Total elbow anthroplasty and distal humerus elbow fractures

Hand Clin 20 (2004) 475–483

Total elbow anthroplasty and distal humerus elbow fractures April D. Armstrong, MD, FRCSCa,*, Ken Yamaguchi, MDb a

Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Orthopaedics and Rehabilitation, H089 500 University Drive, P.O. Box 850, Hershey, PA 17033, USA b Shoulder and Elbow Service, Department of Orthopaedic Surgery, 1 Barnes–Jewish Hospital Plaza, Suite 1130, West Pavilion, St. Louis, MO 63110, USA

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 [1] 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. Open reduction and internal fixation Recent literature has shown that open reduction and internal fixation of distal humerus * Corresponding author. E-mail address: [email protected] (A.D. Armstrong).

fractures in individuals over the age of 60 years with comminuted distal humerus fractures may not be likely to achieve acceptable outcomes with this procedure in some instances [2–5]. The least satisfactory results have been found when treating AO C3 (comminuted intra-articular distal humerus fracture) classification of fractures [6]. This type of fracture pattern is not uncommon in the older age group [7] and typically occurs as a result of a minor fall [7–9]. Pajarinen et al reviewed their results of internal fixation for 18 patients with a mean age of 44 years (range, 16–81 years) [4]. There were 29% type C1, 57% type C2, and 14% type C3 fracture patterns. All 8 patients younger than 40 years of age had an excellent or good postoperative result compared with only 2 of the 10 patients over the age of 50 years. Patients younger than 40 years had on average a shorter period of immobilization postoperatively compared with those patients over the age of 50 years. The investigators speculated that the poorer results in patients over the age of 50 years were caused by this longer period of postoperative immobilization and subsequent elbow stiffness. Poor bone quality and extensive comminution of the fracture were provided as an explanation for the prolonged immobilization to avoid nonunion of the fracture. Caja et al also reported a lower final range of motion obtained in their patient subgroup over 40 years of age compared with those patients younger than 40 years [5]. Robinson et al reported difficulty in obtaining stable fixation and a higher risk for union complications in ‘‘low’’ transcondylar type A and C distal humeral fractures [7]. They proposed that TEA

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as a primary treatment for these types of fractures in elderly patients should be considered. There are, however, reports of optimistic results with open reduction and internal fixation of distal humerus fractures [10–18]. John et al examined 39 patients treated with open reduction and internal fixation for distal intra-articular humeral fractures, with an average age of 80 years (range, 75–90 years) [17]. There were 8 type A, 13 type B, and 28 type C fractures. At follow-up (an average of 18 months), 31% of the patients reported a very good result, 49% good, 15% fair, and 5% poor. Flexion and extension range of motion was reported very good in 41% and good in 44%. Pereles et al examined 12 patients with an average age of 71 years (range, 63–85 years) [15]. The number of comorbidities in this patient group averaged 1.4. They reported 25% excellent and 75% good results. None of the fractures experienced loss of fixation. It was their conclusion that open reduction and internal fixation of distal humerus fractures in patients older than 60 years of age can yield good results. Papaioannou et al documented that the most important factor for a good final outcome for type C distal humerus fractures was the ability to achieve stable fixation and allow early motion [14]. They reported that it was more difficult to obtain stable fixation in type C3 distal humerus fractures, with only 9 of the 18 patients in their group having stable fixation. Holdsworth et al reported that age was not a contraindication to open reduction and internal fixation of distal humerus fractures, but that instead this decision should be based on the quality of the bone and fracture pattern [18]. Total elbow arthroplasty Cobb and Morrey were the first to review retrospectively their results of primary TEA (Coonrad-Morrey) for treatment of acute fractures of the distal humerus in 20 patients (21 elbows) who had a mean age of 72 years (range, 48–92 years) [8]. Ten of these patients had extensive comminution of an acute fracture of the distal humerus in addition to destruction of the articular surface secondary to rheumatoid arthritis. The other 11 patients had extensive comminution of an acute intra-articular fracture of the distal humerus and were older than 65 years of age. The investigators report that the presence of rheumatoid arthritis had a direct influence on their decision to treat with a TEA. Three patients underwent an initial attempt at open reduction

