Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature (original) (raw)
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Total elbow anthroplasty and distal humerus elbow fractures
Hand Clinics, 2004
The indications for total elbow arthroplasty (TEA) have expanded over the last few decades. The initial primary indication for TEA was inflammatory arthritis of the elbow; however, more recently there have been reports on the successful use of TEA for other clinical situations, such as post-traumatic or primary osteoarthritis, nonunion or malunion of the distal humerus, and comminuted distal humerus fractures in elderly patients. As the indications for TEA have expanded, unfortunately the incidence of complications and implant failure also has increased. In 1994 Kraay et al reported their cumulative survival of TEA for post-traumatic arthritis, fractures, or supracondylar nonunion at 3 and 5 years compared with a second group of TEA in patients with inflammatory arthritis. The cumulative survival in the first group was 73% and 53% at 3 and 5 years, respectively, compared with 92% and 90% for the inflammatory group. This has raised concerns for expanding indications of TEA beyond patients with inflammatory arthritis. This article addresses the issues around TEA in the setting of comminuted distal humerus fractures in elderly patients and provides a review of the recent literature on this subject.
Acta bio-medica : Atenei Parmensis, 2016
BACKGROUND The treatment of complex distal humerus fractures is challenging and is often associated with unsatisfactory results. Anatomic reduction and stable internal fixation is difficult to obtain, especially in elderly osteoporotic patients. For these reasons, total elbow arthroplasty (TEA) has recently evolved as a valid procedure in selected cases following these injuries. The aim of this study was to analyze outcomes of TEA for the treatment of complex distal humerus fractures in 20 low-demanding patients over 65 years of age. MATERIALS AND METHODS All patients, at a mean follow-up of 60 months, were evaluated clinically using the Mayo Elbow Performance Score (MEPS) and radiographically in order to assess the positioning of the prosthetic components and signs of loosening. Statistical analyses investigated the presence of clinical and radiographic variables as predictive factors of poor functional outcomes. RESULTS Similar MEPSs were observed in the affected and unaffected ar...
Injury, 2014
Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures. Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit. Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with...
Linked total elbow arthroplasty as treatment of distal humerus fractures
Acta orthopaedica Belgica, 2012
Treatment of distal humerus fractures may be challenging, especially in the elderly patient. Total elbow replacement has been proposed as an option in selected patients. We present the results of a linked elbow replacement in 16 patients with a comminuted fracture of the distal humerus which was not considered amenable to reliable open reduction and internal fixation. At a mean follow-up of 57 months, average range of motion was from 28 degrees to 117 degrees of flexion-extension. Five patients with moderate to severe pain (31%) were not satisfied with the results of the operation. Three patients had an infection which resulted in implant removal in one patient. Eight patients had symptoms of sensory ulnar nerve neuropathy. Our results show that elbow replacement may be an optimal solution for highly comminuted osteoporotic fractures, if there are no associated complications. However, the rate of significant and minor complications such as infection or postoperative ulnar nerve symp...
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Disclosures and Conflicts of Interest: The authors did not received payments or services, either directly or indirectly (ie, via their institution) from a third party in support of any aspect of this work. The authors' institution has had a financial relationship with entities in the biomedical arena (Zimmer and Tornier) that could be perceived to influence, or have the potential to influence, what is written in this work. The authors have had no other relationships or have engaged in no other activities that could be perceived to influence, or have the potential to influence, what is written in this work.
Primary total elbow arthroplasty in complex fractures of the distal humerus
World journal of orthopedics, 2014
To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus. A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo. Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated suc...
