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

doi:10.1016/j.jse.2008.06.005

Journal of Shoulder and Elbow Surgery

Volume 18, Issue 1, January–February 2009, Pages 3-12

https://doi.org/10.1016/j.jse.2008.06.005 Get rights and content

Summary

We conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction–internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Forty-two patients were randomized by sealed envelope. Inclusion criteria were age greater than 65 years; displaced, comminuted, intra-articular fractures of the distal humerus (Orthopaedic Trauma Association 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. The Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were determined at 6 weeks, 3 months, 6 months, 12 months, and 2 years. Complication type, duration, management, and treatment requiring reoperation were recorded. An intention-to-treat analysis and an on-treatment analysis were conducted to address patients randomized to ORIF but converted to TEA intraoperatively. Twenty-one patients were randomized to each treatment group. Two died before 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 range of motion. This resulted in 15 patients (3 men and 12 women) with a mean age of 77 years in the ORIF group and 25 patients (2 men and 23 women) with a mean age of 78 years in the TEA group. Baseline demographics for mechanism, classification, comorbidities, fracture type, activity level, and ipsilateral injuries were similar between the 2 groups. Operative time averaged 32 minutes less in the TEA group (P = .001). Patients who underwent TEA had significantly better MEPSs at 3 months (83 vs 65, P = .01), 6 months (86 vs 68, P = .003), 12 months (88 vs 72, P = .007), and 2 years (86 vs 73, P = .015) compared with the ORIF group. Patients who underwent TEA had significantly better DASH scores at 6 weeks (43 vs 77, P = .02) and 6 months (31 vs 50, P = .01) but not at 12 months (32 vs 47, P = .1) or 2 years (34 vs 38, P = .6). The mean flexion-extension arc was 107° (range, 42°-145°) in the TEA group and 95° (range, 30°-140°) in the ORIF group (P = .19). Reoperation rates for TEA (3/25 [12%]) and ORIF (4/15 [27%]) were not statistically different (P = .2). TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS. DASH scores were better in the TEA group in the short term but were not statistically different at 2 years' follow-up. TEA may result in decreased reoperation rates, considering that 25% of fractures randomized to ORIF were not amenable to internal fixation. TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients have an increased baseline DASH score and appear to accommodate to objective limitations in function with time.

Section snippets

Methods

We performed a prospective, randomized, double-blind clinical trial beginning in January 2001 at 4 university-affiliated Canadian academic medical centers: St Michael's Hospital, University of Toronto (Toronto, Ontario); Royal Columbian and Vancouver General Hospitals, University of British Columbia (New Westminster/Vancouver, British Columbia); and McMaster Medical Center, McMaster University (Hamilton, Ontario). Each patient was randomly assigned by sealed envelope drawn by the site

Results

Forty-two patients were enrolled in the study. Two died of unrelated causes before complete follow-up and were excluded from the analysis of data. Data were, therefore, collected on 40 patients: 20 randomized to ORIF and 20 randomized to TEA.

Baseline variable for the groups after randomization are summarized in Table I. There were no significant differences between the groups in terms of age, gender, weight, baseline preinjury DASH, injury severity score, mechanism of injury, smoking status,

Discussion

Displaced, comminuted, intra-articular fractures of the distal humerus are difficult to treat because of the complex anatomy of the elbow. Although osteosynthesis with double-plate fixation is the recommended treatment in adults, the presence of osteoporotic bone, metaphyseal comminution, poor-quality soft tissue, and intolerance for joint immobilization increases the challenge in the elderly.5, 10, 12, 13, 27 Loss of basic elbow function can severely affect activities of daily living: for an