and internal fixation of the elbow before implantation of the TEA. Five of the 11 patients without rheumatoid arthritis had a fracture classification of C3 according to the AO classification system for intra-articular distal humerus fractures. The mean duration of follow-up was 3.3 years (range, 3 months to 10.5 years). The Mayo elbow performance score showed excellent results in 15 elbows and 5 good results. On follow-up radiographs, three elbows demonstrated radiolucent lines that were present immediately postoperatively and had not progressed since the surgery. Complications reported included fracture of the ulnar component after the patient fell on an outstretched arm (this patient required revision TEA), one superficial wound infection, three patients with ulnar neuropraxia, and one patient with reflex sympathetic dystrophy. The investigators supported primary TEA in patients older than 65 years with extensive comminution of the articular surface of the distal humerus and in patients with significant rheumatoid arthritic change with extensive comminution. It was their opinion that the hospital costs of open reduction and internal fixation versus primary TEA were the same and primary TEA was a simple procedure compared with open reduction and internal fixation, provided the surgeon was experienced with performing TEA. They stressed, however, that out of 129 acute distal humerus fractures in an 11-year period, only 21 primary TEA were performed, indicating that there are strict criteria for the selection of the treatment option. More recent literature reports also have demonstrated encouraging results using TEA as a primary mode of treatment for carefully selected comminuted distal humerus fractures in elderly patients [9,19–21]. Ray et al reported on seven patients with a mean age of 81.7 years who were treated with a primary TEA (Coonrad-Morrey semi-constrained) for a distal humerus fracture with gross comminution and osteoporosis [19]. Three patients had destruction of the articular surface secondary to rheumatoid arthritis. Follow-up ranged from 2–4 years. Six patients at follow-up had no pain and one had only mild pain. The mean Mayo elbow performance score was 92, with five elbows rated excellent and two elbows good. The investigators reported early elbow mobilization and shorter hospital stays as an advantage of this treatment approach. Gambrisio et al evaluated the functional outcome of 10 patients who underwent a primary TEA for distal humerus fractures with a minimum

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follow-up of 1 year. The mean Mayo score was 94, with high patient satisfaction [20]. Their criteria for TEA were a fracture not amenable to osteosynthesis because of small size of the distal fragments or poor quality of the bone. Two patients showed radiolucent lines around the humeral stem; however, these had not progressed with radiologic examination at follow-up. Garcia et al reported on 19 consecutive patients with fractures of the distal humerus treated with primary TEA using the CoonradMorrey prosthesis [21]. No patient had inflammatory or degenerative arthritis. Indications for surgery were fracture comminution and osteopenia in patients older than 60 years of age. Mean follow-up was 3 years and the mean age was 73 years. Eleven patients were classified as having an OA classification C3 fracture pattern. The mean Mayo elbow performance score was 93 and 94% of the patients were satisfied with the outcome. Radiolucent lines were present on the initial postoperative radiographs for one patient, which had not progressed at final follow-up. Frankle et al compared open reduction and internal fixation for intra-articular distal humerus fractures to primary TEA (Coonrad-Morrey) in women older than 65 years of age [9]. All fractures were OA classification C2 or C3. This was a retrospective review with 12 patients in each study group. In the open reduction, internal fixation group, 5 of the 12 patients had comorbid conditions, and olecranon osteotomy was performed in 10 patients. In the TEA group, all patients had comorbid conditions; eight of these patients had rheumatoid arthritis. For the open reduction, internal fixation group, the Mayo score was excellent in four, good in four, fair in one, and poor in three patients. The three poor results were caused by fixation failure and all were revised to a TEA. Two of these patients went on to develop ulnar component loosening and required revision surgery at 8 and 12 months. It was the investigators’ opinion that associated medical comorbidities adversely affected the results in this patient group. The average Mayo elbow performance score for the 9 patients not revised to TEA was 87.7. For the TEA group, the Mayo score demonstrated 11 excellent results and 1 good result. No patient required revision implant surgery. Three patients required subsequent surgery, one to reconnect an uncoupled prosthesis, one for postoperative hematoma, and one for superficial wound infection. The overall average Mayo elbow performance score was 95. Follow-up radiographs

