Authors: Ron Gurel, Shai Factor, Tamir Pritsch, Daniel Tordjman, Gilad Eisenberg, Oren Rudik, Tal Nativ, Yishai Rosenblatt
Categories: Original Article, Elbow hemiarthroplasty, Distal humerus fractures, Functional outcomes, Complications, Mayo Elbow Performance Score
Source: Clinics in Shoulder and Elbow
Authors: Ron Gurel, Shai Factor, Tamir Pritsch, Daniel Tordjman, Gilad Eisenberg, Oren Rudik, Tal Nativ, Yishai Rosenblatt
To evaluate the outcomes of distal humerus hemiarthroplasty (DHH) in a series of eight consecutive patients with unreconstructible distal humeral fractures or failed open reduction and internal fixation (ORIF).
Retrospective data including demographics, postoperative outcomes, and complications were extracted from electronic records at a level 1 trauma center. Surgeries were performed by a single fellowship-trained upper extremity surgeon. The indications for DHH were unreconstructible distal humerus fracture or failed ORIF. Eventually, as accepted by current literature, no weight restrictions were applied. Range of motion (ROM), functional scores, and pain levels were evaluated during follow-up appointments. Minimum follow-up time was 12 months.
Between 2014 and 2024, eight consecutive patients underwent DHH. The mean patient age at the time of surgery was 68.1 years, with an average follow-up of 46.6 months. Patients exhibited satisfactory ROM, with near-complete pronosupination and mean flexion and extension of 125° and 25°, respectively. Functional scores, including Quick Disabilities of the Arm, Shoulder and Hand score (35.2) and Mayo Elbow Performance Score (78.1), were good. Mean Numeric Pain Rating Scale was 3.9. Complications included two conversions to total elbow arthroplasty due to elbow instability and postoperative infection (staged conversion), one ligament reconstruction for postoperative elbow instability, two cases of ulnar periprosthetic fracture, and one case of ulnar nerve neuropathy.
DHH for unreconstructible distal humerus fractures and failed ORIF allows for unrestricted postoperative lifting and yields satisfactory functional outcomes but does have a relatively high complication rate.
IV.
Intra-articular distal humerus fractures, accounting for 2%–5% of all fractures, present a significant challenge to orthopedic surgeons [1]. Up to 50% of cases treated with conventional open reduction and internal fixation (ORIF) may experience loss of reduction [2] due to extensive comminution or poor bone quality. Consequently, alternative treatment modalities, such as elbow arthroplasty, have been explored [3-15].
Total elbow arthroplasty (TEA) and distal humerus hemiarthroplasty (DHH) have emerged as viable options for managing unreconstructible distal humeral fractures, with promising outcomes [15,16]. While TEA imposes lifelong weight-lifting restrictions on the operated extremity, necessitating lifestyle modifications to minimize stress on the implant, DHH offers distinct advantage. By eliminating the need for an ulnar component and polyethylene, and using a linkage mechanism, DHH theoretically reduces the risk of mechanical failure and early loosening. Therefore, most surgeons allow weight bearing as tolerated following DHH [4,5,15-18].
Newer convertible prosthetic designs, such as the Latitude EV (Wright Medical Group), allow easier conversion of elbow hemiarthroplasty to TEA, without the need to replace the stem of the humeral component.
Currently, there are insufficient data to definitively favor either DHH or TEA in cases of unreconstructible distal humerus fractures [15,19]. A recent meta-analysis of elbow trauma cases treated with DHH included 13 level 4 studies, comprising a total of 207 cases. The authors reported that a mean range of motion (ROM) of ≥100° was achieved in 11 of the 13 studies. All studies reported good to excellent mean outcome scores. Reoperation and revision rates were 17% and 3%, respectively [16]. This body of evidence still requires further data accumulation to enhance our understanding of the long-term outcomes, complications, and their management, especially in the younger patient population. This will enable surgeons to provide better counsel to their patients and make more informed recommendations regarding complication management. The purpose of this study is to evaluate the outcomes of DHH in a series of eight consecutive patients with unreconstructible distal humeral fractures or failed ORIF.
This study was approved by the Institutional Ethical Review Board of Tel Aviv Sourasky Medical Center (No. TLV-0247-24). Informed consent was waived due to the retrospective nature of the study and the use of de-identified data.
