Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty

Revision Total Elbow Arthroplasty

Despite improvements in our understanding of elbow biomechanics and implant design, early revision are higher following total elbow arthroplasty (TEA) compared with hip and knee arthroplasty. Revision TEA remains a standard but technically challenging procedure with the potential for substantial morbidity. This review discusses the diagnosis and management of the failed primary TEA. Current concepts related to surgical treatment with revision TEA indicated for prosthetic joint infection, periprosthetic fracture, and aseptic osteolysis will be reviewed. In addition, strategies and adjunctive procedures for dealing with bone loss in the revision setting will be discussed.

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.

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.

Type III open complete articular fractures of the distal humerus: case series outcomes after orthoplastic reconstruction

Background

Open complete articular injuries of this distal humerus are rare injuries which are challenging to manage. The study unit aims to present a small case series of Gustilo-Anderson type III open complete articular fractures which have undergone a single-stage definitive fixation and soft-tissue coverage, presenting their functional outcomes.

Methods

Retrospective case series identifying all type IIIB AO 13-C3 distal humeral fractures from the unit trauma database. The primary outcome was the Oxford Elbow Score. Secondary outcomes included deep infection, nonunion, and reoperation.

Results

A total of six patients were identified, (four open type IIIA, 2 type IIIB). All patients underwent single-sitting definitive fixation and soft-tissue coverage. Mean range of motion arc was 90 degrees. The median Oxford Elbow Score was 35 (range 21-43), representative of mild to moderate arthritis. One patient (n = 1) developed deep infection at 24 months and required reoperation. All patients (n = 6) proceeded to union at the latest follow-up. We present a case report of a 59-years-old patient who sustained a type IIIB, AO 13-C3 distal humeral fracture who underwent single-sitting definitive fixation and flap coverage.

Conclusion

This case series reports that positive functional outcomes representative of mild/moderate arthritis at short to midterm follow-up can be achieved after definitive fixation and soft-tissue coverage in a single sitting, including when the soft tissue is deficient. This is a rare injury which is under-reported in the literature.

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

Background

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

Methods

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

Results

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

Discussion

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

Comparison of open reduction and internal fixation with total elbow arthroplasty for intra-articular distal humeral fractures in older age: a retrospective study

Background

Intra-articular distal humeral fractures can be surgically challenging. It remains under discussion whether open reduction and internal fixation (ORIF) or total elbow arthroplasty (TEA) is more beneficial for treatment of the elderly. This study aimed to compare the clinical and functional outcomes of ORIF and TEA for managing intra-articular distal humerus fractures in patients aged 65 years or older.

Methods

Patients who underwent ORIF (n=28) or TEA (n=43) for in intra-articular distal humerus fracture between May 2008 and December 2018 were reviewed. Range of motion, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiologic outcomes, and surgical complications were evaluated at the final follow-up visit.

Results

The ORIF and TEA groups showed a mean arc of flexion–extension of 97°±21° and 101°±12°, respectively. The mean MEPS and DASH scores were 94±15 and 27±12 points, respectively, in the ORIF group and 81±27 and 47±28 points in the TEA group. This difference was statistically significant. The incidence of total complications was similar between the groups.

Conclusions

In patients older than 65 years with intra-articular distal humerus fracture, ORIF had better outcomes than TEA.

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

OBJECTIVES

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

DESIGN

Retrospective, observational study.

SETTING

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

PATIENTS/PARTICIPANTS

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Distal Humerus Fractures in the Elderly Population

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

Distal Humeral Hemiarthroplasty Versus Total Elbow Arthroplasty for Acute Distal Humeral Fractures

For acute distal humeral fractures not amenable to open reduction and internal fixation, total elbow arthroplasty has become an established alternative. However, lifelong activity restrictions designed to prevent early mechanical failure make this a poor option for some patients. This has led to a renewed interest in distal humeral hemiarthroplasty. Using modern implants and techniques, distal humeral hemiarthroplasty has shown outcomes comparable to those of total elbow arthroplasty at short- to mid-term follow-up, with an overall higher but different complication rate. Long-term data are needed, but the available literature suggests that distal humeral hemiarthroplasty be considered as another option on the treatment spectrum in select patient populations. [Orthopedics. 2017; 40(1):13-23.].

