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Total Elbow Arthroplasty As The Salvage procedure of Nonunion or

Malunion of Distal Humeral Fracture

JUI-KUO HUNG MD.Department of Orthopaedic Surgery

Changhua Christian Hospital, Taiwan

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Distal Humeral Fracture • 1~2% of adult fractures• 1/3 of humeral fractures

– Low energy trauma in elderly– High energy trauma in young

• Treatment challenge – Complex anatomy and common comminution

• Anatomic reduction: therapeutic goal– Splinting, casting– Open reduction and internal fixation

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Distal Humeral Fracture -- Complications --

• Stiffness of elbow joint• Post-traumatic arthritis• Ulnar neuropathy• Heteroptic ossification• Nonunion or Malunion

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Nonunion and Malunion

• 2% ~10% after open reduction and internal fixation

• Causes– Complex fracture, poor bone quality, soft tissue

lesions, bad patient and implants selection

• Resulting – Marked instability, pain, strength loss and

significant functional limitation

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Nonunion and Malunion -- Management --

• Open reduction and internal fixation with bone-grafting– Most often recommended

• Allograft reconstruction• Distraction arthroplasty• Total elbow arthroplasty

– Poor bone stock– Severe destruction of articular surface

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Total Elbow Arthroplasty

• Poor results with highly constrained or custom joint implants

• Modern linked semiconstrained implants– Undisturbed extensor mechanism– Reliably restored stability– Predictable range of motion– Minimal pain and limited motion

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MATERIALS AND METHODS

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Materials and Methods

• Feb. 2001 ~ Jan. 2008• 12 patients

– 65.8 y/o ( 56~ 78 )– ♂：♀ = 6： 6

• Clinical presentation– Pain, elbow instability– Fracture of distal humerus s/p ORIF

• Follow up– 63 months (25 ~ 108)

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Patient Selection

• These 12 patients with TEA– Nonunion/malunion of distal humeral fracture– Pain, weakness and instability– Unsuitable for revision ORIF

• Poor bone quality• Extensive articular comminution

• 42 patients with acceptable bone stock– Revision ORIF with bone-grafting

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Implants Selection Stryker’s Solar Total Elbow

Zimmer’s Coonrad-Morrey Total Elbow

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Surgical Technique

• Posterior midline incision• Triceps-sparing approach • Anterior ulnar nerve transposition• Soft tissue release• Prepare humeral and ulnar compartments• Trial and permanent implants insertion

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Assessment• Clinical assessment

– Complication– Mayo Elbow Performance Score (MEPS)– Prosthesis survival

• Radiographic assessment– Implants position – Loosening

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Mayo Elbow Performance Score (MEPS)

• ≧90 Excellent• 75~89 Good• 60~74 Fair• <60 Poor

Function Point

Pain 45

Daily functional activities 25

Motion 20

Stability 10

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Implant Loosening

Type 0A radiolucent line <1mm thick, involves < 50% of the interface

Type 1A radiolucent line is 1 mm thick, involves < 50% of the interface

Type 2A radiolucent line >1mm thick, involves > 50% of the interface

Type 3A radiolucent line >2mm thick, involves 100% of the interface

Type 4Gross loosening

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RESULTS

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Complication • Transient ulnar paresthesia

– 6 patients, remission 3~6 months

• Superficial wound infection– 3 patients– Improved after wound care and debridement

• Well implant position• Inadequate cement infiltration

– 4 patient

• 1 had type 4 septic loosening one year later • No implant-related complication

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Mayo Elbow Performance Score (MEPS)

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Implant Loosening

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One Patient with Gross Loosening

• 72 Y/O, male• Deep infection 1 year later• Post-OP 13 months• Humeral stem loosening

due to infection• Management

– Revision TEA at other

clinic

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CASE PRESENTATION

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65 Y/O Male Post-OP 49 Mons

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78 Y/O Female Post-OP 25 Mons

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72 Y/O Male Post-OP 13 Mons

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DISCUSSION

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Management of Nonunion and Malunion

• ORIF with bone-grafting– Most often recommended – Difficulty in poor bone stock patients

• Allograft reconstruction– Graft resorption, infection, nonunion

• Distraction arthroplasty– Technically demanding– High rate of complication– Inconsistent outcome

• Total elbow arthroplasty– Increase success rate with new designed implants

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Open Reduction and Internal Fixation with Bone-Grafting

• Most recommended method

• Long term disability– Residual elbow

stiffness and pain

• Improved outcome– New designed fixation

implants– Elbow capsulectomy

• Helfet et al. JBJSB 2003

• 52 Nonunion/Malunion

• 98% union rate• Union time 6 months• 94° ROM• 15 (29%)

– Reoperation– Prominent hardware

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Total Elbow Arthroplasty• Poor bone stock and destruction of joint• Modern linked semiconstrained implants• Advantages

– Undisturbed extensor mechanism– Reliably restored stability– Predictable range of motion– Minimal pain and limited motion

• Disadvantage– Implant-related complications– Limit use of the upper extremity

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Implants Loosening and Component Fracture

• Infection • Poor implants position • Inadequate cementing technique• Use of pre-coated ulnar component• Patient’s in-cooperation about weight-lifting

restriction– Increase bushing wear– Components fracture

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Linked Elbow Replacement: A Salvage Procedure for Distal Humeral Nonunion

• Akin Cil, Bernard F. Morrey. et al JBJSA 2008 • 1982~2003, 92 patients, 65Y/O (22~84)• 85% with excellent/good MEPS• 74% no pain or mild pain• 23 (25%) with revision TEA or removal of

implant– Comparable with ORIF-patients

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Linked Elbow Replacement: A Salvage Procedure for Distal Humeral Nonunion

• Risk factors of implant failure– Age < 65Y/O– > 2 prior surgical procedures– History of infection

• Rate of prosthesis survivalF/U Years Survival

2 years 96%

5 Years 82%

10~15 Years 65%

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Distal Humerus Nonunion after Failed Internal Fixation: Reconstruction with Total Elbow Arthroplasty

• LaPorte et al. AM J Orthop. 2008

• 12 patients, 63 months F/U • 11 patients with good pain relief• Mean total arc 117 ° • 75% complication rate

– Most are soft tissue problems– No need for revision TEA

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Total Elbow Arthroplasty as Primary Treatment for Distal Humeral Fractures in Elderly Patients

• Ray P.S. et al. Injury 2000• 7 patients, 81.7Y/O, 48 months F/U• 6 patients with no pain, one had mild pain• Mean arc 20-130 °• MEPS 5 is excellent, 2 is good • 1 patients had superficial infection• No need re-operatoion • Conclusion

– Good short-term results– For selected comminuted distal humeral fracture

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Summary• Treatment challenge• ORIF with bone-grafting

– Treatment of choice if possible

• Total elbow arthroplasty– Poor bone stock and joint destruction– Good short-term result, long term result ？ – High complication rate– Patient selection is crucial

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THANK YOU