Retrospective data were collected from electronic medical records at a single level 1 trauma center over a 10-year period. All surgeries were performed by a single fellowship-trained upper extremity surgeon who specialized in elbow surgery. The surgeon has been in practice for 17 years since completing an upper extremity fellowship and has performed about 10 elbow arthroplasty cases per year since then. The study included a series of eight consecutive patients who underwent elbow hemiarthroplasty for ORIF distal humerus fracture failure or severely comminuted distal humerus fractures. All patients who underwent DHH at our center during the study period were included. All fractures were classified as AO Foundation/Orthopaedic Trauma Association (AO/OTA) 13C3 and 13B3.3, with significant articular damage and poor bone quality, and were deemed likely unreconstructible by an upper extremity surgical team. This assessment was based on preoperative radiography and computed tomography (CT). Patient age and the degree of radiographic articular comminution were considered when evaluating bone quality and reconstruction potential. The final determination of fracture reconstructibility was made intraoperatively by the surgeon. Coronal shear fractures were considered unreconstructible when they involved the trochlea and the capitellum, exhibited comminution and bone impaction, had posterior wall involvement with thin osteochondral fragments, and were unlikely to achieve stable fixation and union if ORIF was attempted.
Data collected included patient demographics, comorbidities, postoperative outcomes, and complications. ROM, functional scores (Quick Disabilities of the Arm, Shoulder and Hand [qDASH] and Mayo Elbow Performance Score [MEPS]), and Numeric Pain Rating Scale (NPRS) were evaluated during routine follow-up visits at the hand and upper extremity clinic. Preoperative radiographs and computed tomography scans were used for injury assessment and preoperative planning. Postoperative radiographs were performed on postoperative day 1 and at every clinic visit. The minimum follow-up period was 12 months.
Following general anesthesia and regional block, patients were positioned supine with the arm placed across the chest, and a sterile tourniquet was applied to the upper arm. A posterior midline incision was made, and the ulnar nerve was identified, mobilized, and protected throughout the surgery. At the end of surgery, the nerve was transposed anteriorly. A triceps-on or Chevron olecranon osteotomy approach was used to access the elbow joint [14,20]. Fracture fragments of the distal humerus were carefully identified, debrided, and assessed. Nonviable bone fragments and soft tissue were debrided. Once the decision was made that the fracture was unreconstructible or in case of failed attempted reduction, the surgical team proceeded to DHH using the conventional technique suggested by the prosthetic designer. Latitude EV (Wright Medical Group) implants were used.
Prosthetic size was chosen according to the dimensions of the assembled broken fragments, and the fit of the anatomical humeral trial spool to the patient's olecranon and radial head. The humeral canal was reamed to accommodate the prosthesis, and sequential broaching was performed. Trial implants were used to assess the component fit and elbow ROM. The definitive prosthetic humeral component was selected and implanted, with cement used in all cases. Collateral ligaments, preferably attached to bony columns, were fixed to the implant according to the technique described by Phadnis et al. [14,17]. In cases involving olecranon osteotomy, a tension band wire or plate fixation was used to restore the olecranon’s anatomy.
At the end of the surgical procedure, the elbow was placed in a long arm cast for 3–5 days, followed by an early active and active-assisted ROM protocol. Gentle passive ROM exercises were initiated 6 weeks postoperatively. By 10 to 12 weeks, weight bearing was no longer restricted. Routine follow-up visits were scheduled for 2, 6, and 12 weeks, and at 6, 12, 18, and 24 months postoperatively, with yearly visits thereafter.
Between 2014 and 2024, eight consecutive patients with unreconstructible distal humeral fractures, underwent elbow hemiarthroplasty at our institution (Table 1). Seven of them had primarily unreconstructible distal humeral fractures (four AO/OTA 13B3.3 and three 13C3) and one had a failed prior ORIF of a distal humerus fracture. Mean patient age at the time of surgery was 68.1 years (range, 58–77 years), with an average follow-up duration of 46.6 months (range, 12–120 months). Olecranon osteotomy and triceps-on approaches were utilized in 5 and 3 cases respectively. Fig. 1 presents the radiographs and computed tomography images of patient no. 6, from preoperative fracture assessment to radiographs taken at the final follow-up visit.
Analysis of postoperative outcomes revealed favorable results in terms of ROM. Patients demonstrated near-complete pronosupination (average: 65.6°±7.7° to 68.8°±10.5°), with mean flexion and extension of 125°±14.8° and 25°±10.3°, respectively. Functional scores, including qDASH score (35.2±24.8) and MEPS (78.1±17.7), indicated satisfactory postoperative function. Mean pain levels, as assessed by NPRS, were 3.9±1.1. There were no clinical or radiographic signs of implant loosening among the study patients.
Complications included three patients who presented with instability and required reoperation (patients 2, 4, and 7). Patients 2 and 4 also developed prosthetic joint infections and underwent staged conversion to TEA, while patient 7 underwent ligament reconstruction (Fig. 2). Patient 2 underwent revision for instability associated with early postoperative infection. In the first stage, she underwent removal of the convertible component of the humeral prosthesis and placement of a cement antibiotic spacer. After completing 6 weeks of intravenous antibiotics and showing resolution of infection symptoms, she underwent conversion to TEA. Patient 4 underwent conversion to TEA due to instability. She then developed a prosthetic joint infection and underwent staged revision, which included the removal of all hardware and placement of temporary implants with cement antibiotics in the first stage. After completing 6 weeks of intravenous antibiotics and demonstrating infection resolution, she underwent second-stage revision to TEA. Two patients (patients 1 and 7) sustained periprosthetic ulnar fractures after a fall. Both underwent ORIF, achieved union, and regained satisfactory function. One patient (patient 3) developed postoperative ulnar nerve sensory neuropathy.
