Chapter 55 Supracondylar Humeral Fractures: Is Open Reduction and Internal Fixation or Primary Total Elbow Arthroplasty Better in Poor Quality Bone?
In young patients, open reduction and internal fixation (ORIF) with double-plate fixation is the gold standard for displaced intra-articular fractures of the distal humerus, regardless of comminution.1 This procedure, however, can be technically challenging even when excellent bone quality is present, and elbow stiffness, malunion, nonunion, failure of fixation, and ulnar neuropathy are common sequelae.1 In elderly patients, the complication rate is increased because of osteoporotic bone, metaphyseal comminution, poor soft-tissue quality, and limited tolerance for joint immobilization; this is important because although distal humeral fractures represent only a small proportion of adult upper extremity fractures, the incidence of osteoporotic fractures of the distal humerus is increasing.1,2 According to the Finnish National Hospital Discharge Register, the current trend in the number and incidence of osteoporotic fractures of the distal humerus in Finnish women aged 60 or older is increasing rapidly.3 The annual incidence of these types of fractures has escalated from 11 per 100,000 in 1970 to 30 per 100,000 in 1995 and 2000; the increase is greatest in the oldest age group (women > 80 years) where the age-specific incidence rates showed a nine-fold increase (8 in 1970 vs. 75 in 2000). These results (which reflect trends seen in Europe and North America) reinforce the need to identify the optimal type of treatment for comminuted distal humeral fractures in the elderly to reduce the risk for reoperation and maximize functional outcome and independence. It should also be pointed out that, in most studies on this topic, women predominate in a 5:1 or 6:1 ratio.
OPTIONS
Although semiconstrained TEA has been recognized as a standard treatment for the complications or failure of primary ORIF of intra-articular distal humeral fractures,4,5 the role of primary TEA in the setting of acute supracondylar humeral fracture is more controversial. Although the advantages are obvious, including immediate stability and enhanced rehabilitation, no requirement for bone grafting or concern for delayed or nonunion, and possibly shorter operative times, the longevity of the prosthesis in the increasingly active elderly population remains a concern. In a landmark study, Cobb and Morrey6 report a series of 21 elderly patients (mean age, 72 years) who had primary TEA for comminuted fractures of the distal humerus and described a 95% good or excellent result rate at a mean follow-up of 3.3 years with a reoperation rate of 5% (one elbow).6 Several other similar single-institution reviews have described remarkably similar results in smaller series.7–11 More recently, Frankle and colleagues12 performed a retrospective comparison of ORIF with TEA, and the Canadian Orthopaedic Trauma Society (COTS)13 conducted a randomized clinical trial comparing these two treatment methods in older individuals. Although there is now an increasing amount of data to guide the clinician in decision making for elderly patients with intrinsically poor bone quality who sustain an intra-articular fracture of the distal humerus, it must be emphasized that this is a technique restricted to older patients and is contraindicated for patients younger than 65 years unless there are special circumstances (i.e., preexisting elbow arthritis).
EVIDENCE
Outcome after Open Reduction and Internal Fixation
Although there is substantial evidence for the benefits of ORIF in younger patients with fractures of the distal humerus,1,2 the evidence is less clear in older patients because only retrospective studies with small numbers have been reported (Table 55-1).14–19 Several of these studies have suggested that the majority of elderly patients achieve good or excellent functional results with ORIF; however, critical analysis of these results indicates a large variability in outcome and less predictable results than optimal.
TABLE 55-1 Results of Open Reduction and Internal Fixation for Distal Humeral Fractures in Elderly Patients
Huang and coauthors14 report on 19 patients with a mean age of 72 years who required ORIF for AO type “C” distal humeral fractures. They describe good results with no hardware failures, a mean range of flexion-extension from 17 to 128 degrees, with 15 excellent and 4 good results (according to the Mayo elbow score). Imatani and coworkers15 describe a technique in the Japanese population of using a small AO “T” plate for fixation of transcondylar fractures with good or excellent results in 14 of 17 patients older than 70 years. However, these “A”-type extra-articular fractures were not the more severe intra-articular injuries typically seen; results are usually worse in the “C”-type injuries. Srinivasan and researchers16 report their results of treatment with ORIF for “C”-type fractures in 21 patients with a mean age of 85 years (range, 75–100 years) and found 43% fair or poor outcomes. Korner and investigators17 report on the outcome of 45 patients with a median age of 73 years (range, 61–92 years) and a minimum follow-up of 2 years. Overall, 19 patients (42%) had a fair or poor outcome according to the Mayo elbow score. Fourteen of these patients (74%) had an AO/OTA type C fracture. In the subset of 29 patients with AO/OTA type C fractures, only 45% had an excellent or good outcome.17 Postoperative complications were recorded in 13 patients (29%), and revision surgery was required in 7 patients. Pereles and colleagues18 report more favorable results in 14 patients with a mean age of 71 years (mean Mayo elbow score, 89 points). John and coauthors19 reviewed the results of 49 patients with an average age of 80 years (range, 75–93 years) treated with ORIF of the distal humerus after a mean of 18 months.5 Twenty-eight fractures (57%) were classified as AO/OTA type C. Fair and poor functional results were observed in 26% of patients with an overall complication rate of 18%.19 Clearly, the results of ORIF for this type of fracture in the elderly do not match those seen for younger patients, especially for the more severe C-type fractures, and there is significant room for improvement.
Outcome after Total Elbow Arthroplasty
Several studies suggest that semiconstrained TEA may have a role to play in the primary treatment of severe intra-articular distal humeral fractures (Table 55-2). Cobb and Morrey6 reported in 1997 their initial experience of primary TEA in 20 patients (21 elbows) with a mean age of 72 years (range, 48–92 years) and a mean follow-up of 3.3 years. A follow-up report on 43 patients was published in 2004 that revealed similar results. The mean flexion-extension arc was 24 to 131 degrees, and the mean Mayo elbow score was 93 points. Mean follow-up had increased to 7 years, although 9 elbows had required a total of 10 additional procedures, ranging from simple hematoma evacuation to revision arthroplasty for infection.20 Gambirasio and coworkers9 report the functional outcome at a minimum of 1 year for 10 women (mean age, 85 years) treated with primary TEA for a comminuted, intra-articular distal humeral fracture. Eight patients had an excellent outcome and two had a good outcome based on the Mayo elbow score.9 Garcia and colleagues10 evaluated 16 patients with a mean age of 73 years (range, 61–95 years) treated by primary TEA using the Coonrad–Morrey prosthesis at a mean follow-up period of 3 years (range, 1.5–5 years). No patients had inflammatory or degenerative arthritis of the elbow. OTA type C3 fractures were present in 11 patients. The mean DASH (a patient-based disability score) was 23 (range, 1–63), and the mean Mayo elbow score was 93 (range, 80–100).
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