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Original article
a r t i c l e i n f o a b s t r a c t
Article history: Introduction: Total elbow arthroplasty (TEA) is one option in distal humerus fracture in elderly osteo-
Received 29 November 2016 porotic patients.
Accepted 6 June 2017 Hypothesis: The study hypothesis was that, in patients aged 70 years or more, TEA provides functional
results and ranges of motion compatible with everyday activity, with a complications rate equal to or
Keywords: lower than with internal fixation, and no loss of autonomy or cognitive impairment.
Distal humerusfracture Material and methods: In this retrospective study, 21 patients receiving TEA for distal humerus fracture
Total elbow arthroplasty
were included. Mean follow-up was 3.2 years, with functional (Quick DASH and MEPS), cognitive (MMSE),
Osteoporotic fracture
Elderly
autonomy-related (ADL) and radiological assessment (Morrey).
Results: Mean MEPS was 84 and QuickDASH 32.4. Mean extension deficit was 22◦ , and mean flexion 125◦ .
There was no loss of autonomy or cognitive impairment. The complications rate was 9.5%. There were no
revision surgeries.
Discussion: TEA proved reliable in comminuted distal humerus fracture in elderly patients. Functional
results were comparable to those in the literature, and the complications rate was lower. Long-term
implant survival needs confirmation to validate this option as a treatment of choice in these indications
in geriatric traumatology.
Type of study: Retrospective non-comparative, single-center.
Level of evidence: 4.
© 2017 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.otsr.2017.06.009
1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.
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892 D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897
Table 1 A3 C1 C2 C3
Demographic data.
8
Age (years)
Mean 81.3 7
Range 70–92
6
SD 5.7
5
BMI
Mean 25.61
4
Range 19.4–32
3
ASA
ASA 1 6 2
ASA 2 15
1
Gender
Male 1 0
Female 20 70-74 Yrs 75-79 Yrs 80-84 Yrs 85-89 Yrs 90-95 Yrs
ADL
Fig. 1. AO anatomic types by age group.
Mean 5.1
Range 4–6
MMSE
by age group. The two A3 fractures were in very elderly patients
Mean 25.35 with very low bone density. There were two open grade 1fractures.
Range 23–28 One patient showed humeroulnar osteoarthritis; 1 had ipsilateral
proximal humerus fracture, treated functionally; 2 had sustained
Side
distal radius fracture at the same time as the humeral fracture, both
Dominant 15
Non dominant 6 treated by antebrachial cast.
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D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897 893
Table 2
Complications.
3. Results
Fig. 2. The perineural tissue is conserved to respect the ulnar nerve against the
implant. Mean follow-up for the 21 elbows was 3.2 years (range:
2–7.4 years). Mean operating time was 95 minutes (range,
any suture loosening, which did not in fact occur. The flexor carpi 70–120 min). Fifteen of the humeral implants were size 4, 5 size
ulnaris fascia was sutured. There was no postoperative immobiliza- 6, and 1 size 8; 14 were “extra-small”, 5 “small”, and 2 “regular”.
tion, apart from a simple scarf to minimize pain, and immediate Eighteen of the ulnar implants were of normal length, and “3 long”.
mobilization was authorized. Rehabilitation was initiated on day 2,
without limitation on motion, and without force, associated to ergo 3.1. Complications
therapy. Mobilization was according to pain.
One patient died of acute coronary syndrome at 3 years, with
2.3. Clinical assessment no complications related to the TEA observed at last follow-up
(Table 2).
Patients were followed up in consultation at 1, 3 and 6 months, There were 2 principal complications (9.5%): 1 case of severe
1 year and then annually. Ranges of motion were recorded. Elbow stiffness, and 1 of skin necrosis at the tip of the olecranon. The
extension, flexion and pronation-supination were assessed using a patient with stiffness had suffered peritonitis at day 18, necessitat-
circular goniometer. Functional recovery was assessed on Quick- ing 32 days’ admission to the visceral surgery department which,
DASH and Mayo Elbow Performance scores [22], autonomy on combined with the resulting asthenia, involved extreme immobil-
ADL [18], and cognitive status on MMSE [19]. Satisfaction was ity and hence stiffness; the patient and family declined revision
self-assessed on a simple 4-level scale: very satisfied, satisfied, surgery to release the prosthetic joint, and rehabilitation failed
moderately satisfied, and dissatisfied. Intraoperative complications to restore a functional range of motion. The case of skin necro-
were recorded in the surgical report and general complications in sis followed an in-hospital fall with skin abrasion at the olecranon
the hospital file. Skin healing was recorded at the first postoperative and shoulder dislocation, which was irreducible due to associated
consultation. Subjective clinical assessment of force in extension glenoid fracture, for which the patient declined further surgery; the
screened for complications related to triceps release/reinsertion. constant pressure of the limb on the olecranon caused ulceration of
Neurologic disorder in the ulnar territory was screened for by the abrasion (Fig. 3), without exposing the implant. Iterative dress-
analyzing interosseous muscle function and any self-reported ing and preventing pressure on the tip of the olecranon allowed
paresthesia. satisfactory healing without further intervention. For these two
patients, functional outcome was poor and showed no improve-
2.4. Radiologic assessment ment during follow-up.
There were no cases of infection or of revision surgery.