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for one patient showed progressive radiolucency of the ulnar component. Ombresky et al in 2003, as part of the Evidence-Based Orthopaedic Trauma Working Group, reported on their evaluation of the available literature to help guide clinicians in their clinical decision making for open reduction and internal fixation versus arthroplasty of distal intra-articular humeral fractures in elderly patients. A computerized data search from 1969–2003 was performed [22]. They identified loosening and infection as the main long-term problems of TEA. They believed that the studies to date have reported a low incidence of these problems. For open reduction and internal fixation, they reported that the elbow range of motion achieved with open reduction and internal fixation was equivalent to that found with TEA. The overall functional outcome for open reduction and internal fixation was considered less predictable, reported as 75%–85% versus 90% for TEA. Elderly patients who did achieve union with primary osteosynthesis, however, had nearly equivalent functional scores compared with those patients who underwent a TEA. Overall, it was their opinion that with the limited 4-year followup provided with these studies, strong evidence favoring either open reduction and internal fixation or primary TEA for distal humerus fractures in elderly patients was lacking. They believed that surgeon experience and judgment should guide clinical decision making until larger comparative studies (prospective, randomized) and long-term follow-up studies were available. Indications As it seems that many patients over the age of 60 years can do well with traditional open reduction and internal fixation of distal humerus fractures, the decision to implant a TEA for this condition should be limited to those patients in whom bone quality and coexisting medical comorbidities would not favor traditional methods of treatment (Fig. 1). The literature supports that an inability to obtain stable internal fixation and early mobilization may lead to poorer results [4,5,7]. In this same clinical scenario, primary TEA for distal humerus fractures has been shown to allow for early therapy and good to excellent short-term functional results [8,9,19–21]. TEA also should be considered in patients with preexisting joint damage, such as rheumatoid arthritis or other inflammatory conditions [8,23]. It is

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Fig. 1. Low distal intra-articular humerus fracture with osteopenic bone.

well supported in the literature that patients with inflammatory arthritis do well with primary TEA, with excellent long-term follow-up [1,24–28]. Another indication for TEA would be when there is so much comminution of the articular surface that anatomic reduction can not be achieved. This is not uncommon in women over the age of 60 years. If the patient is able to comply with the weightlifting and activity restriction imparted with a TEA, it may be in his or her best interest to undergo implant surgery. This could spare the patient from a second procedure, such as a conversion to a TEA, following a failed attempt of internal fixation (Table 1). There are risks and complications with either treatment approach. Open reduction and internal fixation carries the risk for nonunion, loss of fixation, infection, and stiffness. Arthroplasty implantation runs the risk for loosening, infection, and periprosthetic fractures. There is a theoretic concern that trauma patients have a greater Table 1 Indications for primary total elbow anthroplasty for distal humerus fractures in patients >60 years of age Unreconstructable with traditional stable open reduction and internal fixation techniques, allowing for early mobilization Pre-existing articular damage from inflammatory condition of the elbow Extensive articular comminution Low physical demand of patient