This study presents the outcomes of eight consecutive patients who underwent DHH for unreconstructible distal humerus fractures or failed ORIF. Our analysis demonstrated satisfactory functional outcomes with a mean follow-up period of 46.6 months (range, 1–10 years). All patients achieved functional or nearly functional ROM according to Morrey et al. [21]. The qDASH score (mean, 35.2) indicated moderate disability, mean NPRS was 3.9, and MEPS (mean, 78.1) suggested satisfactory functional outcomes in most patients. Postoperative follow-up showed no clinical or radiographic signs of implant loosening. However, we observed a substantial complication rate, including two conversions to TEA due to elbow instability and postoperative infection (staged conversion), one ligament reconstruction for postoperative elbow instability, two cases of ulnar periprosthetic fracture, and one case of ulnar nerve neuropathy. Our functional outcomes align with previously published data on elbow hemiarthroplasty, highlighting its ability to provide meaningful functional improvement in cases where ORIF has failed or is not feasible [16,17,19]. However, our complication rate was slightly higher than previously reported in the literature. This may be partially attributed to the small sample size and the relatively long-term follow-up period.
Treating intraarticular distal humerus fractures, particularly in elderly patients with poor bone quality or severe comminution, presents a significant challenge for orthopedic surgeons. ORIF, when feasible, remains the gold standard for managing these fractures [4,15-17,22]. Nevertheless, the high failure rates associated with ORIF in patients with poor bone quality or highly comminuted fractures have prompted the exploration of alternative treatments.
In our study, the determination of a distal humerus fracture as unreconstructible was created preoperatively by a hand surgery team based on radiography and CT. All fractures were classified as AO/OTA 13C3 and 13B3.3. Patient age was considered a proxy for bone quality. The final decision regarding reconstructibility was made intraoperatively by the surgeon, taking into account factors such as severe articular comminution, bone impaction, thin osteochondral fragments, and a low likelihood of achieving stable fixation and union. The factors we considered when defining a fracture as unreconstructible were similar to those described in the current literature [15,17]. Several treatment options are currently available for unreconstructible distal humerus fractures. Bag of bones is a treatment option for patients who are not candidates for surgery due to significant comorbidities, high surgical risk, and lack of compliance [23].
TEA, the most common alternative for the treatment of comminuted unreconstructible distal humeral fractures, carries the risk for significant complications such as infection and early failure, among others. Hence, postoperative weight-lifting restrictions and lifestyle modifications are imposed on patients in an attempt to minimize stress and early loosening of the prosthesis [15,24].
In recent decades, DHH designs have evolved and gained popularity as an alternative to TEA. DHH does not burn any bridges and provides a good surgical option that theoretically reduces loosening rates, reserves bone stock, eliminates the need for restrictions on weight lifting and associated lifestyle changes while facilitating conversion to TEA when needed [15,16,19,25]. Jonsson et al. [15] recently published a randomized controlled trial comparing TEA to DHH in distal humerus fractures in patients >60 years old and concluded that during the study period there was no significant difference in functional outcomes or adverse events.
This study adds to the growing body of literature evaluating DHH as a viable option for managing unreconstructible distal humerus fractures. Recent publications on DHH use in unreconstructible distal humerus fractures also show satisfactory functional outcomes and high complication rates. Piggott et al. [16] performed a meta-analysis including 13 level 4 studies with 207 patients. They reported that functional ROM (according to Morrey et al. [21]) was achieved in 11 of 13 studies, with all studies reporting good to excellent outcome scores. The reoperation rate was 17%. MEPS ranged between 76 to 90 and qDASH between 11 to 35. Aseptic loosening rate was 0.5% (1 patient). Burden et al. [19] also performed a meta-analysis of TEA and DHH outcomes in patients aged over 65 with unreconstructible distal humerus fractures. Their analysis consisted of 122 DHH cases. They reported mean qDASH score of 17.2, mean MEPS of 87 and a complication rate of 22%. The aseptic loosening rate of DHH in their study was 1/70.
Our study was limited by its retrospective design, small sample size, and lack of a control group. The outcomes reflect the experience of a single surgeon, which may limit the generalizability of the findings.
DHH for unreconstructible distal humerus fractures and failed ORIF allows for unrestricted postoperative lifting and yields satisfactory functional outcomes, but does have a relatively high complication rate. Further studies on the indications and long-term outcomes of DHH in younger patients are needed to provide greater insight into this topic.