Distal humeral fractures typically occur in a bimodal fashion in young men and in elderly women1,2. Although most fractures allow for open reduction and internal fixation with acceptable clinical outcomes3,4, fixation may be jeopardized in the elderly by poor bone stock and comminution1,5. Total elbow arthroplasty has been used selectively for patients older than 65 years of age in whom open reduction and internal fixation was deemed unwise because of fracture complexity, osteoporosis, or joint damage from rheumatoid arthritis6,7. Recent studies have shown that even in the absence of prior inflammatory or degenerative joint involvement, total elbow arthroplasty may offer improved short-term functional outcomes, with similar complication rates to open reduction and internal fixation of distal humeral fractures in elderly patients5,8. In a randomized controlled trial comparing linked total elbow arthroplasty with open reduction and internal fixation of intra-articular distal humeral fractures in patients older than 65 years, similar complications rates were found among groups, with significantly higher patient function after total elbow arthroplasty at a 2-year follow-up5. However, total elbow arthroplasty is subject to lifelong activity restrictions and the potential for complications, including loosening and infection.
Total elbow arthroplasty has become the treatment of choice for rheumatoid arthritis and management of posttraumatic complications in elbows9-11. Prasad and Dent compared the outcomes of 15 patients undergoing total elbow arthroplasty for acute distal humeral fractures with those of 17 patients managed with total elbow arthroplasty for distal humeral nonunions. After a mean follow-up of 56.6 months (range, 18 to 88 months), no significant differences were found with regard to function and complications. However, implant survival was 93% at 88 months for acute fractures and 76% at 84 months after delayed total elbow arthroplasty12, suggesting that total elbow arthroplasty might be beneficial if performed in the acute setting rather than for treating posttraumatic complications. Several studies have shown the short-term and intermediate-term outcomes of total elbow arthroplasty after acute distal humeral fractures7,13-19. In 2004, Kamineni and Morrey reported good or excellent function in 40 (93%) of 43 patients treated with total elbow arthroplasty for distal humeral fractures, with a mean follow-up of 7 years (range, 2 to 15 years)13. Radiographic loosening was found in 3 cases (1 ulnar and 2 humeral) and revision was required in 5 patients (12%), 1 with infection, 3 with periprosthetic fractures, and with 1 aseptic loosening. Recently, Prasad et al. reported on 19 patients with a minimum 10-year result after total elbow arthroplasty for fracture without rheumatoid arthritis, with a survivorship of 86%20.
The purpose of this study was to assess the outcome of total elbow arthroplasty for the treatment of acute distal humeral fractures and differences in outcomes between patients with rheumatoid arthritis and patients without rheumatoid arthritis, at a minimum follow-up of 10 years.
Materials and Methods
We performed a retrospective cohort study using our institutional total joint registry database. At our institution, total elbow arthroplasty for the treatment of a distal humeral fracture was first performed in 1982. We identified all primary total elbow arthroplasties performed consecutively for this diagnosis between 1982 and 2005, comprising a 24-year period (Fig. 1). Pathologic fractures were excluded. The Coonrad-Morrey Total Elbow (Zimmer), a linked, semiconstrained, total elbow implant, was used in most cases, and the study was limited to this particular design.
Forty-four Coonrad-Morrey implants were implanted during the study period for management of acute distal humeral fractures, with a mean of 2 implants per year (range, 0 to 6 implants). During the same study period, most distal humeral fractures treated at our institution underwent open reduction and internal fixation (approximately 92%)13. At the time of data collection for this study, 25 patients had died. Death occurred at a mean of 5.2 years (range, 1 month to 11 years) after the index surgical procedure, but the deceased patients were included to avoid underreporting complications. Thus, a total of 44 patients who underwent a Coonrad-Morrey arthroplasty for a distal humeral fracture with a potential follow-up of >10 years formed the final study group; of these 44 patients, 15 had rheumatoid arthritis.
Details of the surgical technique used for total elbow arthroplasty in acute distal humeral fractures have been described previously7. All surgical procedures were performed using a bilaterotricipital approach or a Brian-Morrey approach. Fractured fragments were resected. All implants were fixed with antibiotic-loaded polymethylmethacrylate (PMMA). The surface finish of the ulnar component was porous-coated in 21 elbows, PMMA-precoated in 17 elbows, and plasma-spray-coated in 6 elbows. The length of the humeral component was 4 inches (10.16 cm) in 28 elbows and 6 inches (15.24 cm) in 16 elbows.
We obtained data from our joint registry for all patients undergoing total elbow arthroplasty. This registry prospectively follows all patients at 1 year, 3 years, and every 5 postoperative years with a medical history, a physical examination, and radiographs. In the absence of contact, a questionnaire or telephone contact was made. Important clinical information is exhaustively sought and recorded. The lead author, an orthopaedic surgeon, reviewed all medical records with a special focus on complications. These were defined as any event occurring during the lifespan of the implant documented on operative notes, clinical follow-up notes, letters to patients, or follow-up questionnaires.
