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Corresponding author: Graham J.W. King, MD, MSc, FRCSC, Roth–McFarlane Hand and Upper Limb Center, St Joseph’s Hospital, London, Ontario, Canada N6A 4L6.
Total elbow arthroplasty (TEA) is increasingly used for the management of comminuted distal humeral fractures in elderly patients. There are limited data on the outcome of modern elbow arthroplasty designs in larger patient cohorts. The aim of the current study was to review the outcomes and complications using a cemented convertible TEA system in a linked configuration in patients with distal humeral fractures.
Methods
Patients with distal humeral fractures treated with TEA and a minimum of 2 years’ follow-up were reviewed. Demographic information, patient-reported outcome, functional and radiographic outcome assessments, and complications were reported.
Results
Forty patients met inclusion criteria; 35 were female. Median follow-up was 4 years (range, 2–13 years). Average age of patients at the index procedure was 79 ± 9 years. All implants were linked. Range of motion was: extension 16° ± 13°, flexion 127° ± 14°, supination 79° ± 11°, and pronation 73° ± 20°. Patient-reported outcome scores were: Patient-Rated Elbow Evaluation 37 ± 35, Quick–Disabilities of the Arm, Shoulder, and Hand 31 ± 31, and Mayo Elbow Performance Index 90 ± 18. Seven patients had heterotopic ossification. Lucent lines were noted predominantly in humeral implant zone V. No lucent lines were noted around the ulnar component in any radiographic zone. Complications occurred in 9 patients (22%) and 2 revisions were performed: one for infection and one for a late periprosthetic fracture.
Conclusions
Total elbow arthroplasty for fracture in elderly patients provides pain relief, functional range of motion, and good patient-reported outcome scores. No implant-related complications of this convertible implant system were encountered, but longer-term follow-up is needed.
Historically, comminuted unreconstructible distal humerus fractures in the elderly population were managed with a “bag of bones” approach; however, advances in both open reduction internal fixation (ORIF) and arthroplasty have led to improved outcomes.
A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65.
A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65.
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.
These studies suggest that appropriately selected patients with complex unreconstructible distal humeral fractures treated with TEA have improved outcomes compared with ORIF; however, the rate of complications and the overall mortality rate in these patients remain high. Many surgeons consider low capitellar-trochlear shear fractures, fractures with extensive comminution and poor bone quality, or those with extensive low metadiaphyseal comminution and intra-articular extension to be injury patterns for which management with TEA may be favored.
Convertible TEA systems provide the capability for the surgeon to choose among linked, unlinked, and hemiarthroplasty designs during surgery while using the same humeral stem. The surgeon can assess the integrity of the soft tissues, supporting ligamentous structures and bone loss around the elbow during surgery and choose between a distal humeral hemiarthroplasty and total elbow replacement in patients with distal humeral fractures. Currently, only one convertible TEA is commercially available (Latitude EV, Wright Medical Group, Bloomington, MN) and no study has evaluated the clinical results of this device in a cohort of patients with distal humeral fractures.
Importantly, the convertible implant in this study has not been approved by the Food and Drug Administration in the United States for hemiarthroplasty and is off-label for this indication on the US market.
The purpose of this study was to report the outcomes and complications of a linked convertible TEA for the management of distal humeral fractures.
Materials and Methods
Patient selection and enrollment
We retrospectively analyzed a cohort of patients treated at our center for an acute unreconstructible fracture of the distal humerus with a cemented TEA between 2003 and 2016, from our TEA database (Fig. 1). A minimum of 2 years’ follow-up was required for inclusion in the current review. Exclusion criteria included patients undergoing TEA for another indication, delayed treatment or presentation beyond 3 weeks from injury, and those who refused follow-up, were unable to consent, or were unable to provide clinical outcome data.
Figure 1A Preoperative lateral radiograph and B 3-dimensional computed tomographic image and C, D 4 months postoperative radiographs of a 78-year-old woman with a complex articular fracture of the right distal humerus who met inclusion criteria for the study and underwent a linked elbow arthroplasty.