Immediate postoperative AP and lateral elbow views screened
for leakage, implant malpositioning or protrusion. Ulnar and 3.2. Clinical results
humeral cementation was checked on immediate postoperative
X-rays, and classified in 3 types, following Morrey [23]: type 1, Mean hospital stay was 4.3 days (range, 2–32days). Seven
adequate cementation with < 1 mm radiolucency at the cement- patients were referred to a rehabilitation center, due to their social
bone interface and cement going beyond the implant stem; type 2, isolation, and 14 were discharged home. There were no cases
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894 D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897
Table 3
Average functionnal results.
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D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897 895
Table 4
Radiologic results.
distal humerus fracture treated in first line by total elbow arthro- to validate the medico-economic aspect [35] and long-term results
plasty, and to determine immediate and short-term complications [30]. Obert also reported that complications were fewer with elbow
and impact on autonomy and cognitive status. arthroplasty, but liable to be more difficult to manage [36]. Ducrot
Functional results were altogether satisfactory, with a mean et al. reported 2 cases of ulnar neuropathy in their series [13], which
QuickDASH of 32, MEPS of 87, extension loss of 22◦ and flexion they thought might be due to medial bone fragments.
of 125◦ . Our hypothesis was confirmed. All patients were able to Internal fixation remains the reference treatment, and elbow
return home, with mean ADL score > 4, due to an average 1-point arthroplasty needs to demonstrate functional results that are at
loss mainly concerning the “dressing” item. There was no major least equivalent if it is to be used in this indication. It is probably
cognitive impairment, with mean MMSE of 23.61 at last follow-up; wise to be cautious, and reserve TEA for type B and C fracture in
the patient who deteriorated the most had a hospital stay of more over-70 year-old subjects, especially as follow-up is lacking in the
than 1 month. The complications rate was 9.5%, notably associated various reports of elbow arthroplasty in traumatology. In type-A
with concomitant acute pathologies necessitating immobilization fracture, internal fixation, thanks to the rigidity of locked assem-
and severe asthenia during the first postoperative month. Early bly, is stable despite osteoporosis [2]. However, type A is not the
mobilization seems to be vital. One patient showed true radiologic most frequent form of fracture in this age group and, although
signs of humeral loosening, without functional impact. There were extra-articular, can be highly comminuted in the metaphysis, and
no cases of infection or heterotopic ossification. There were no revi- particularly unstable [6–8]. Non-operative management has its
sion surgeries. Mean BMI, elevation of which is usually a factor of place in treatment strategy, especially when patients do not meet
poor prognosis, was 25.61 (range: 19.4–32). One patient was dis- the criteria for surgery or have excessive comorbidity [37]; sec-
satisfied and another only moderately satisfied, and had BMIs of ondary implantation remains possible in case of failure, if pain or
respectively 20.6 and 19.4; thus, obesity was not implicated, but functional impact is unacceptable for the patient or family [38].
rather the complications described above. Only 1 patient was obese Extrapolating results for other joints, such as the hip [39], to the
(BMI > 30), with a BMI of 32; he was 70 years old at time of surgery, humerus, it would seem that revision is more complex after failed
and was followed up for 4 years, with MEPS 85, QuickDASH 24.45, internal fixation than in a non-operated elbow. McKee [32], in
“very satisfied”, ADL 5, MMSE 23, extension/flexion −20/125◦ and a prospective study, found equivalent ranges of motion between
unrestricted pronation-supination. Obesity was thus not a factor for elbow arthroplasty (−26◦ /133◦ ) and internal fixation (−28◦ /123◦ ).
poor functional outcome. Neurologic complications are frequently Leigey reported a mean range of motion of about 105◦ in elderly
reported, but did not occur in the present series, perhaps thanks to patients with medial and lateral double plate internal fixation [3].
the conserved perineural tissue sheath, although this could not be Even so, some comparative studies reported better functional
confirmed by comparison against a control group. results with total elbow arthroplasty [40]. Frankle [29] reported
The present results confirm those already published in this indi- a mean −30◦ extension deficit with internal fixation versus −15◦
cation; sample size was small, but the findings were similar to those with elbow arthroplasty. McKee andMansat et al. reported similar
of most previous studies. Table 5 presents published results on the findings [12,21].
subject [4,6,11–14,24–34], which we averaged and compared to our The present results show similar mean values for extension,
own. The present sample size was comparable to those of other flexion and pronation-supination, and contribute an extra series
studies. The implant used was that most frequently found in the with a respectable sample size, confirming the reliability of these
literature. The mean age was 6 years greater than the average, and implants in terms of functional recovery in this indication. Another
follow-up 6 months shorter. Functional outcome and complications strong point was the inclusion of autonomy and cognitive scores,
were as in the other reports [28]. which are part of standard assessment in geriatrics. A major
The complications rate was 9.5%, lower than in comparative limitation was the short follow-up, especially regarding late com-
studies, which favored elbow arthroplasty over internal fixation. plications and implant survival.