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Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial
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Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.
This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength.
Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of −5.6 points (95% CI: −18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group.
In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.
Distal humeral hemiarthroplasty compared to total elbow replacement for distal humeral fractures: a registry analysis of 906 procedures
2024, Journal of Shoulder and Elbow Surgery
Total elbow replacement (TER) is an accepted treatment for complex intra-articular distal humerus fractures in elderly patients. Distal humeral hemiarthroplasty (HA) is also a potential surgical option for unreconstructable fractures and avoids the concerns regarding mechanical wear and functional restrictions associated with TER. In the current literature, there are limited data available to compare the revision rates of HA and TER for the treatment of fracture. We used data from a large national arthroplasty registry to compare the outcome of HA and TER undertaken for fracture/dislocation and to assess the impact of demographics and implant choice on revision rates.
Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from May 2, 2005, to December 31, 2021, included all procedures for primary elbow replacement with primary diagnosis of fracture or dislocation. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazards models.
There were 293 primary HA and 631 primary TER procedures included. The cumulative percentage revision (CPR) rate at 9 years was 9.7% for HA (95% confidence interval [CI] 6.0, 15.7), and 11.9% (95% CI 8.5, 16.6) for TER. When adjusted for age and gender, there was a significantly higher risk of revision after 3 months for TER compared to HA (HR 2.47, 95% CI 1.22, 5.03, P = .012). There was no difference in the rate of revision for patients aged <55 years or ≥75 years when HA and TER procedures were compared. In primary TER procedures, loosening was the most common cause of revision (3.6% of primary TER procedures), and the most common type of revision in primary TER involved revision of the humeral component only (2.6% of TER procedures). TER has a higher rate of first revision for loosening compared to HA (HR 4.21, 95% CI 1.29, 13.73; P = .017). In HA procedures, instability (1.7%) was the most common cause for revision. The addition of an ulna component was the most common type of revision (2.4% of all HA procedures).
For the treatment of distal humerus fractures, HA had a lower revision rate than TER after 3 months when adjusted for age and gender. Age <55 or ≥75 years was not a risk factor for revision when HA was compared to TER. Loosening leading to revision is more prevalent in TER and increases with time. In HA, the most common type of revision involved addition of an ulna component with preservation of the humeral component.
Top fifty cited articles on humeral fractures
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Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature.
The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables.
Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = −0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01).
The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.
AO/OTA type C3 distal humeral fractures in patients aged 75 years and older: Is ORIF with double precontoured anatomical locking plates a reliable treatment?
2023, Injury
The incidence of osteoporotic distal humeral fractures (DHF) is on the rise. Their operative management is demanding. Fixation with non-locking reconstruction plates was associate with a high number of complications. Elbow arthroplasty (total or hemi) has been proposed as an alternative treatment, in spite of lifetime activity restrictions, and risk of complications, unknown implant survival and problematic revision surgery. Precontoured anatomical locking plates have increased the strength of the fixation in complex fractures. Hypothesis: double plating ORIF with precontoured anatomical locking plates is a safe and reliable treatment option for the management of AO/OTA type C3 DHF in patients aged 75 and older.
A retrospective case series study of patients aged 75 years old and older with an AO/OTA type C3 DHF treated with ORIF with double precontoured anatomical locking plates between 2007 and 2021. Pathologic fractures were excluded. Patients’ demographic, surgical, clinical, and radiological data were reviewed.
A total of 27 women and 3 men, mean age of 80.1 years (range 75–93 years), were included. Mean Charlson index was 5 (range 3–8). Out of 30 patients, 19 had already died. Mean survival time after the surgical treatment was 72.3 months. Mean Mayo elbow performance score was 88.9 (range 60–100); 23 patients scored excellent or good. All fractures healed with no cases of delay union or non-union, hardware failure or loss of reduction. No patient needed a revision surgery to arthroplasty. The total number of complications was 12 (40%), mainly ulnar neuropathy (5) and cerclage removal (4).
ORIF with double pre-contoured locking plates may be a safe and reliable treatment for type C3 DHF in patients aged 75 years and older, with a good functional outcome. Complications are expected but not related to loss of reduction, fixation failure or revision to elbow arthroplasty.
Key drivers of 90-day costs in primary total elbow arthroplasty
2023, Seminars in Arthroplasty JSES
A comprehensive understanding of both surgical care costs and the factors influencing these costs is critical to make progress toward value-based care in orthopedics. Therefore, the purpose of this study was to assess 90-day health system costs in primary total elbow arthroplasty (TEA), the proportion of contribution from each cost group to total hospital cost, and to determine key drivers of 90-day costs in primary TEA.