Total Elbow Arthroplasty for Distal Humerus Fractures

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

Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches

BACKGROUND

Total elbow arthroplasty (TEA) is associated with high complication rates compared with other large-joint arthroplasties. The frequency and type of complication may differ, depending on the surgical approach. A comparison of outcomes with triceps-off and triceps-on approaches was investigated.

METHODS

Seventy-three patients underwent 83 primary TEAs between 2003 and 2012. Forty-six elbows had a triceps-off approach, and 37 had a triceps-on approach. Results were reviewed at a mean of 4.2 years. Cementing technique was graded according to Morrey's criteria, and clinical outcomes were assessed by means of the Mayo Elbow Performance Score.

RESULTS

There was no statistically significant difference between the triceps-off and triceps-on groups with regard to the patient's age, gender, preoperative Mayo Elbow Performance Score or range of motion, or previous surgery on the affected elbow. Among patients who underwent a TEA for an inflammatory arthropathy, there was a significant difference in outcome between groups with regard to final flexion, extension, arc of motion, and pronation. Cementing technique in the triceps-off group was adequate in 70%. In the triceps-on group, cementing technique was adequate in 92%. The complication rate in the triceps-off group was 32.6% and included 7 triceps ruptures. Three patients who had attempted repairs of the triceps rupture developed deep infections requiring multiple further surgeries. The complication rate in the triceps-on group was 8.1%.

CONCLUSION

A triceps-on approach in TEA results in consistently good clinical outcomes with no risk of triceps rupture, and the approach does not compromise the cement mantle. We believe that this approach will reduce complication rates in TEA.

The role of total elbow arthroplasty in traumatology

Fractures of the distal humerus account for 5% of osteoporotic fractures in subjects older than 60 years. A history of osteoporosis, co-morbidities, and joint comminution make their management difficult. The therapeutic options are limited to functional treatments, osteosynthesis, or either partial or total arthroplasty. Functional treatment of distal humerus fractures in the elderly subject provide inconsistent results, often with persistence of pain with a stiff or unstable elbow. Osteosynthesis remains the reference treatment for these fractures, following the principle of stable and rigid osteosynthesis allowing early mobilization. However, joint comminution and a history of osteoporosis occasionally make it impossible to meet this objective, with a considerable rate of complications and surgical revisions. Total elbow arthroplasty remains an alternative to osteosynthesis with very satisfactory immediate results restoring a painless, stable, and functional elbow. These results seem reproducible and sustainable over time. The complication rate is not uncommon with an approximately 10% surgical revision rate. Elbow hemiarthroplasty remains to be validated in this indication.

LEVEL OF EVIDENCE

V.

Is total elbow arthroplasty indicated in the treatment of traumatic sequelae? 19 cases of Coonrad-Morrey(®) reviewed at a mean follow-up of 5.2 years

INTRODUCTION

Traumatic sequelae of the elbow are difficult to manage because of bone deformities, changes in joint congruency and bone defects.

MATERIALS AND METHODS

Total elbow arthroplasty is a therapeutic option when the joint space has disappeared. Nineteen patients underwent semi-constrained Coonrad-Morrey(®) total elbow arthroplasty in 12 cases for post-traumatic elbow arthritis (group 1) and in seven cases for 7 non-union of the distal humerus (group 2). The mean age at surgery was 60 years old (56 in group 1 and 67 in group 2). The mean delay between the initial trauma and arthroplasty was 16 years (group 1) and 22 months (group 2).

