Treatment of Distal Humeral Fractures in Elderly Patients

Where Are We in 2020? A Review Article

Anthony V. Christiano, MD; James D. Dieterich, MD; Gregory M. Frechette, MD; Andrew J. Lovy, MD; Jaehon M. Kim, MD; Michael R. Hausman, MD

Disclosures

Curr Orthop Pract. 2020;31(6):579-581. 

In This Article

Discussion

Nonoperative treatment for elderly patients with distal humeral fractures remains an option but should be reserved for low-demand patients with unacceptable risks of surgery. Without open reduction of the fracture fragments, restoring the joint becomes nearly impossible. Pidhorz et al.,[5] in their retrospective review of 34 elderly patients with distal humeral fractures who were treated nonoperatively, demonstrated high rates of extraarticular malunion and intraarticular malunion with associated risk of developing osteoarthritis. Nonunion was also a common problem affecting as many as 47% of patients after nonoperative therapy. Despite these problematic radiographic findings, they correctly identified that low-demand elderly patients with distal humeral fractures can regain a functional range of motion with good to excellent subjective outcomes after nonoperative therapy.[6,7] Patients who do not achieve satisfactory outcomes with nonoperative treatment can be converted to total elbow arthroplasty (TEA) with satisfactory results.[7]

In elderly patients who are healthier and higher-demand, operative management of distal humeral fractures has been advised. Many methods of operative fixation have been advocated including parallel plating, 90–90 plating, column screws, and external fixation.[8–11] Open reduction internal fixation (ORIF) restores the native anatomy of the distal humerus, and most series found in this review focused on methods of ORIF for the treatment of elderly patients. Clavert et al.,[12] in their review of 289 distal humeral fractures in elderly patients who were treated with ORIF, found good to excellent function as measured by the Mayo Elbow Performance Score (MEPS). However, there is cause for concern with ORIF of distal humeral fractures in elderly patients. In their review of complications after ORIF of distal humeral fractures, Savvidou et al.,[13] found mechanical failure in 7% to 27% of patients, ulnar neuropathy in an average of 13% of patients, formation of heterotopic ossification in 8.6% of patients nonunion rates of 2% to 10%, and malunion rates as high as 30%. This has led orthopaedic surgeons to consider other treatment modalities for distal humeral fractures.

As has been described for fractures of the hip and the proximal humerus, elbow arthroplasty has been suggested as a "one-and-done" option for the treatment of carefully selected elderly patients with distal humeral fractures. Rajaee et al.,[14] in their review of the Nationwide Inpatient Sample, demonstrated a 2.6-fold increase in TEA for distal humeral fractures from 2002 to 2012. Several authors[15,16] have reported excellent functional and radiographic results at short-, mid-, and long-term follow-up for elderly patients who had TEA for distal humeral fractures. At a minimum of 10-year follow-up, Barco et al.,[16] in their cohort of 44 patients treated with TEA for distal humeral fractures, demonstrated retained range of motion (mean 24 to 123 degrees), excellent function (mean MEPS 90.5), and excellent pain control (mean pain visual analog scale 0.6). However, in this nonrandomized cohort there were eight patients (18%) with revision or resection. A review of the Norwegian arthroplasty register supported these findings of decreasing survivorship for all causes for TEA, with 92% survivorship at 5 yr to 61% survivorship at 20 yr. Patients who received TEA for acute fracture had decreased survivorship at 5 yr (82%) when compared to the total population (92%).[17]

TEA additionally comes with activity restrictions for life, including not lifting any weight greater than 10 lbs or repetitively lifting any weight greater than 3 lbs, and only 64% of patients remember and comply.[18] With these complications of TEA and the associated activity restrictions it is important to compare fully TEA to ORIF to determine the best treatment for distal humeral fractures in elderly patients. Furthermore, as patients age, they become more dependent on their upper limbs for necessary activities such as rising from a chair or ambulating with a cane or walker. Thus, they become obligate quadrupeds and routinely exceed recommended loading of the TEA.

In their systematic review and meta-analysis comparing ORIF to TEA for geriatric distal humeral fractures, Githens et al.,[19] reviewed 27 studies of 563 patients demonstrating similar range of motion and functional outcome. There was a higher rate of major complications and reoperation after ORIF compared to TEA, but this finding was not significant. In their multicenter, prospective, randomized trial comparing ORIF to TEA for geriatric distal humeral fractures, McKee et al.,[20] demonstrated no statistically significant difference in reoperation or complication rates, but did find improved functional outcome at all time points up to 2 yr with TEA compared to ORIF. However, as highlighted in the article commentary, the study was underpowered to determine a difference in reoperation rate, despite a trend toward a large clinical difference. The study also relied on an intention-to-treat analysis despite a large amount of treatment crossover from ORIF to TEA because of fractures that were deemed unamenable to fixation intraoperatively by the treating surgeon.[21] Also, ORIF was frequently performed using a 90/90 plating technique that is not as strong as parallel plates in the older, osteopenic cohort.

To compare short-term outcomes of ORIF to TEA, Lovy et al.,[22] queried the National Surgical Quality Improvement Program database for geriatric patients treated with TEA or ORIF for distal humeral fractures and found no difference in adverse events, but did demonstrate significantly longer operative time and postoperative length of stay in patients receiving TEA. This fits with the higher average hospital charges ($16,358) associated with TEA compared to ORIF.[14] However, in an analysis by Federer et al.,[23] Markov modeling was used to compare cost-effectiveness of TEA to that of ORIF using quality of life data obtained from patients at least 2 yr after surgery; they found the total cost of TEA ($19,407) was slightly lower than the total cost of ORIF ($20,669), driven by an increased need for reoperation.

Fixation failure, nonunion, or post-traumatic arthritis after ORIF of distal humeral fractures can lead to further surgery. Conversion of ORIF to TEA has been successful in many case series. Pogliacomi et al.,[24] in their review of 20 geriatric patients with distal humeral nonunion after ORIF, demonstrated significant functional improvement. However, the functional improvement in this study was compared to their preoperative status with a distal humeral nonunion. To more accurately define the functional status of geriatric patients converted from distal humeral ORIF to TEA, Fritsche et al.,[25] compared 19 geriatric patients who underwent primary TEA for distal humeral fracture to 25 patients who were converted from ORIF to TEA. They found similar range of motion and functional outcome. Logli et al.,[26] corroborated these findings in their comparison of 22 primary TEA for distal humeral fracture to 66 TEA after previous ORIF, demonstrating no significant differences in functional outcome (MEPS acute 85, salvage 81), range of motion, or reoperation rate.

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