Consecutive patients who underwent primary TEA between 2014 and 2021 at a tertiary care academic medical center were included. An institutional accounting database was queried to determine direct costs to the health system attributed to TEA. All costs within 90 days of the surgical encounter were included for analysis to reflect the global postoperative period. Descriptive statistics were used to summarize patient and surgical characteristics, as well as cost data. Subcategories were determined to assess the key cost groups that contribute to total hospital fees for the entire cohort, and subanalysis was performed to evaluate only readmitted patients. Furthermore, a linear regression analysis was used to determine key drivers of 90-day costs in the setting of primary TEA.
Thirty-five patients who underwent primary TEA were identified from 2014 to 2021; 28 patients with 90-day cost data were included in this study. The mean surgical encounter cost was $18,075 (+/− $9772) and mean 90-day cost was $19,875 (+/− $9885). The largest proportion of health system costs in primary TEA was surgical implants (48%), followed by operating room fees (18%), surgical supplies (9%), and anesthesia (7%). Among readmitted patients, the most significant share of health system costs was attributed to surgical implants (30%) followed by operating room fees (22%). However, hospital fees (19%) experienced a substantial increase. In assessing the key drivers of 90-day health system costs, length of stay (B = 1304.30, 95% confidence interval [CI] 674.54 to 1934.05; P < .001), readmission (B = 16,148.55, 95% CI 7055.01 to 25,240.08; P = .001∗), and Charlson comorbidity index (B = 2247.43, 95% CI 68.64 to 4426.22; P = .044) were statistically significant predictors of increased 90-day costs.
Implant costs comprise nearly half of total 90-day costs in primary TEA, with operating room costs making the second largest contribution. Additionally, length of stay, readmission, and patient comorbidity burden were significantly associated with increased 90-day costs.
Incidence and pattern of concurrent capitellum fracture associated with radial head and neck fractures
2023, Orthopaedics and Traumatology: Surgery and Research
Radial head and neck fracture is a common fracture around the elbow. It is mostly caused by axial or valgus loading after a fall in elbow extension and forearm pronation. When a radial head and neck fracture occurs, the capitellum collides with the radial head and experiences a shear force, leading to capitellum fracture. The primary aim of this study was to evaluate the incidence of concurrent capitellum fracture and analyze its patterns among patients treated for radial head and neck fractures based on computed tomography. Secondary aim is to determine factors associated with concurrent capitellum fractures.
Capitellum fractures are more common than expected in radial head and neck fractures and show a consistent pattern. With the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture will be shown.
A total of 101 patients treated surgically (27 patients) or non-surgically (74 patients) for radial head and neck fractures from January 2017 to December 2020 were retrospectively analyzed. Initial computed tomography was reviewed to identify concurrent capitellum fractures. A fracture was diagnosed when the bone continuity was lost in two consecutive images in any one of the three directions of computed tomography scan images. Seventeen patients with capitellum fractures were classified as group 1 and 84 patients without capitellum fractures as group 2. Each group of patients was assessed using Mason classification, whether fracture extended to the radial neck or not, fracture location, and treatment method. To determine the fracture location, radial head was trisected using three anatomical landmarks: safe zone, posteromedial zone, and anteromedial zone. And it was determined as the location where the fracture was most comminuted.
The average age of the 101 patients was 44.6 years old. There were 54 (53.5%) males and 47 (46.5%) females. Capitellum fracture was accompanied in 17 cases. Its incidence was 16.8%. The rate of accompanying capitellum fracture was 9.5% (6/63) for Mason type 1, 25.0% (6/24) for Mason type 2, and 41.7% (5/12) for Mason type 3. The ratio of radial neck extension of fracture was significantly higher in group 2. There was no isolated radial neck fracture in group 1. However, there were 33 in group 2. After eliminating isolated radial neck fracture patients, significantly more fractures were located in the safety zone in group 1. Group 1 had a significantly higher rate of surgical treatment than group 2 (52.9% (9/17) vs. 21.4% (18/84) p = 0.007).
For radial head and neck fractures, the higher the Mason type fracture, the higher the incidence of concurrent capitellum fracture. When the fracture extended to the radial neck, the comorbidity of the capitellum fracture was decreased. Among radial head fractures, when the fracture was located in the safe zone, the comorbidity of capitellum fracture was increased. The rate of surgical treatment was higher in radial head and neck fracture patients with concurrent capitellum fractures.
IV; diagnostic study.

View all citing articles on Scopus

: This study was supported by grants from the Orthopaedic Trauma Association and Zimmer (Warsaw, IN).

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Featured ArticleA multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients

Summary

Section snippets

Methods

Results

Discussion

Hand Clin

Hand Clin

Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity

J Hand Ther

Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients

J Bone Joint Surg Am

Salvage of non-union of supracondylar fracture of the humerus by total elbow arthroplasty

J Bone Joint Surg Am

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

J Orthop Trauma

Total elbow replacement for complex fractures of the distal humerus. An option for the elderly patient

J Bone Joint Surg Br

Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment

J Bone Joint Surg Br

The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery

BMC Musculoskelet Disord

The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: a critical analysis of the results

J Trauma

Distal humerus fractures in patients over 75 years of age. Long-term results of osteosynthesis

Helv Chir Acta

Distal humeral fractures treated with noncustom total elbow replacement

J Bone Joint Surg Am

A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates

J Orthop Trauma

Distal humerus fractures in elderly patients: results after open reduction and internal fixation

Osteoporos Int

Featured Article
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