RESULTS

At a mean follow-up of 5.5 years (24-156 months) in group 1, the Quick-DASH score was 34 points with outcomes that were considered to be good to excellent in 75% of the cases according to the Mayo Elbow Performance Score (MEPS). A progressive radiolucency was identified on X-ray in 33% of the cases, and moderate wear of the polyethylene insert in 17%. There were 7 complications (58%) requiring revision in 3 cases (25%). At a mean follow-up of 4.6 years (24-108 months) in group 2, the Quick-DASH score was 39 points with good and excellent results in 86% according to the MEPS. A radiolucency was noted in 28% and moderate wear of the inserts in 14%. There were 2 complications (28%) requiring revision in 1 case (14%).

CONCLUSION

Semi-constrained total elbow arthroplasties provide recovery of functional range of motion with a stable and pain-free elbow for post-traumatic conditions. The age at surgery is a risk factor for complications. The indication for total elbow arthroplasty in patients under 60 should be carefully considered in relation to alternative treatment options.

LEVEL OF EVIDENCE

Level IV Retrospective study.

Total elbow arthroplasty for distal humerus fractures

Total elbow arthroplasty has become increasingly popular for the treatment of distal humerus fractures in elderly patients with poor bone quality, comminution, and/or pre-existent elbow abnormalities. The procedure is performed without violating the extensor mechanism; the fractured fragments are exposed and resected on both sides of the triceps, and the components can be implanted through the same exposure. Early outcomes are satisfactory in most elbows and compare favorably with internal fixation in this same group of elderly patients. Advances in elbow arthroplasty for fractures will likely combine refinement of the indications and development of implants with lower rates of failure.

[Elbow replacement]

Elbow replacement or arthroplasty is a good therapeutic option for a large percentage of patients with significant joint destruction. However, many orthopaedic surgeons are no familiar with the surgical approaches or techniques associated with elbow replacement implants. Furthermore, the incidence of complications is higher than in other joint replacements, the most important being infections, mechanical failure, cubital neuropathy, and problems with the triceps. For these reasons, the use of bone arthroplasty in Spain may be less than ideal. Although, inflammatory arthritic diseases, such as rheumatoid arthritis, are the most frequent indication for this operation, distal humerus fractures and post-traumatic disease are a growing indication. This work attempts to summarise the most important current concepts associated with elbow replacement.

The Kudo humeral component as primary hemiarthroplasty in distal humeral fractures

BACKGROUND

Treatment of intra-articular fractures of the distal humerus in the elderly is challenging. In patients with very distal fractures and severe comminution, primary arthroplasty has been advocated. Recently, a few reports have described promising results of hemiarthroplasty. This study describes the medium-term results of using the Kudo humeral implant (Biomet Ltd, Bridgend, U.K.) as replacement of the distal humerus.

MATERIAL AND METHODS

Eight women (mean age, 79 years) were treated. Follow-up was conducted at a mean of 4 years after the procedure and consisted of the Mayo Elbow Performance Score (MEPS), radiographic images, and range of motion (ROM).

RESULTS

All patients had a good or excellent outcome according to the MEPS. Mean ROM was 31° to 126°. Radiographic signs of attrition of the ulna were observed in 3 patients but did not correlate with the functional outcome. A periprosthetic fracture occurred in 1 patient 3 years after the index operation, and ROM was unsatisfactory in 1 patient. No other complications were observed.

CONCLUSION

The use of the Kudo humeral implant as a hemiarthroplasty resulted in a reasonable functional outcome in the medium-term, but the radiographic signs of attrition suggest that the implant is not recommended as a hemiprosthesis.

Current perspectives in the treatment of periprosthetic upper extremity fractures

Periprosthetic fractures around the shoulder and elbow are rare and are often difficult to treat. Treatment options depend on the stability of the prosthesis, the location of the fracture, and the bone quality. The basic principles of treatment are that loose or unstable prostheses are removed and revised to a longer prosthesis with the possible addition of cortical struts and/or plate and screws. If the prosthesis is stable, nonoperative measures may be tried initially. In cases of nonunion, surgical treatment is recommended. This article describes the current literature related to periprosthetic fractures around the shoulder and the elbow.

