals followed by an olecranon osteotomy. The articular exposure was marked after performing each approach, and the percent of articular exposure was quantified by using 3D scanning. Standard deviations were calculated for each.

RESULTS

The average percent visualization of the distal humerus articular surface in the fascial tongue approach while maintaining the collaterals was 36% in the first cohort and 37% in the second cohort with a standard deviation of 5% in both cohorts. The average percent of the distal humerus articular surface exposed in the fascial tongue approach with the collaterals released off the ulna and elbow dislocated was 85.09% with a standard deviation of 4%. The average percent of the distal humerus articular surface exposed in the olecranon osteotomy group was 57.9% with a standard deviation of 5%.

CONCLUSION

The triceps fascial tongue approach allows for visualization of about one-third of the joint, which may be adequate for many intra-articular distal humerus fractures. For added exposure of the articular surface, the collaterals may be elevated from the ulna and the elbow dislocated allowing for a substantial increase in percent of articular exposure compared with the collateral retaining fascial tongue approach and the olecranon osteotomy.

Controversies in the Management of Bicolumnar Fractures of the Distal Humerus

Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

Hemiarthroplasty versus open reduction internal fixation for intra-articular distal humerus fractures in older patients

Background

Intra-articular distal humerus fractures in the older population remain a challenge to fix, due to the comminution of fragments and poor bone stock. Recently Elbow Hemiarthroplasty (EHA) has gained popularity to treat these fractures, however no studies exist comparing EHA to Open Reduction Internal Fixation (ORIF).

Objectives

To compare the clinical outcomes of patients over the age of 60 years treated with ORIF or EHA for multi-fragmentary distal humerus fractures.

Methods

Thirty-six patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of thirty-four months (12-73 months). Eighteen patients were treated with ORIF and eighteen with EHA. The groups were matched for fracture type, demographic characteristics and follow up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes. The quality of ORIF was judged against set radiographic criteria in order to understand the effect of sub-optimal ORIF technique.

Results

No significant clinical difference was found between EHA and ORIF in mean OES (42.5 vs 39.6, p = 0.28), mean VAS (0.5 vs 1.7, p = 0.08) or mean flexion-extension arc (123° vs 112°, p = 0.12). There were significantly more complications associated with ORIF compared to EHA (39% vs 6%, p = 0.04). ORIF executed with satisfactory fixation technique had a comparable complication rate compared to EHA (17% vs 6%, p = 0.6). Two ORIF patients required revision to Total Elbow Arthroplasty (TEA). None of the EHA patients required revision surgery.

Conclusion

This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age. Early complications and re-operations were higher in the ORIF group, although this could be related to improper ORIF technique and patient selection.

Complications of Early Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures

PURPOSE

The purpose of this study was to compare the rates of wound complications and heterotopic ossification (HO) between patients who underwent acute total elbow arthroplasty (TEA) and those who underwent delayed TEA performed for the treatment of distal humerus fractures. Our hypothesis was that delayed surgery will have fewer wound complications but a higher rate of HO.

METHODS

We retrospectively reviewed 104 patients who had undergone TEA performed at 1 of 3 institutions following a distal humerus fracture. The acute cohort, comprising 69 patients, underwent TEA within 2 weeks; the delayed cohort, comprising 35 patients, received treatment between 2 weeks and 6 months. The rates of wound complications, HO, clinically relevant HO (requiring excision or resulting in loss of functional range of motion), and reoperation were recorded. These patients were followed up for an average of 52 (interquartile range, 18.5-117) weeks.

RESULTS

Wound complications occurred in 10 patients (14.5%) in the early group and 7 (20.0%) in the delayed group. The overall rate of HO was 56.7% (59 patients). The rate of clinically relevant HO was 26.0% (27 patients), which was similar between the groups. Reoperation occurred in 20 patients (19.2%), which was similar between the groups. In the early group, 3 reoperations were performed for wound complications and 4 for HO. No patients required reoperation for these indications in the delayed group. The mean flexion-extension and supination-pronation arcs were 20°-130° and 80°-80°, respectively, which were similar between the groups. Rheumatoid arthritis and younger age were associated with increased odds of wound complications and reoperation.

