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.

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).

Ray and colleagues⁷ describe good results in seven elderly (mean age, 82 years) women treated with semiconstrained arthroplasty for intra-articular distal humeral fractures.⁷ The mean range of motion was 20 to 130 degrees, and there were five excellent and one good results according to the Mayo elbow score. Lee and researchers¹¹ report nearly identical results in seven elderly Asian women (mean age, 73 years).¹¹

Comparative Studies

In one of the few comparative studies, Frankle and colleagues¹² compared primary TEA versus ORIF for the treatment of distal humeral fractures in women older than 65 years (all comminuted type C fractures) (Table 55-3). They found that in the 12 patients in the TEA group, 11 had excellent results and 1 had good results; no fair and no poor results were reported.¹² Notably, eight patients (67%) had associated rheumatoid arthritis. Three patients (25%) required subsequent operations, one to reconnect an uncoupled prosthesis, one to drain a postoperative hematoma, and one to débride a superficial infection. All of these complications resolved without subsequent sequelae, and no patient required revision implant surgery. The ORIF group had four excellent, four good, one fair and three poor results. The poor results were all salvaged by conversion to TEA (a difficult procedure with a high complication rate). The authors recommend primary TEA as a viable alternative in type C fractures of the distal humerus in elderly patients, especially in the setting of associated comorbidity such as rheumatoid arthritis, osteoporosis, and systemic steroid use.

In a study that has been presented at the 2007 Annual American Academy of Orthopedic Surgeons (AAOS) Meeting (J Shoulder Elbow Surg, accepted) the COTS randomized 42 elderly patients (mean age, 78 years) with comminuted intra-articular distal humeral fractures to either semiconstrained TEA (Coonrad–Morrey prosthesis) or conventional ORIF (two small fragment plates).¹³ Twenty-one patients were randomized to each group: one patient in each group died, and five patients randomized to ORIF had to be converted to TEA during surgery because of the inability to stably fix the fracture. This was anticipated and allowed as part of the study protocol. This left 25 patients in the TEA group and 15 patients in the ORIF group for evaluation. Despite the fact that the TEA group theoretically had worse injuries (by inclusion of the five most severe cases from the ORIF group), they had superior outcome, especially early. At 6 months, the mean DASH score in the TEA group was 43 versus 77 in the ORIF group (P = 0.02), although this difference was not statistically significant at 1 year (TEA vs. ORIF: 32 vs. 47; P = 0.10). The Mayo elbow scores were better in the TEA group at 6, 12, and 24 months (TEA vs. ORIF: 86 vs. 73, P = 0.015). The reoperation rate was not statistically different (TEA vs. ORIF: 3/25 [12%] vs. 4/15 [27%]; P = 0.20), although it must be remembered the TEA group included five patients who did not respond successfully to operative fixation. The authors’ conclusion was that TEA improved functional outcome compared with ORIF for these difficult fractures, and this was the treatment of choice, especially when comminuted, osteoporotic bone made fixation technically difficult. However, to date, only short-term results (2 years) are available, and these patients will require longer follow-up before establishing the ultimate superiority of replacement arthroplasty in this population.

Length of Follow-up

Prosthetic longevity is a significant concern whenever arthroplasty is used as a treatment for fracture. The mean life expectancy for a healthy North American woman aged 70 years is 15 more years. This is an important fact to remember, especially when one considers the increasingly active lifestyles (golf, tennis, etc.) of the modern retired population, and the increased demands that the prosthesis may experience. The majority of reports describing TEA for severe distal humeral fracture have follow-up that at best can be described as short term (2–5 years). The longest follow-up period in the literature is from Kamineni and Morrey’s²⁰ 2004 article, averaging 7 years.²⁰ They describe five patients who required a revision arthroplasty; only one patient required revision in their original 1997 report that had a mean follow-up period of just more than 3 years. It is reasonable to assume that with longer follow-up more TEA patients will require revision. This emphasizes the fact that this procedure should be restricted to older (≥70 years) patients, and that a more sedentary lifestyle or at least some physical restrictions on elbow use is preferred.

Effect of Condylar Resection

The use of semiconstrained TEA for comminuted fractures of the distal humerus typically requires resection of the fracture fragments, which include the humeral condyles. Because the condyles serve as origin for the collateral ligaments, the common extensor origin and flexor-pronator mass, their resection could have a detrimental effect on a number of functions, including elbow stability and forearm and hand strength. McKee and coworkers’²¹ study examined the effect of condylar resection by comparing 16 total elbow arthroplasties with intact condyles versus 16 with resected or absent condyles.²¹ Comparing strength to the opposite normal arm in each patient, the authors found no difference in objectively measured hand, forearm, or elbow strength. Mayo elbow scores were also similar between the two groups (intact: 79; resected: 77), suggesting that practically, condylar resection did not have a clinically relevant effect on strength. It is important to note, however, that this study did not address the question of stability and longevity of the prosthesis after condylar resection.

Hemiarthroplasty versus Total Elbow Arthroplasty

Conventional wisdom dictates that the treatment of a severe distal humeral fracture by arthroplasty requires a semiconstrained total joint prosthesis to provide immediate stability and allow early motion. However, this mandates resection of a (usually normal) ulnar articulation, which may not be necessary. Some have advocated replacement of the fractured distal humerus alone with a hemiarthroplasty, in conjunction with a ligament repair or reconstruction. Adolfsson and Hammer⁸ provide a preliminary report on four elderly (mean age, 80 years) female patients with an unreconstructable distal humeral fracture treated with distal humeral hemiarthroplasty. The described excellent results in three and a good result in one. Although this technique has promise and does make some sense on a theoretical level (only replacing what is broken, potentially better longevity of the prosthesis), it should be considered experimental at the present time until further data are available.

Open Fractures of the Distal Humerus

Infection is a devastating complication for patients with an implanted elbow arthroplasty, and it should be avoided at all costs. For this reason, the presence of an open wound has been considered a relative, if not absolute, contraindication to TEA after supracondylar humeral fracture. However, although there is no specific article on this topic, some information is available that suggests it may be reasonable to perform primary TEA in the presence of an open wound. It is a question of some relevance because the fractures with an open wound tend to be of the more severe variety that makes ORIF difficult or impossible. Kamineni and Morrey²⁰ describe two patients with grade I open wounds treated with immediate debridement and arthroplasty, and neither became infected; the COTS study had three similar cases treated in the same fashion, and none suffered any infectious complications.¹³

Although it appears that primary TEA in the presence of a grade I wound may be safe, it is important to emphasize proper technique. First, all the above cases were treated within 12 hours of injury: It may be prudent to temporize with patients presenting late for treatment. Second, the open wound tends to be posterior and is made as the condyles break away as the elbow hits the ground and the distal humeral shaft drives through the soft tissue and skin to impact the ground. Thus, although a thorough debridement and copious irrigation of the entire wound tract is mandatory, careful attention must be given to debriding and cleaning the distal humeral shaft and associated intramedullary canal, and antibiotics should be added to the cement.