Total elbow arthroplasty

Total elbow arthroplasty has continued to evolve over time. Elbow implants may be linked or unlinked. Unlinked implants are attractive for patients with relatively well preserved bone stock and ligaments, but many favor linked implants, since they prevent instability and allow replacement for a wider spectrum of indications. Inflammatory arthropathies such as rheumatoid arthritis represent the classic indication for elbow arthroplasty. Indications have been expanded to include posttraumatic osteoarthritis, acute distal humerus fractures, distal humerus nonunions and reconstruction after tumor resection. Elbow arthroplasty is very successful in terms of pain relief, motion and function. However, its complication rate remains higher than arthroplasty of other joints. The overall success rate is best for patients with inflammatory arthritis and elderly patients with acute distal humerus fractures, worse for patients with posttraumatic osteoarthritis. The most common complications of elbow arthroplasty include infection, loosening, wear, triceps weakness and ulnar neuropathy. When revision surgery becomes necessary, bone augmentation techniques provide a reasonable outcome.

Custom triflange outrigger ulnar component in revision total elbow arthroplasty

HYPOTHESIS

This study describes the rationale for, and tests the hypothesis that, a custom outrigger triflange ulnar component for revision total elbow arthroplasty would decrease the contact stresses at the bushings and overcome excessive bushing wear in active patients who have bone and ligamentous deficiency.

MATERIALS AND METHODS

Five consecutive revisions for failed Coonrad-Morrey total elbow arthroplasties were performed with the custom outrigger triflange ulnar component for patients with accelerated bushing wear, ulnar component loosening, and deficient humeral condyles. The mean age at the time of surgery was 48 years (range, 32-64 years). Follow-up averaged 81 months (range, 65-124 months). The average number of previous operations was 2.4 (range, 2-3).

RESULTS

The Mayo Elbow Performance Score improved from 40 (range, 15-65) preoperatively to 91 (range, 80-100) at the latest follow-up. There were two excellent and three good results. There was no radiographic or clinical evidence of bushing wear at 6.8 years of follow-up (range, 5.5-10.3 years). One patient required further revision of the humeral component due to mechanical loosening, which had not been revised at the time of the index surgery.

DISCUSSION

A custom outrigger triflange ulnar component is an effective alternative for revising loose Coonrad-Morrey ulnar components in active patients with absent humeral epicondyles and accelerated bushing wear.

CONCLUSION

It may be an alternative to revision with standard components until improved surgical designs addressing this problem become commercially available.

Total elbow arthroplasty: history, current concepts, and future

Total elbow arthroplasty (TEA) has proven to be a reliable joint replacement procedure that has a high degree of patient satisfaction. The long-term functional and implant survival scores rival those of total knee arthroplasty. Despite these favorable outcomes, few patients with disabling elbow degenerative conditions have TEA recommended to them as an alternative procedure by rheumatologists, physiatrists, or orthopedists. This article reviews the history, current concepts, and future of TEA.