CONCLUSIONS

The rates of reoperation, wound complications, and HO were overall higher than those previously reported; however, the study was underpowered to determine a difference between early and delayed treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Efficacy and safety of anterior transposition of the ulnar nerve for distal humerus fractures: A systematic review and meta-analysis

Background

This systematic review and meta-analysis was performed to summarize available evidence of anterior transposition of the ulnar nerve for patients with distal humerus fractures.

Materials and Methods

The databases were searched from PubMed, Cochrane, Embase, Scopus, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database up to June 2022. The clinical outcome included operation time, fracture healing time, hospital stays, elbow joint function, and ulnar neuritis rate. Statistical analysis was performed with Review Manager 5.3 (Cochrane Collaboration).

Results

A total of 17 studies were included (8 RCTs and 9 retrospective studies), and 1280 patients were analyzed. The results of this meta-analysis showed anterior transposition group had longer operation time (MD = 20.35 min, 95%CI: 12.56-28.14, P < 0.00001). There was no significant difference in fracture healing time (SMD = -0.50, 95%CI: -1.50-0.50, P = 0.33), hospital stays (MD = -1.23 days, 95%CI: -2.72--0.27, P = 0.11), blood loss (MD = 2.66 ml, 95%CI: -2.45-7.76, P = 0.31), and ulnar neuritis rate (OR = 1.23, 95%CI: 0.63-2.42, P = 0.54) between two groups. Finally, elbow joint motion, elbow joint function, fracture nonunion, and post-operative infection (P > 0.05) between two groups were not significantly statistic difference.

Conclusion

This meta-analysis showed that anterior transposition group is not superior to non-transposition group for patients with distal humerus fractures without ulnar nerve injury. On the contrary, non-transposition group have shorter operation time than that of anterior transposition group. Non-transposition group did not increase the post-operative ulnar neuritis rate. Therefore, both anterior transposition group and non- transposition group are the treatment options for patients with distal humerus fractures without ulnar nerve injury. Besides, these findings need to be further verified by multi-center, double-blind, and large sample RCTs.

Elbow arthroplasty in trauma-current concepts review

Introduction

Despite advancements in modern locking plate technology, distal humerus fractures in the elderly remain difficult to treat. A subset of fractures in this osteoporotic bone includes multiple, shallow articular fragments that renders fixation unreliable, precluding early motion and acceptable functional outcomes. Arthroplasty, in the form of either Total Elbow Arthroplasty (TEA) or Distal Humeral Hemiarthroplasty (DHH) are alternative treatment options in this cohort and are being increasingly used.

Methods

This article reviews the use of TEA or DHH for acute distal humerus fracture, including patient selection, pre-operative planning, surgical approach, implant positioning, rehabilitation, outcomes and complications.

Results

Arthroplasties are being increasingly used for acute distal humerus fractures, however they introduce potential complications not seen with fixation. Due care must be employed to correct implant positioning which is a function of implant rotation, implant length and implant sizing. We describe a robust technique for epicondyle repair in DHH and unlinked TEA to avoid instability. Outcomes of DHH and TEA for acute distal humerus fracture are encouraging, however further long-term outcome and comparative data regarding arthroplasty is required.

Conclusions

Short to medium term outcomes demonstrate that both DHH and TEA are valuable options for selected patients, although attention to technique is required to minimise potential complications.

Modified Masquelet Technique Assisting 3D Printed Elbow Prosthesis for Open Elbow Fracture with Severe Bone Defect: A Case Report and Technique Note

BACKGROUND

Internal fixation for severe open articular bone defects is sometimes ineffective or dangerous. In the emergency stage, radical debridement and infection prevention are demanded to provide a good tissue base and the space-occupying effect to provide enough necessary space to avoid soft-tissue contraction for the reconstruction. In addition, the 3D printing technology makes individual limb reconstruction a reality.