functional demand compared with patients with inflammatory arthritis and therefore are at a higher risk for early failure of the implant. One significant potential benefit of internal fixation, if stable osteosynthesis is achieved, is that there are no activity limitations caused by preservation of the native joint. This is not the case with TEA. Most investigators recommend up to a 5-kg lifetime weightlifting restriction following surgery [29]. In this older population, however, some patients place fewer demands on their elbow and do not consider this a difficult requirement to comply with. It is important to elicit activity-related information from the patient preoperatively, so that patient and surgeon understand the expectations of surgery. One considerable advantage of implant arthroplasty is the ability to preserve the triceps tendon. In most situations TEA for these fractures can be performed with a triceps-sparing approach with allows for early unrestricted range of motion with active elbow extension exercises, resulting in a quicker return to activity. With open reduction and internal fixation it is not uncommon for an olecranon osteotomy to be performed, particularly for type C3 fractures, which requires protecting triceps activity and potentially flexion range of motion if fixation of the osteotomy is concerning. Olecranon osteotomy also carries a risk for delayed union or nonunion and prominent hardware. Active infection is a definite contraindication to implant arthroplasty. Open fractures of the distal humerus are a relative contraindication to TEA. Cobb and Morrey had three patients in their series with type I open injuries, two of which were treated with irrigation and debridement 3 days before the replacement arthroplasty [8]. No subsequent deep infections were reported. Obviously TEA for an open distal humerus fracture should be performed with caution and is mostly a judgment call on the part of the surgeon. It is recommended that implant arthroplasty not be performed until the second 48-hour irrigation and debridement. Physical examination/investigations Patients should undergo the usual physical examination for distal humerus fractures, including AP, lateral, oblique, and possibly traction radiographs of the elbow. Special notation should be made of the neurovascular status of the extremity and whether this is an open or closed injury. The surgeon also should make note of the condition of

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the patient’s skin. In older individuals there tends to be more concern over wound healing, because many patients have thin, friable tissue or they have comorbid conditions that predispose them to poor wound healing. If there is any question regarding the ‘‘fixability’’ of the fracture, CT with threedimensional reconstructions may help with this operative decision-making process. Surgical technique Elbow arthroplasty implants are divided into linked and unlinked designs. There is no role for unlinked total arthroplasty designs in the setting of a distal humerus fracture. This type of implant requires good bone stock, little deformity of the elbow, and stable ligamentous support. This clearly is not the case with a distal humerus fracture. More recently the concept of hemiarthroplasty has gained some popularity in the treatment of distal humerus fractures. In this scenario, an anatomic distal humeral arthroplasty is performed, and the ulna and radial head preserved. Currently two different prosthetic designs are amenable to this type of treatment. The Sorbie implant from Wright Medical (Arlington, Tennessee) provides distal humeral anatomy that approximates closely the normal anatomy. It is available in three sizes and thus a congruent articulation can be achieved in many people. Alternatively, the

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newly released Latitude implant from Tornier (Stafford, Texas) offers the ability to have interchangeable modular spools on the humerus. An anatomic distal humeral spool can be implanted (Fig. 2). The anatomic spool comes in four sizes, again offering a potential match for a large number of people. This design also adds a further potential advantage in that the spool can be replaced with a prosthetic design in the future for revision into a TEA if necessary. A humeral stem revision should not be necessary. The results of these types of designs and techniques are preliminary at this time and long-term outcome is unknown. For the elderly, low-demand patient, it is recommended that a linked TEA design be chosen. This allows for the implant to provide stability to the elbow joint. All reports in the literature regarding TEA in the fracture setting have used the Coonrad-Morrey elbow implant (Fig. 3). This linked implant allows for approximately 8( of varus/valgus and internal/external rotational laxity through arc of motion closely simulating the normal axis of rotation of the elbow [30]. Although short-term follow-up has been promising, early wear and failure of the prosthesis is a concern in a fracture situation. Typically the soft tissue support of the elbow is compromised, because the condyles usually are removed. Theoretically, if the condyles were intact, the surrounding soft tissues could act as

Fig. 2. (A) AP and (B) lateral hemiarthroplasty with Latitude components.

