V. Arthroplasty for Distal Humeral Fractures in the Elderly is the Way to Go
Michael D. McKee MD, FRCS(C)
Treatment of displaced intra-articular fractures of the distal humerus is one of the most technically challenging procedures in elbow surgery. In young patients, open reduction and internal fixation (ORIF) with plate fixation of both columns is the gold standard. However, elbow stiffness, malunion, nonunion, failure of fixation and ulnar neuropathy are common sequelae with overall complications rates of over 35% reported. In elderly patients, combinations of osteoporotic bone, metaphyseal comminution, poor soft tissue conditions, and limited tolerance for joint immobilization have resulted in less predictable outcomes with internal fixation.
Semi-constrained total elbow arthroplasty (TEA) is a standard treatment for the complications or failure of primary ORIF of intra-articular distal humeral fractures. TEA is considered effective for nonunion, malunion, post-traumatic arthritis and post-traumatic instability, following these serious injuries, with literature describing 85% to 90% good and excellent results in five to ten years post- surgery. However, TEA in this setting is technically difficult and complication rates are higher than in elbows that have not had prior operative procedures.
In 1997, Cobb and Morrey reported a series of 21 elderly patients (mean age 72 years) who had primary TEA for comminuted fractures of the distal humerus. They reported a 95 percent good or excellent result rate at a mean follow-up of 3.3 years with a re-operation rate of five percent (one elbow). More recently, Frankle et al. performed a retrospective comparison of ORIF with TEA for intra-articular distal humeral fractures in 24 women older than 65 years of age . At a minimum of 2 years, TEA resulted in excellent or good results in all twelve patients with improved range of motion and less physical therapy required compared with ORIF. Failure of fixation occurred in 25% of patients with ORIF and required revision to TEA. Although primary TEA may be a viable treatment option for comminuted intra-articular distal humeral fractures in older patients, the current recommendations are based solely on retrospective reviews from single institutions.
We compared the effectiveness of ORIF with primary TEA for the treatment of displaced, comminuted intra- articular distal humerus fractures in elderly patients (>65 years). Our primary outcome measure was re- operation rate while secondary outcome measures were patient function as measured with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand Instrument (DASH). Forty-two patients were randomized by sealed envelope. Inclusion criteria were age >65 years, displaced, comminuted intra-articular fractures of the distal humerus (OTA Type 13C), and closed or Gustilo grade I open fractures treated within 12 hours of injury. Both ORIF and TEA were performed following a standardized protocol. Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were collected at 6 weeks, 3 months, 6 months, 12 months and 2 years. Complication type, duration, management, and treatment requiring re-operation were recorded. Twenty-one patients were randomized to each treatment group. Two patients died prior to follow-up and were excluded from the study. Five patients randomized to ORIF were converted to TEA intraoperatively because of extensive comminution and inability to obtain fixation stable enough to allow early ROM. This resulted in 15 patients (3 male, 12 female) with an average age of 77 years in the ORIF group and 25 patients (2 male, 23 female) with an average age of 78 years in the TEA group. Baseline demographics for mechanism, classification, co-morbidities, fracture type, activity level and ipsilateral injuries were similar between the two groups. MEPS was significantly improved at 3 months (83 vs 65, p=0.01), 6 months (86 vs 68, p=0.003), 12 months (88 vs 72, p=0.007) and 2 years (86 vs 73, p=0.015) in patients with TEA compared with ORIF. DASH scores showed a significant improvement for TEA compared with ORIF between 6 weeks (43 vs 77, p=0.02) and 6 months (31 vs 50, p=0.01) but not at 12 months (32 vs 47, p=0.1) and 2 years (34 vs 38, p=0.6). The mean flexion-extension arc was 107 degrees (range 42-145) for the TEA group and 95 degrees (range 30-140) for the ORIF group (p=0.19). Re-operation rates for TEA (3/25, 12%) and ORIF (4/15, 27%) were not statistically different (p=0.2). TEA for the treatment of comminuted intra-articular distal humeral fractures provides improved functional outcome compared with ORIF based on both objective elbow performance scores and patient self-rated upper extremity disability and symptoms. TEA may result in decreased re-operation rates considering 25% of OTA Type 13C fractures were not amenable to internal fixation.
In conclusion, our study is the first randomized prospective trial to evaluate the efficacy of ORIF compared to TEA for comminuted distal humeral fractures in patients 65 years of age or older. Primary semi-constrained TEA was superior to ORIF as measured by both surgeon-based (MEPS) and patient- based (DASH) outcome scores, especially in the early post-operative period. There were trends towards a reduced re-operation rate and an improved range of motion in the TEA group that were not statistically significant. In addition, 25% of patients randomised to ORIF required intra-operative conversion to TEA, a consistent figure in multiple studies that we believe represents a subset of individuals with this fracture type that are not amenable to ORIF. We believe that our study supports the use of primary TEA in elderly (mean age 78 years) patients with comminuted intra-articular distal humeral fractures.