CASE PRESENTATION

Here, we present a 31-year-old patient with an open fracture and severe bone defect of his left elbow caused by traffic accident, classified as Gustilo-Anderson IIIB. We adopted aggressive debridement and insertion of polymethyl methacrylate (PMMA) to prevent the infection and temporarily construct the bone defect in the emergency stage. Secondly, the total elbow arthroplasty was performed using a unique three-dimensional (3D) printed prosthesis to reconstruct the elbow joint. During the follow-up, the elbow movement function was satisfactory.

CONCLUSIONS

The modified Masquelet technique assisting 3D printing of personalized elbow joint makes the satisfactory functional reconstruction for open high-energy injuries come true. It could be promoted for the similar surgery of other open joints fractures with severe bone defects.

Outcomes and complications after open reduction and internal fixation of distal humeral fractures with precontoured locking plates

Objectives

The aim of this study was to evaluate functional and radiographic results after open reduction and internal fixation of distal humeral fractures using precontoured locking plates. Our main hypothesis was that patients older than 65 years have inferior outcomes compared with younger patients.

Methods

All patients treated for a distal humeral fracture with precontoured locking plates between 2006 and 2017 at a level 1 trauma center were identified. Included patients underwent a clinical examination, and new radiographs were obtained. Functional outcomes were evaluated using Quick Disability of the Arm, Shoulder and Hand, Mayo Elbow Performance Score, visual analog scale elbow satisfaction, and range of motion. Complications and reoperations were recorded.

Results

Fifty-seven patients with a median age of 60 years were included in this study. Median Quick Disability of the Arm, Shoulder and Hand was 14, and median Mayo Elbow Performance Score was 85. There was no difference in functional scores in patients younger than 65 years or 65 years or older. However, the median flexion-extension arc was 121 degrees in patients younger than 65 years and 111 degrees in patients 65 years or older (P = 0.01). The overall complication rate was 68%, and 24 patients had at least 1 reoperation. Ulnar neuropathy was the most common complication followed by reduced range of motion.

Conclusions

Operative management of distal humeral fractures with precontoured locking plates provides good functional outcome. The patient-reported outcomes were good, independent of patient age. The implant failure rate is low with precontoured locking plates; however, the complication rate remains high, and reoperations are common.

Level of Evidence

Level 4, retrospective study.

Elbow arthroplasty research methods, outcome domains, and instruments used in clinical outcome studies : a scoping review

AIMS

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

METHODS

A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review.

RESULTS

A total of 362 studies met the inclusion criteria. Most were of total elbow arthroplasty (246; 68%), followed by radial head arthroplasty (100; 28%), distal humeral hemiarthroplasty (11; 3%), and radiocapitellar arthroplasty (5; 1%). Most were retrospective (326; 90%) and observational (315; 87%). The median sample size for all types of implant across all studies was 36 (interquartile range (IQR) 21 to 75). The median length of follow-up for all studies was 56 months (IQR 36 to 81). A total of 583 unique outcome descriptors were used and were categorized into 18 domains. A total of 105 instruments were used to measure 39 outcomes.

CONCLUSION

We found that most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. Many outcomes have been used with many different instruments for their measurement, indicating a need to define a core set of outcomes and instruments for future research in this area.Cite this article: Bone Joint J 2022;104-B(10):1148-1155.

Comparison of the Complications, Reoperations, and Clinical Outcomes between Open Reduction and Internal Fixation and Total Elbow Arthroplasty for Distal Humeral Fractures in the Elderly: A Systematic Review and Meta-Analysis

Distal humeral fractures are challenging injuries seen in the elderly. Open reduction and internal fixation (ORIF) are the gold standard treatments. Total elbow arthroplasty (TEA) is an alternative to ORIF. This study aimed to pool and analyze the outcomes and complications in elderly patients with distal humeral fractures treated with either ORIF or TEA by performing a meta-analysis. We searched the PubMed, Embase, Google Scholar, and Cochrane Library databases for studies that compared the clinical and functional outcomes of ORIF and TEA in patients aged 60 years or older. After screening and performing a quality assessment of the articles, we obtained one randomized control study and nine retrospective comparative studies. The odds ratio and standardized mean difference were used to analyze the differences in outcomes between the two surgical options. In terms of the flexion/extension arc, TEA produced significantly better outcomes than ORIF (p = 0.02). The rates of reoperation and elbow stiffness were significantly lower in the TEA group than in the ORIF group (p = 0.003 and p = 0.04, respectively). However, the functional scores and other ranges of motion (flexion, loss of extension, pronation, supination) after surgery were similar between the two groups. The outcomes from the present meta-analysis can provide guidance when selecting a surgical option for distal humeral fractures in the elderly.