Baseline patient demographics, medical comorbidities, and indications for TEA were collected. Functional outcomes including elbow range of motion (ROM), measured by long-arm goniometer, were recorded by a research assistant. Patient-reported scores, impairment measurements, and objective assessments, including physical examination and radiographic outcomes, as validated assessment tools were employed. We recorded patient-rated outcomes and clinical outcome scores including Quick–Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Rated Elbow Evaluation (PREE), the simple descriptive pain intensity scale, and the Mayo Elbow Performance Index (MEPI). Radiographs were reviewed by 3 upper-extremity fellowship-trained surgeons. Implant subsidence, periprosthetic fracture, as well as signs of implant wear, osteolysis, uncoupling, and loosening were evaluated. The zones of lucency were described using the modified Gruen zone technique described by Wagener et al.
Measurements in millimeters were taken at the widest point of loosening between implant–cement or cement–bone interfaces to provide a measure of the amount of loosening present (Fig. 2). Radiographs were also reviewed for the presence of heterotopic ossification and scored using the Hastings classification.
Three upper-extremity fellowship-trained surgeons practicing at a dedicated upper-extremity teaching facility were involved in patient care and surgical treatment. Routine preoperative antibiotic prophylaxis was employed, including preoperative intravenous cefazolin followed by 24 hours of postoperative intravenous cefazolin, or an alternative if the patient was allergic. A tourniquet was used. The choice of surgical approach evolved during the study period. Initially, a paratricipital approach was used; however, in later years, a lateral paraolecranon approach was employed owing to the improved exposure for placement of the ulnar component.
An ulnar nerve transposition was routinely employed during the period of this study. Fractured condyles were routinely excised. All patients underwent a Latitude or Latitude EV Convertible Total Elbow Arthroplasty (Wright Medical Group). Implant linkage was routinely performed in this cohort owing to distal humeral bone loss and the low-demand nature of the patients. Preoperative, intraoperative, and postoperative patient and injury characteristics facilitated decision-making. Implant stability was maximized by optimizing implant positioning, careful intraoperative decision-making regarding instrumentation including implant sizing and linkage mechanism, and soft tissue management. Careful stability assessment after implantation ensured concentric elbow tracking. The radial head was either excised or retained at the surgeon’s discretion. If the radial head was fractured or not articulating well with the humeral component, it was excised. The standard postoperative protocol included a period of immobilization after surgery for 1 to 2 weeks until the incision was stable, at the discretion of the treating surgeon. Heterotopic ossification prophylaxis was not used. Then, progressive rehabilitation to regain elbow motion, stability, and strength commenced. A dedicated upper-extremity therapist was involved in early patient rehabilitation to teach patients a home-based therapy program. Patients were reviewed and radiographs were performed at 2 and 6 weeks, 3, 6, and 12 months, and annually thereafter.
We performed statistical analyses using quantitative measures. Institutional review board approval was granted before patient chart review and radiographic analysis.
Results
After database and chart review, 62 cases were available for review. Forty patients met inclusion criteria (22 were excluded for insufficient follow-up and associated injuries). Nineteen patients were deceased at the time of final analysis (48%), but complications and reoperations were included in the final analysis. These patients died of unrelated causes. Three fellowship-trained upper-extremity surgeons performed the surgeries with similar case distributions. Thirty-five patients were female (88%). Median follow-up was 4 years (range, 2–13 years; mean, 5 ± 3years). Thirty-two patients had dominant-side injuries (76%). At follow-up, mean elbow extension was 16° ± 13°, flexion was 127° ± 14°, supination was 79° ± 11° and pronation was 73° ± 20°. No triceps deficiency or elbow instability was present. We used 31 Latitude and 9 Latitude EV implants. All implants were linked. Eight short-stem ulnar components were used; the remainder were standard-length stems. No radial head prostheses were implanted. Eleven patients retained the native radial heads and 29 patients underwent radial head excision.