Distal Humeral Fractures Treated with Noncustom Total Elbow Replacement
Journal of Bone and Joint Surgery-american Volume, 2005
The purpose of this study was to review the cases of patients with a distal humeral fracture that was treated with a noncustom total elbow arthroplasty. We hypothesized that, on the basis of the functional and clinical outcome, total elbow replacement is a reliable option for the treatment of elderly patients with a severe, comminuted fracture of the distal part of the humerus. We retrospectively reviewed forty-nine acute distal humeral fractures in forty-eight patients who were treated with total elbow arthroplasty as the primary option. The average age of the patients was sixty-seven years. Forty-three fractures were followed for at least two years. According to the AO classification, five fractures were type A, five were type B, and thirty-three were type C. The average age of the forty-three patients was sixty-nine years and the average duration of follow-up was seven years. Fourteen patients died during the review period. Postoperative clinical function was assessed with use of the Mayo elbow performance score, and anteroposterior and lateral radiographs made at follow-up examinations were reviewed. At the latest follow-up examination, the average flexion arc was 24 degrees (range, 0 degrees to 75 degrees ) to 131 degrees (range, 100 degrees to 150 degrees ) and the Mayo elbow performance score averaged 93 of a possible 100 points. Heterotopic ossification was present to some extent in seven elbows, with radiographic abutment noted in two. Thirty-two (65%) of the forty-nine elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Fourteen elbows (29%) had a single complication, and most of them did not require further surgery. Ten additional procedures, including five revision arthroplasties, were required in nine elbows; five were related to soft tissue and five were related to the implant or bone. Complex distal humeral fractures should be assessed primarily for the reliability with which they can be reconstructed with osteosynthesis. When osteosynthesis is not considered to be feasible, especially in patients who are physiologically older and place lower demands on the joint, total elbow arthroplasty can be considered. This retrospective review supports a recommendation for total elbow arthroplasty for the treatment of an acute distal humeral fracture when strict inclusion criteria are observed.
Total elbow replacement for complex fractures of the distal humerus
The Journal of Bone and Joint Surgery, 2001
T he treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125° (110 to 140) and loss of extension was 23.5° (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly.
Primary Total Elbow Replacement for Fractures of the Distal Humerus
Operative Orthopadie Und Traumatologie, 2005
Operationsziel Erreichen einer stabilen und schmerzfreien Funktion durch primäre Implantation einer totalen Ellenbogenprothese bei komplexen intraartikulären distalen Humerusfrakturen älterer Patienten. Indikationen Fraktur mit freien Fragmenten oder schlechter Knochenqualität, die eine stabile Osteosynthese nicht zulassen. Geschlossene, komplexe intraartikuläre distale Humerusfraktur (Typ C nach der AO-Klassifikation). Typ-A- und B-Fraktur des distalen Humerus bei Patienten mit vorbestehenden degenerativen Veränderungen, rheumatoiden Erkrankungen oder Voroperationen des Gelenks. Gute Mitarbeit des Patienten, geringer Funktionsanspruch, Patientenalter > 65 Jahre. Kontraindikationen Offene Frakturen (Typ II oder III nach Gustilo-Anderson). Infizierte Wundverhältnisse, offene Weichteilverletzungen. Fehlende Mitarbeit des Patienten, hoher Funktionalitätsanspruch, Patientenalter > 65 Jahre. Paralyse des Bizepsmuskels. Operationstechnik Rückenlagerung des Patienten. Dorsaler Zugang zum Ellenbogengelenk. Darstellen der medialen Anteile des Musculus triceps an der Insertion des dorsalen Humerus und der Gelenkkapsel, Abdrängen in Kontinuität mit dem ulnaren Periost und der Unterarmfaszie. Bei Entfernung des frakturierten distalen Anteils des Humerus kann der Ansatz des Musculus triceps belassen werden. Vorbereitung des Humerusschafts: Bei mehrfach frakturierten Kondylen ist eine Rekonstruktion nicht notwendig; intramedulläres Entfernen des Knochens von der medialen und lateralen suprakondylären Kante mit einer Fräse. Entfernen der Olekranonspitze. Knochenspananlagerung hinter der anterioren Lasche der humeralen Komponente. Einzementieren der humeralen und ulnaren Komponente. Nachresektion des Radiuskopfes bzw. Processus coronoideus bei Impingement der Gelenkfacetten. Transossäre Reinsertion des Musculus triceps am Olekranon. Weiterbehandlung Selbständige Bewegungsübungen. Vermeidung des Hebens von Gewichten > 5 kg, keine wiederholten Dauerbelastungen > 1 kg Gewicht und keine forcierten Bewegungen im Ellenbogengelenk, z. B. Schlagsportarten. Ergebnisse 49 Totalendoprothesen wurden bei 48 Patienten (Durchschnittsalter 67 Jahre) aufgrund distaler Humerusfrakturen eingesetzt. 