[Elbow prosthesis after acute fractures : Indications and technique]

Good to very good clinical results can be achieved in older patients with the implantation of a total elbow prosthesis in cases of distal humeral fractures by taking the morphological features of the fractures, the bone quality as well as the individual patient requirements and variables into account. The most commonly used design is the cemented semiconstrained linked total elbow endoprosthesis. The unlinked prosthesis design and hemiarthroplasty require intact or adequately reconstructable musculoligamentous structures or condyles and a preserved or replaced radial head. The recommended weight limit after total elbow prosthesis as well as potential intraoperative and postoperative complications must be considered and discussed with the patients. A secondary total elbow arthroplasty is also possible after primary conservative treatment approaches, e.g., in the case of contraindicated surgery in the fracture situation, persistent pain and functional restrictions. This article provides an overview of the technique and the appropriate indications.

Bi-columnar locking plate fixation through a combined medial and lateral approach for the treatment of low transcondylar fractures of the distal humerus in the elderly

Background

Low transcondylar fractures (LTFs) of the distal humerus are relatively uncommon elbow injuries in elderly patients after low-energy injuries. Although there is still debate regarding the method of fixation, several surgeons prefer bi-columnar fixation using pre-contoured locking plates. However, posterior approaches, which are usually used to perform the above procedure, have disadvantages, such as ulnar nerve neuropathy, damage to the extensor mechanism, and the need for general anesthesia. To solve these problems, the authors designed a combined medial and lateral approach. The purpose of this study was to present the outcomes of bi-columnar internal fixation through a combined medial and lateral approach for the treatment of LTFs of the distal humerus in the elderly. 

Methods

A total of 46 patients diagnosed with distal humeral fractures between May 2017 and April 2020 were included. Thirty patients were excluded, and 16 patients who underwent open reduction and internal fixation by the medial and lateral approach were selected. We carried out all the surgeries under brachial plexus anesthesia. The clinical outcomes were assessed based on the visual analog scale (VAS) score, Mayo elbow performance score (MEPS), disabilities of the arm, shoulder, and hand (DASH) score, and range of motion (ROM) of the elbow joint. Standardized radiographs were obtained at 3, 6, and 12 months after surgery and at the last follow-up visit to evaluate for bony union and to check for complications, such as ulnar nerve neuropathy and heterotopic ossification.

Results

The mean age was 81 years (range, 65–91 years). Bony union was achieved in 15 out of 16 patients. The mean VAS score was 2.1 (range, 0–6), the mean MEPS was 84.4 (range, 70–100), and the mean DASH score was 20.6 (range, 9.5–33.6). There were three complications including reduction loss, skin necrosis, and stiffness of the elbow. There was no ulnar nerve neuropathy. The post-operative ROM was 100 degrees or higher in all cases, which did not cause any impairment in daily life.

Conclusion

LTFs of the distal humerus in the elderly can yield satisfactory results with bi-columnar internal fixation through a combined medial and lateral approach.

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.

Surgical management of osteoarthritis in the shoulder and elbow

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

Outcomes of AO/OTA C-type fractures of the distal humerus after open reduction and internal fixation with locking plate constructs in patients at least 65 years old

Background

Modern treatment options of distal humerus fractures of active elderly patients are osteosynthesis and total elbow arthroplasty. The evidence of outcomes of ORIF after AO/OTA C-type fractures mostly predates the adoption of locking plates. We evaluated the results of open reduction and internal fixation of these fractures treated exclusively with anatomic locking plates.