McKee reported a 27% rate with internal fixation, in contrast to 12% Implant survival is, indeed, a legitimate question, which few
with elbow arthroplasty [29]. Elweinn, studying type-C fracture in studies have answered in traumatology. Plaschkeshowed implant
over-60 year-olds, likewise found a major complications rate of 55% survival to be shorter in distal humerus fracture than in other
with internal fixation, versus 13% with elbow arthroplasty, the main indications, but with overall 10-year survival of 81%, taking all indi-
cause of failure being loss of reduction due to disassembly of the cations for TEAtogether [41]. The life expectancy and activity level
internal fixation [4]. Githens’ meta-analysis found a higher overall of our patients may make this survival rate worrying.
complications rate with internal fixation, although the difference The study hypothesis was that functional results are satisfactory
was not significant [1], and stressed the need for further studies and the complications rate is low, without cognitive deterioration
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896
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Table 5
Previously published results in the literature.
Patients/Elbows Gender Implant type Mean age Mean Mean exten- Mean Supina- Mean MEPS Infection Radiolucency Fracture Neural Revision
(years) follow-up sion/flexion tion/pronation lesions
(years) (degrees) (degrees)
Gallucci et al. (2016) 23/23 21F-2M Coonrad-Morrey 79 3.1 17–123 N/D 83 0 4 1 3 3a
semi-constrained hinged
Prasad et al. (2016) 19/19 12F-7M Coonrad-Morrey 68 13.2 34–118 N/D 90 1 6 0 2 2b
semi-constrained hinged
Pogliacomi et al. (2016) 20/20 19F-1M Latitude/Tornier 74.1 5 N/D > 100 N/D 88.7 1 4 0 0 0
D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897
Coonrad-morrey/Zimmer
Ellwein et al. (2015) 29/29 21F-8M Latitude/Tornier 70 1.8 13–123 87–89 94 1 0 0 3 0c
Giannicola et al. (2014) 24/24 Prospective 15F-9M Discovery Elbow system Djo 78 2.9 15–138 84–83 99.5 0 2 0 0 0d
surgical
Mansat et al. (2013) 70/78 N/D 18 Fractures Coonrad-Morrey 70 3.5 30–126 70/67 78 1 1+1 0 0 1e
semi-constrained hinged deterotopic
ossification
Ducrot et al. (2013) 15/15 18F-2M Coonrad-Morrey 80 3.6 33–130 N/D 83 0 6 0 2 0
semi-constrained hinged
Chalidis et al. (2009) 11/11 9F-2M Coonrad-Morrey 80 2.8 17–125 70–60 90 0 0 1 0 1
semi-constrained hinged
Charissoux et al. (2008) 36/44 N/D Coonrad-Morrey 81 2 27–124 94–91 84 N/D N/D N/D N/D 2
semi-constrained hinged
McKee et al. (2008) 25/25 19F-1M Coonrad-Morrey 77 2 26–133 N/D 86 4 1 0 3 1
semi-constrained hinged
Prasad et Dent (2008) 32/32 25F-7M Coonrad-Morrey 78 4.6 26–118 80–70 85 2 6 0 2 2
semi-constrained hinged
Lee et al. (2006) 7/7 5F-2M Coonrad-Morrey 72.9 2 41.4–130 72.9–75.7 94.3 0 0 0 0 0
semi-constrained hinged
Kamineni et Morrey (2004) 48/49 31F-12M Coonrad-Morrey 69 7 24–131 N/D 93 1 3 3 3 5
semi-constrained hinged
Frankle et al. (2003) 12/12 12F Coonrad-Morrey 72 3.8 15–125 N/D 95 1 1 0 2 0
semi-constrained hinged
Gambirasio et al. (2002) 10/10 10F Coonrad-Morrey 84.6 1.5 23.5–125.5 74.5–79 94 0 2 0 0 0
semi-constrained hinged
Garcia et al. (2002) 19/19 12F/4M Coonrad-Morrey 73 3 24–125 90–70 93 1 1 0 0 0
semi-constrained hinged
Ray et al. (2000) 7/7 7F Coonrad-Morrey 81.7 3.8 25–130 N/D 92 1 2 0 0 0
semi-constrained hinged
Cobb et Morrey (1997) 20/21 15F-5M Coonrad-Morrey 72 3.3 25–130 73–74 N/D 1 3 1 1 1
semi-constrained hinged
Means 20.8 15.9F-3.8M 75.2 3.8 24.4–124.8 78.7–74.3 89.3 0.8 2.5 0.3 1.2 1
Present series (2017) 21 20F-1M Coonrad-Morrey 81.3 3.2 22–125 N/D 85.4 0 4 0 0 0f
semi-constrained hinged
N/D: No data; OA: osteoarthritis.
a
Two Revisioons for wear 1 technical error
b
Minimum follow-up 10 years; 36 patients initially; revision-free survival at last follow-up 89.5%.
c
Twenty-one Internal fixations 9 Implants.
d
Ten fractures.
e
Forty-five inflammatory OA 3 Traumas: 18 fractures, 10 non-unions, 5 OA.
f
One skin necrosis + 1 peritonitis.
D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897 897
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