Pain and patient-reported outcome measures
The study sample mean PREE was 37 ± 35, QuickDASH was 31 ± 31, and MEPI score was 90 ± 18. No pain was reported by 70% of patients, whereas 25% reported mild discomfort and 5% reported moderate pain scores on the simple descriptive pain intensity scale. No patient reported severe pain. Patient MEPI outcome scores were good to excellent in all except 3 patients. One patient who experienced a postoperative ulnar olecranon fracture had a PREE score of 73, QuickDASH score of 73 points, and MEPI score of 45 points (2%). One patient had poor outcome scores with a PREE score of 76 points, QuickDASH score of 71 points, and MEPI score of 35 after developing notable heterotopic ossification limiting ROM, but chose not to undergo a secondary procedure. The last patient had a PREE score of 23, QuickDASH score of 65, and MEPI score of 50 at 8 years of follow-up. This patient had excellent restoration of motion and strength; however, he reported discomfort with heavy lifting activities and strength functions on the PREE, QuickDASH, and MEPI indexes.
Radiology
Radiographically, humeral component Gruen zones I and V demonstrated the greatest amount of radiolucent lines. Ten percent of patients had lucent signs in zone I with an overall average of 0.8 ± 0.1mm. Similarly, zone V lucencies were seen in 10% of patients with an average of 1.6 ± 0.3 mm of lucency. Conversely, Gruen zone III on the lateral radiograph suggested a higher overall prevalence of lucent lines (15% of patients) around the dorsal aspect of the ulnar component. No patients underwent reoperation for loosening.
Complications
Complications occurred in 9 patients (22%) (Table 1), with 5 patients requiring reoperation. Component revision was required in 2 patients: one for a periprosthetic olecranon fracture around an ulnar component after a fall and the second for a 2-stage revision for infection. Additional reoperations not requiring implant revision included one ORIF of a periprosthetic fracture of the ulna distal to the stem, one irrigation and debridement with component retention in another patient, and one excision of heterotopic ossification. Component retention with irrigation and debridement was performed for the early presentation of deep infection with successful eradication of the infection as a single-stage procedure. After surgical excision of the heterotopic ossification, the patient had a ROM of 15° extension to 100° flexion. A superficial infection was treated successfully with antibiotics in one patient. Four patients had transient ulnar neuropathies that spontaneously resolved. At 12 years, 29% of patients had undergone revision based on survival analysis. No triceps complications were identified in this cohort.
With increasing use of TEAs for the management of unreconstructible distal humerus fractures, there is a pressing need for literature on the outcomes and complications of this procedure in larger cohorts. The current study evaluates the outcomes of a newer convertible TEA implant used for patients with distal humeral fractures. Patients in this study demonstrated good to excellent patient-reported outcomes beyond a mean of 5 years of follow-up. Although complications were high, they were in keeping with the literature. We had a nearly 50% mortality rate in the patient sample over the study time frame, which indicates that these injuries are a marker of patient frailty.
Treatment strategies for distal humerus fractures include nonsurgical treatment, ORIF, and arthroplasty. Successful surgical management requires careful patient selection and a firm understanding of the fracture morphology, patient comorbidities, and surgeon familiarity with the techniques. Desloges et al
demonstrated successful clinical outcomes including union and pain control in selectively treated nonsurgical cases of low-demand, medically frail patients. A total of 68% of patients experienced good to excellent subjective outcomes and one patient with symptomatic nonunion was successfully converted to TEA as a salvage procedure. Likewise, a number of studies evaluating ORIF compared with TEA have suggested similar overall complication rates with a higher rate of major complications in the ORIF group.
A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65.
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.
Open reduction and internal fixation versus total elbow arthroplasty for the treatment of geriatric distal humerus fractures: a systematic review and meta-analysis.
The complication rates from our study are similar to the outcomes seen in previously published studies. Overall, in carefully selected patients, the use of a linked convertible TEA may be a useful tool for the orthopedic surgeon in the management of these difficult injuries.
The current study had a number of strengths. Patients were treated in a tertiary center using standardized techniques provided by 3 fellowship-trained upper-extremity surgeons. This single-center approach ensures a level of reproducibility within the current cohort. The study sample was homogeneous and treated with similar indications and consistent techniques. Only 2 previous studies (Wagener et al
) reported the outcomes of this implant; however, they evaluated patients with multiple indications and neither included patients with acute fractures. Previous studies evaluating the outcomes of TEA after acute distal humeral fractures with other implants demonstrated good clinical outcomes.
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.
The overall rate of reoperation was 13% including 2 component revisions (one ulnar revision for a periprosthetic fracture and one 2-stage procedure for infection) and 3 reoperations for other causes including one periprosthetic fracture, one irrigation and debridement with component retention, and one patient with heterotopic ossification.