43 Frakturen konnten nach einem Zeitraum von 7 Jahren nachuntersucht werden. Nach der AO-Klassifikation wurden fünf Typ- A , fünf Typ-B und 33 Typ-C Frakturen behandelt. Der durchschnittliche Bewegungsumfang lag zwischen 24° und 131°. Der „Mayo Elbow Performance Score“ betrug durchschnittlich 93. Die Komplikationen aller 49 Patienten wurden anhand der Akten erfasst. 32-mal bestanden im Verlauf keine Komplikationen. Insgesamt mussten zehn Revisionseingriffe durchgeführt werden, fünfmal war im Verlauf eine Revisionsarthroplastie erforderlich. Retrospektiv kann die Totalendoprothese des Ellenbogens in der Versorgung distaler Humerustrümmerfrakturen unter strenger Berücksichtigung der genannten Indikationen empfohlen werden. Objective Achieving stability and pain-free function for osteoporotic intraarticular multifragmentary fractures of the distal humerus in elderly patients by primary total elbow replacement (TER). Indications Non-soft-tissue-attached fragments, poor-quality bone, where stable osteosynthesis is not attainable. Severely comminuted intraarticular closed type C fractures according to the AO classification with multiple small bone/cartilage fragments. In case of degenerative joint diseases and/or previous surgery in rheumatoid patients also type A and B fractures. High compliance, low demand, and old patient > 65 years. Contraindications Type II or III Gustilo-Anderson open fractures (primary irrigation and debridement). Preexisting infection, open wounds. Younger, high-demand or noncompliant patient. Paralysis of the biceps muscle. Surgical Technique Supine positioning of patient. Triceps-sparing dorsal approach. Elevation of medial aspect of the triceps from posterior aspect of the humerus and capsula, reflecting the triceps in continuity with the ulnar periosteum and the forearm fascia. If removal of distal part of the humerus, the triceps insertion can be left intact. Preparation of humerus: no reconstruction of multifractured condyles; excavate bone from medial and lateral supracondylar ridges with burr. Preparation of ulna: remove tip of olecranon. Cemented humeral and ulnar components. Bone graft interposition behind anterior flange of humeral component. Resection of radial head and coronoid process, if impingement after trial reduction. Triceps reattachment transosseous through olecranon. Postoperative Management No formal physical-therapy sessions. Avoid single-event weight lifting of > 5 kg and repetitive lifting of > 1 kg. Discourage playing racquets sports. Results 49 acute distal humeral fractures in 48 patients (average age: 67 years) were treated with TER. 43 fractures were followed at an average of 7 years. According to the AO classification, five fractures were type A, five type B, and 33 type C. The average flexion arc at follow-up was 24–131°, the Mayo Elbow Performance Score averaged 93. Data of complications were obtained from records in all 49 patients. 32 of the 49 elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Ten additional operative procedures, including five revision arthroplasties, were required. The retrospective review supports recommendation for TER for the treatment of an acute distal humeral fracture, when strict inclusion criteria are observed.
Unlinked elbow arthroplasty as primary treatment for fractures of the distal humerus
2008
This study reviews our experience with primary total elbow arthroplasty in the management of acute distal humeral fractures by use of the iBP unlinked elbow prosthesis. We followed up 9 elbows in 9 patients (including 2 with rheumatoid arthritis), with a mean age of 73 years, for a mean of 3.5 years. Functional outcome was assessed with the Mayo Elbow Performance Score and the recently developed Liverpool Elbow Score. Clinical examination and radiologic assessment were performed by an independent surgeon. All elbows were stable at the latest follow-up examination, all patients were able to perform daily activities, and pain relief was satisfactory. The median value for the Mayo Elbow Performance Score was 95 (range, 65-100). This is the first report of the use of an unlinked prosthesis for the treatment of distal humeral fractures. Our results show that this method of treatment provides a reliable and effective way of dealing with these very difficult fractures when internal fixation is not a viable option. (