Methods

A retrospective cohort of 39 patients aged 65 years or above with ORIF for AO/OTA C-type distal humerus fracture using locking plates was analysed. 23 provided follow-up data and 14 attended a follow-up visit. Primary outcome was the Oxford Elbow Score. Secondary outcomes were Mayo Elbow Performance Score, quickDASH, satisfaction, range of motion, complications and revision surgeries.

Results

Mean Oxford Elbow Score pain was 83 (SD 17), Oxford Elbow Score function 83 (17) and Oxford Elbow Score social-psychological 79 (20). Mean total Oxford Elbow Score was 81 (15). Among the 14 patients who attended a follow-up visit, Mayo Elbow Performance Score was 85 (17), qDASH 19 (16), active arc of motion 119 (19) degrees. Mayo Elbow Performance Score and arc of motion were worse than on the healthy side. One patient had a serious deep infection. Eleven patients had at least one revision surgery, of which 6 were implant removals and 2 subsequent total elbow arthroplasties.

Conclusions

Distal AO/OTA C-type distal humerus fractures in older adults can be treated reliably and with good outcomes with ORIF using modern locking plates. The mean qDASH scores are similar to population normal values, but when compared to the healthy arm, single-arm outcomes indicated somewhat impaired function. About 1 in 4 patients had at least one revision surgery.

Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study

BACKGROUND

There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures.

METHODS

We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared.

RESULTS

A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7).

CONCLUSIONS

The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

The Outcomes of Intra-Articular Distal Humerus Open Reduction Internal Fixation Using Parallel Precontoured Plates in the Elderly

PURPOSE

Inconsistent outcomes have been reported in several prior studies of elderly patients with distal humerus fractures treated with open reduction and internal fixation (ORIF). We evaluated the outcomes of ORIF using modern precontoured plates exclusively in a parallel orientation.

METHODS

A retrospective review was performed to identify the patients aged over 65 years who sustained an isolated distal humerus fracture between 2015 and 2019. We identified 22 patients who underwent distal humerus ORIF using parallel, precontoured locking plates. Electronic medical records were reviewed for demographic characteristics, physical examination findings, and radiographic data. Outcomes were assessed with Quick Disabilities of the Arm, Shoulder, and Hand scores and Mayo Elbow Performance scores. Complications were evaluated by a review of the patient's medical record and postoperative radiographs.

RESULTS

Of the included patients, 18 were women and 4 were men; the average age was 78 years (SD, 8.5 years), and the patients were followed for an average of 33 months. The sample consisted of 19 AO type C, 1 type B, and 2 type A fractures. At the final follow-up, the mean arc of total elbow flexion was 107° (SD, 18.9°; range 40° to 130°), with mean elbow flexion of 129° (SD, 11.7°; range, 120° to 140°) and mean extension of 22° (SD, 12.9°; range 0° to 90°). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (SD, 14.4), and the mean Mayo Elbow Performance score was 86 (SD, 10.2). Complications occurred in 5 (23%) patients, requiring 4 subsequent surgeries, of which 1 was a conversion to total elbow arthroplasty.

CONCLUSIONS

Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Modified pin and plate fixation for low intercondylar fractures of the humerus: biomechanical study corroborated with a case series

BACKGROUND

Establishing fracture union of low and comminuted intercondylar fractures of the humerus is inherently challenging. The purposes of the present study were to investigate the biomechanical effectiveness of pin & plate (PP) fixation compared to other dual-plating techniques by finite element analysis, and to present a technical description as well as retrospectively review the outcomes of PP fixation in such difficult fractures.

METHODS

Low-level intercondylar fracture 3D models of the humerus were virtually stabilized with three fixations on lateral side including PP, lateral pre-contoured locking compression plate (L-LCP), and variable angle lateral pre-contoured locking plate (VA-L-LCP) whereas medial pre-contoured locking compression plate (M-LCP) on medial side. Loading conditions under consideration were axial compression, internal rotation, posterior bending, and valgus rotation. Regarding the clinical series, eight patients with intra-articular and comminuted fractures of the distal humerus (6 intercondylar fractures, 1 fracture-subluxation, and 1 isolated lateral condylar fracture) were operated by isolated PP fixation or combinations of PP and the other standard implants. Data were collected on fracture union, perioperative complications, and objective clinical outcomes.