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

We conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Forty-two patients were randomized by sealed envelope. Inclusion criteria were age greater than 65 years; displaced, comminuted, intra-articular fractures of the distal humerus (Orthopaedic Trauma Association type 13C); and closed or Gustilo grade I open fractures treated within 12 hours of injury. Both ORIF and TEA were performed following a standardized protocol. The Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were determined at 6 weeks, 3 months, 6 months, 12 months, and 2 years. Complication type, duration, management, and treatment requiring reoperation were recorded. An intention-to-treat analysis and an on-treatment analysis were conducted to address patients randomized to ORIF but converted to TEA intraoperatively. Twenty-one patients were randomized to each treatment group. Two died before follow-up and were excluded from the study. Five patients randomized to ORIF were converted to TEA intraoperatively because of extensive comminution and inability to obtain fixation stable enough to allow early range of motion. This resulted in 15 patients (3 men and 12 women) with a mean age of 77 years in the ORIF group and 25 patients (2 men and 23 women) with a mean age of 78 years in the TEA group. Baseline demographics for mechanism, classification, comorbidities, fracture type, activity level, and ipsilateral injuries were similar between the 2 groups. Operative time averaged 32 minutes less in the TEA group (P = .001). Patients who underwent TEA had significantly better MEPSs at 3 months (83 vs 65, P = .01), 6 months (86 vs 68, P = .003), 12 months (88 vs 72, P = .007), and 2 years (86 vs 73, P = .015) compared with the ORIF group. Patients who underwent TEA had significantly better DASH scores at 6 weeks (43 vs 77, P = .02) and 6 months (31 vs 50, P = .01) but not at 12 months (32 vs 47, P = .1) or 2 years (34 vs 38, P = .6). The mean flexion-extension arc was 107 degrees (range, 42 degrees -145 degrees) in the TEA group and 95 degrees (range, 30 degrees -140 degrees) in the ORIF group (P = .19). Reoperation rates for TEA (3/25 [12%]) and ORIF (4/15 [27%]) were not statistically different (P = .2). TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS. DASH scores were better in the TEA group in the short term but were not statistically different at 2 years' follow-up. TEA may result in decreased reoperation rates, considering that 25% of fractures randomized to ORIF were not amenable to internal fixation. TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients have an increased baseline DASH score and appear to accommodate to objective limitations in function with time.

Prosthetic replacement for distal humerus fractures

Primary total elbow arthroplasty is a treatment option for elderly patients with osteopenic bone, increased comminution, and articular fragmentation. Recently, there has been a renewed interest in distal humerus hemiarthroplasty for the treatment of distal humerus fractures, including coronal shear fractures of the capitellum and trochlea. This article focuses on the evaluation and management of distal humerus fractures with prosthetic replacement.

The outcome of peri-operative humeral condylar fractures after total elbow replacement in patients with rheumatoid arthritis

We compared the outcome of peri-operative humeral condylar fractures in patients undergoing a Coonrad-Morrey semiconstrained total elbow replacement with that of patients with rheumatoid arthritis undergoing the same procedure without fractures. In a consecutive series of 40 elbows in 33 patients, 13 elbows had a fracture in either condyle peri-operatively, and 27 elbows were intact. The fractured condyle was either fixed internally or excised. We found no statistical difference in the patients' background, such as age, length of follow-up, immobilisation period, Larsen's radiological grade, or Steinbrocker's stage and functional class. There was also no statistical difference between the groups in relation to the Mayo Elbow Performance Score, muscle strength, range of movement, or radiolucency around the implants at a mean of 4.8 years (1.1 to 8.0) follow-up. We conclude that fractured condyles can be successfully treated with either internal fixation or excision, and cause no harmful effect.

Coonrad-Morrey total elbow replacement for primary and revision surgery: a 2- to 7.5-year follow-up study

In this study, 23 patients were treated with the Coonrad-Morrey total elbow prosthesis for posttraumatic arthrosis (15 cases), acute distal humeral fracture (1 case), inflammatory arthritis (3 cases), and revision of another type of total elbow prosthesis (4 cases). After a mean follow-up of 4 years (range, 2-7.5 years) or at revision as a result of loosening or infection, 78% had a satisfactory outcome according to the Mayo Elbow Performance Score. Of the patients, 16 (70%) had no or mild pain and 7 had moderate to severe pain. The loosening rate was 17%. Possible risk factors for loosening were poor cementing and anterior coronoid impingement. Of the patients, 10 (43%) had complications and 7 of these (30%) required revision surgery. The Coonrad-Morrey total elbow prosthesis can lead to successful outcomes for difficult elbow pathologies. However, the complication rate was higher in our series than previously reported. Some technical aspects for use of this implant are outlined.

The GSB III elbow prosthesis in rheumatoid arthritis: a 2- to 9-year follow-up

BACKGROUND

The optimal design of an elbow prosthesis for badly damaged elbows is unkown. We evaluated 23 GSB III semi-constrained (sloppy-hinged) total elbow arthroplasties in 16 consecutive patients with rheumatoid arthritis.