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Fig. 3. (A) AP and (B) lateral views of a comminuted distal humerus fracture in an 80-year-old man with multiple comorbidities. (C) AP and (D) lateral views following a Morrey-Coonrad total elbow arthroplasty.

a checkrein, preventing the prosthesis from reaching its limits of varus and valgus laxity. Without normal surrounding soft tissue support, there is concern that most of the load created with elbow motion will be transmitted to the implant–bone interface, because the constraint of the elbow motion now is relying mostly on the implant. This could lead to early polyethylene wear, osteolysis, and early failure. It is these concerns that make the decision to implant a TEA in the fracture setting difficult.

McKee et al examined the effect of condylar resection, in the setting of a TEA, on patient muscle strength [31]. They compared two patient groups: (1) condyles resected and (2) condyles retained during TEA. They concluded that condylar resection did not have a negative effect on patient functional strength. Their article, however, did not address the effect of condylar resection on the survival of the prosthesis. In preparation for these surgical cases, it is recommended that equipment be available for

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a primary TEA and for a formal open reduction and internal fixation. The decision to proceed with a primary TEA is based on an intraoperative decision that the fracture is not amenable to stable internal fixation. In some cases, the surgeon may find that the bone is of better quality than expected and the patient may be better served with an open reduction and internal fixation procedure or vice versa. If the decision is made to proceed with a TEA in the acute fracture setting, a tricepssparing approach is recommended [32,33]. In general, the patient is positioned supine with a roll underneath the ipsilateral scapula. A sterile tourniquet is recommended. If triceps elevation is limited by the tourniquet, it may have to be removed. The approach should start with a midline posterior incision [34]. Full thickness fasciocutaneous flaps should be elevated medially and laterally. The ulnar nerve then is transposed into a medial subcutaneous pouch. Elevating the triceps from the posterolateral and posteromedial aspect of the distal humerus exposes the distal humerus. The elbow joint is exposed by creating medial and lateral windows on each side of the triceps [33]. Care should be taken to protect the radial nerve proximally with the posterolateral dissection. Distally and laterally the dissection can be continued anterolaterally through the Kocher interval to preserve the anconeus muscle and its blood supply. The distal humeral fracture fragments then are removed by subperiosteally releasing the soft tissues from the bone. A linked TEA design can allow for bone loss up to 2 cm proximal to the olecranon fossa and up to the coronoid in the proximal ulna [29,35]. The presence of the radial head also is not required [29]. After removing the fracture fragments, the surrounding soft tissues become lax, allowing the arm to be rotated so that the distal humerus and proximal ulna may be exposed for component implantation (Figs. 4 and 5). The anterior flange of the humeral component provides rotational stability, so that the medial and lateral condyles are not necessary for stability of the component. If bone loss is substantial, implantation of longer stemmed components may be needed.

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Fig. 4. A triceps sparing approach is recommended for distal humerus fractures treated with TEA. The medial and lateral condyles of the distal humerus are removed and the ulna and triceps are translated to the medial or lateral side for exposure of the humerus.

third postoperative day the patient comes out of the splint and begins active assisted motion of the elbow. Preservation of the triceps insertion accelerates the postoperative rehabilitation, allowing for unrestricted motion of the elbow to be initiated immediately postoperatively. A nighttime extension splint also may be used. Complications Potential complications include wound healing problems, infection, triceps insufficiency, neuropraxia, and elbow stiffness. In the trauma situation, early mechanical failure becomes more of

Rehabilitation Immediately postoperatively the patient is placed in an anterior splint to keep their elbow fully extended. The arm should be kept elevated. This helps protect the posterior soft tissues and provides some edema control. On the second or

Fig. 5. Implanted humeral and ulnar component before final reduction with the triceps tendon still intact on the ulna.

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a concern. Higher demands may be placed on the prosthesis because of normal adjacent joints. The patient must understand the limitations of a TEA to minimize this complication.

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Summary Palvanen et al in 2003 collected data on osteoporotic fractures of the distal humerus fractures from the Finnish National Hospital Discharge Register [36]. 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.

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