RESULTS

Biomechanical results revealed the most instability of the fracture occurring under posterior bending. PP fixation presented comparable fracture stability and fragment displacement compared to other dual-plating fixations, except stress on the Kirschner wire under internal rotation which was higher than other fixations. Regarding the clinical series, fracture union was achieved in all cases with an average union time of 17 weeks (range 12-20). All except one patient had good-to-excellent MEPS results with an average Disabilities of the Arm, Shoulder, and Hand (DASH) score of 14.6 (range 0-45) and an average arc of elbow motion of 107.5 degrees (range 60-140).

CONCLUSION

By the biomechanical performance, PP fixation is a reliable technique for fixation of low intercondylar fractures of the humerus. Supported by the clinical outcomes, the present technique could be an alternative for this particular fracture especially when severe comminution prevents the use of the standard dual plating technique.

Treatment trends in distal humerus fractures between ABOS part II candidates

PURPOSE

The purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF).

METHODS

The American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications.

RESULTS

There were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%).

CONCLUSION

Our data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF.

LEVEL OF EVIDENCE

III.

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.

Predictors of reoperation after internal fixation of intra-articular distal humerus fractures

BACKGROUND

Despite good reported outcomes with open reduction and internal fixation of intra-articular distal humerus fractures, complication rates remain high. The objective of this work is to identify factors associated with reoperation.

METHODS

Sixty-three patients treated with open reduction and internal fixation for intra-articular (Arbeitsgemeinschaft für Osteosynthesefragen type C) distal humerus fractures between 2004 and 2010 were identified using an institutional trauma registry, 62 of which were followed for a minimum of six months. Age, gender, fracture subclassification, open fracture presence, Injury Severity Score, time to definitive surgery, length of postoperative immobilization, and type of approach were recorded. Multivariate analysis was utilized to identify factors independently associated with reoperation.

RESULTS

Complications requiring reoperation developed in 25 (40.3%) elbows. The most common reasons were wound dehiscence or infection in nine elbows (14.5%) and symptomatic hardware in six (9.6%). During multivariate analysis, only olecranon osteotomy remained an independent predictor for reoperation (P = 0.043).

DISCUSSION

Despite improved internal fixation techniques, a high proportion of elbows require reoperation after open reduction and internal fixation for distal humerus fractures. Higher complication rates in fractures fixed through an olecranon osteotomy may reflect additional reoperations due to nonunion of the osteotomy or need to remove hardware from the ulna.

LEVEL OF EVIDENCE

Prognostic Level III.

Coronal Shear Fractures of the Distal Humerus

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of distal humerus fractures

Introduction

We hypothesized that the modified Fragility Index (mFI), which predicts surgical complications, would be applicable to surgical complications in patients older than 50 years with distal humerus fractures (DHF).

Methods

We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a DHF. A 5-item mFI score was calculated. Postoperative complications, readmission and reoperation rates, and length of stay were recorded. Univariate as well as a multivariable statistical analysis was performed, controlling for age, sex, body mass index, length of stay, and operative time.

Results

We identified 864 patients (mean age, 68.6 years ± 10.4), and 74.1% were female. As the mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 3% to 10% (P value = .01), rate of discharge to rehabilitation facility increased from 12% to 32% (P value = .0), and any complication rate increased from 4% to 19% (P value = .0). Rates of pulmonary complications increased significantly in patients with the mFI of 2 or greater (P value = .047). Patients with the mFI of 2 or greater were nearly 4 times more likely to be readmitted within 30 days (odds ratio [OR] = 3.5, P value = .007) and had an increased OR of 30-day reoperation and any complication (OR = 3.7, P value = .02; OR = 4.5, P value = .00, respectively) on multivariate analysis.

Conclusion

A fragility state is predictive of postoperative complications, readmission, and reoperation after surgical management of DHF. Our data suggest that a fragility evaluation can help inform surgical decision-making in patients older than 50 years with DHF.

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.