A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65.
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.
In the current cohort, we documented 2 cases of postoperative periprosthetic fracture (5%). Although these were both distant from the index procedure, it highlights the fragility of this population and tendency of these patients to fall repeatedly.
Ulnar neuropathy and infection (deep and superficial) were similar to reported rates in the literature.
Patient-reported outcomes scores within the current cohort were good to excellent. This suggests that most patients with a distal humeral fracture managed with a linked TEA have a relatively pain-free and useful arm. However, this sample was largely female and elderly with limited functional demands. One patient who reported poor subjective patient-reported outcomes scores (PREE of 23 and MEPI of 50) had excellent objective outcomes. His main problems were discomfort and pain when performing heavy lifting and sports-related activities. Despite noncompliance, he continued to have excellent ROM and strength measurements 8 years after arthroplasty.
In keeping with the available literature, we noted higher rates of radiographic lucent lines in humeral zones I and V and dorsal ulnar zone III.
Although progression of radiolucent lines is equally important compared with absolute values, we could not analyze this because of the retrospective nature of the database. Although most lucent lines were less than 1 mm, 2 patients had greater than 1 mm of loosening around zone III of the ulnar component and zones I and V of the humeral components. We could not analyze the issue of radial component loosening because no radial head components were used in the current sample. No implant revisions were required for loosening or bearing wear in this cohort. A convertible implant with greater modularity may theoretically increase the possibility of component disassembly. Stresses on the humeral implant are typically increased in fractures because the medial and lateral condylar fracture fragments are excised, limiting distal bony support. That said, the implant used in this study incorporates fins to resist rotation and bending in addition to the anterior flange. We saw no humeral loosening in this elderly cohort; however, longer follow-up is needed. This convertible TEA cohort had no cases of implant disassembly at the most recent follow-up.
The current study had a number of limitations. Although we used a convertible implant system, no unlinked implants were selected by the treating surgeons. This reflects surgeon bias to use linked implants in these lower-demand patients, allowing more rapid surgery, because column reconstruction was not required to achieve stability, given that this was provided by the implant. Therefore, it is important not to assume that similar results would occur if unlinked implants were used for fracture care. We noted no instability of this prosthesis, which suggests that the linked design of this implant was reliable during the duration of follow-up of these patients. The retrospective nature of the current study has inherent limitations. This is particularly important because of the elderly patient demographic of the current study, because this presented logistical and practical implications for follow-up and continued reevaluation. Elderly patients frequently have medical comorbidities and limited or diminished mobility and independence, which makes returning for frequent visits more challenging. Moreover, because we are a tertiary referral center, many patients travel considerable distances to us for care; this presents an inherent potential bias in the study sample. It may be that those with ongoing elbow trouble are geographically closer to our facility, or more mobile and may be preferentially selected for longer follow-up whereas patients with no ongoing elbow pathology or who live farther away are lost to follow-up. Overall, however, we were able to obtain patient-reported outcome measures, ROM, and radiographic follow-up for a large number of elderly fracture patients. Finally, the study sample was largely elderly female patients. Therefore, additional extrapolation to all patients may be limited. Understanding the restrictions placed on patients after TEA is an important discussion that must occur before the surgical intervention itself. The broader application of these results must also be considered carefully. The patients in this study were treated at a tertiary upper-extremity referral center by experienced elbow surgeons, and these results may not be replicated by lower-volume surgeons.
Total elbow arthroplasty is a useful tool in the management of elderly patients with comminuted distal humeral fractures; it provides a stable functional elbow ROM with good patient-reported outcome. The complication rate following TEA for distal humeral fractures (22%), although similar to other series of both TEA and ORIF, is an important consideration that should be discussed with patients when deciding between surgical and nonsurgical management.
References
Ul Islam S.
Glover A.W.
Waseem M.
Challenges and solutions in management of distal humerus fractures.
A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65.
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.
Open reduction and internal fixation versus total elbow arthroplasty for the treatment of geriatric distal humerus fractures: a systematic review and meta-analysis.
G.J.W. King receives consultant honoraria and royalties from Wright Medical Technology. No benefits in any form have been received or will be received by the other authors related directly or indirectly to the subject of this article.
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