PATIENTS AND METHODS

After a mean follow-up period of 5 (2-9) years, we assessed quality of the cementing technique, signs of aseptic loosening, patient satisfaction, range of movement, and determined the Hospital for Special Surgery (HSS) elbow score. 3 patients had died before follow-up; thus, 20 replacements in 16 patients were available for clinical and radiographic study. All patients had endstage rheumatoid arthritis (RA) of the elbow joint.

RESULTS

In 2 patients, humeral components were revised due to malorientation. 1 arthroplasty was revised due to aseptic loosening of the humeral component. There were 4 cases of intraoperative fracture which healed uneventfully. The total rate of complications was thus one-third. In 17 of 40 components, the cementing technique was rated as marginal or inadequate. We found no association between cementing technique and loosening. The arc of extension/flexion increased by 19 degrees (0-80), and the range of pronation/supination increased by 31 degrees (0-130). There were no cases of infection or ulnar nerve dysfunction. At the latest follow-up, the HSS elbow score was 84 (40-100) points. 11 of 20 elbows were rated as excellent, 4 elbows were rated as good, 2 elbows were rated as fair, and 3 elbows were rated as poor. 14 of 16 patients were satisfied with the result and the 2 patients who were not satisfied had persistent pain.

INTERPRETATION

Despite the inherent problems of cementing in small-calibre medullary cavities, the clinical outcome of the GSB III arthroplasty was encouraging for patients with-end stage RA. The rate of overall complications compared favorably with other studies of semiconstrained elbow arthroplasty for end-stage RA. Most complications of the series were minor and did not necessitate revision.

Elbow arthroplasty using a convertible implant

Total elbow arthroplasty remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow. Complication rates have historically been quite high, and early revision was not uncommon. A greater understanding of elbow anatomy and kinematics has led to advances in prosthetic design and surgical technique. The success of modern elbow arthroplasty for low-demand patients with rheumatoid arthritis has approached that of hip and knee arthroplasty. Mechanical failures have been noted to increase as a complication of both longevity and the use of elbow arthroplasty in a younger, higher-demand patient population. As the indications for total elbow arthroplasty widen to include more complex situations, it becomes more important to precisely recreate the flexion-extension axis of the elbow to optimally balance muscle forces and ligaments in an effort to improve implant durability. Advances in implant modularity and instrumentation can make determination and recreation of the flexion-extension axis more reliable and reproducible. An anatomic convertible implant allows the surgeon great versatility in choosing to perform hemiarthroplasty or unlinked or linked total elbow arthroplasty with assurance that later revision can be performed without the compulsory removal of well-fixed components. Conversion from an unlinked to a linked constraint, and visa versa, can be performed at any time. If late conversion is required, it can be performed in a minimally invasive fashion.

Total elbow anthroplasty and distal humerus elbow fractures

Palvanen et al in 2003 collected data on osteoporotic fractures of the distal humerus fractures from the Finnish National Hospital Discharge Register. They defined an osteoporotic fracture of the distal humerus as a fracture occurring in persons 60 years of age or older following moderate or minimal trauma. The annual rate of incidence of these types of fractures has increased significantly, with 42 fractures reported in 1970 and 208 fractures in 2000(395% increase). The age-specific incidence rates showed a ninefold increase for women 80 years of age or older (8 in 1970 versus 75 in 2000). In the 60-69-year and 70-79-year age groups, the age adjusted increases were twofold. This presents great challenges for future orthopedists, reinforcing the ongoing need to critically analyze results of treatment for this difficult problem. Many patients over the age of 60 years can do well with traditional open reduction and internal fixation of distal humerus fractures. When patients have poor bone quality, however, preventing stable internal fixation or significant medical comorbidities, TEA should be considered. Encouraging results have been reported using TEA as a primary mode of treatment for carefully selected comminuted distal humerus fractures in elderly patients, particularly if the patient also has significant rheumatoid arthritic changes. A triceps-sparing approach is recommended so that patients may be mobilized early following surgery.