Clinical and Radiographic Outcomes
The main clinical outcome measures included pain as estimated on a visual analog scale (VAS), range of motion, and the Mayo Elbow Performance Score. Anteroposterior and lateral radiographs were evaluated prior to the index procedure, at 3 months postoperatively, and at the time of the most recent follow-up. Radiographs were assessed for evidence of polyethylene wear according to Ramsey et al.21, implant loosening as described by Morrey et al.22, and heterotopic ossification. Periprosthetic fractures were classified according to the system described by O’Driscoll and Morrey, which takes into account fracture location, bone loss, and component fixation23.
Results are reported as the mean and the standard deviation for continuous variables and the count and percentage for variables composed of discrete data. Time-to-event outcomes including periprosthetic fractures, reoperations, revision surgical procedures, and survival were evaluated using survivorship techniques such as Kaplan-Meier estimation and Cox proportional hazards regression. Hazard ratios (HRs), which represent the ratio of the risk of an event occurring, were reported from the Cox proportional hazards regression models (HR > 1 represents an increased risk).
Further subanalysis focused on comparing patients diagnosed with inflammatory arthritis with patients without inflammatory arthritis, with respect to demographic characteristics, baseline clinical data, functional outcomes, radiographic findings at the time of the latest follow-up, revision and reoperation rates, and survival. Dependent variables composed of continuous data were compared between the 2 groups using 2-sample t tests (assuming unequal variance), and discrete variables were analyzed using chi-square tests or Fisher exact tests (when low expected counts per cell were observed). Patient populations were comparable except that patients with inflammatory arthritis were younger at a mean age of 62.8 years than patients without the disease at a mean age of 74.8 years (p = 0.0058), and there was a higher proportion of female patients in the non-inflammatory group at 86% than in the inflammatory group at 53% (p = 0.0278) (Table I).
All statistical tests were 2-sided and significance was set at p < 0.05. All analyses were conducted using SAS version 9.4 (SAS Institute) and R version 3.1.1 (R Core Team, R Foundation for Statistical Computing).
Pain and Range of Motion
Total elbow arthroplasty was associated with good pain relief. At the time of the most recent follow-up, the mean VAS for pain was 0.64 point (range, 0 to 4 points). The mean flexion was 123° and the mean loss of extension was 24°. The mean pronation was 70° and the mean supination was 71°. Patients with rheumatoid arthritis had less pronation at 60° ± 16° than patients without rheumatoid arthritis at 76° ± 21° (p = 0.021) (Table II).
Mayo Elbow Performance Score
The mean Mayo Elbow Performance Score was 90.5 ± 10.5 points, without differences between groups. Patients with rheumatoid arthritis had lower scores (p = 0.037) for activities of daily living (17.1 ± 7.5 points) compared with patients without rheumatoid arthritis (22.5 ± 4.1 points) (Table II).
At the time of the most recent follow-up, the Mayo Elbow Performance Score was ≤75 points (a fair result) in 3 patients. One patient with a Mayo Elbow Performance Score of 70 points sustained a fracture of a porous-coated ulnar component 10 years after the index procedure and underwent 2 subsequent revision surgical procedures: ulnar component revision at 10 years, which failed, and repeat revision of that component and exchange of the polyethylene bushings at 14 years. Another patient with severe rheumatoid arthritis of both hands and a Mayo Elbow Performance Score of 60 points had a revision 3 years after the index operation because of the failure of a PMMA-precoated ulnar component. A third patient with a Mayo Elbow Performance Score of 75 points had a chronic infection and had components removed.
Twenty-three events (52%) were observed in 44 patients, 8 (18%) being medical in nature, without differences between groups. Implant revision or resection was performed in 8 (18%) of 44 elbows included in this study, and 4 additional patients required a reoperation, mostly for infection.
Three patients developed perioperative complications, including acute myocardial infarction, atrial fibrillation with pulmonary embolism, and frontal lobe infarct. One patient sustained a transient peroneal nerve palsy attributed to poor positioning. Ulnar nerve symptoms were identified in 2 elbows: 1 transient sensorimotor neuropathy and 1 sensory neuropathy. Two elbows were treated successfully with oral antibiotics for delayed wound-healing.
Deep infection was diagnosed in 5 elbows (11%). One elbow developed an acute postoperative infection and underwent humeral component removal and the use of antibiotic-impregnated cement beads with 2 debridements and a successful humeral component reimplantation. Two additional acute infections were treated with irrigation, debridement, and component retention; 1 of these elbows required 3 debridements and a soft-tissue coverage with a muscle flap, and 1 elbow required 2 debridements and bushing exchange, both with long-term success. The fourth infected elbow was diagnosed with septic loosening 1 year postoperatively and underwent permanent resection. The fifth infection occurred in a patient who had undergone removal of a broken wire, cement, and bone for impingement at another institution 2 months after the index procedure; this elbow developed evidence of deep infection 16 years later and was treated with permanent resection, again at another institution.
Mechanical failure of implants occurred in 5 elbows. One of the arthroplasties performed with implantation of a precoated ulnar component was complicated by implant loosening, osteolysis, and a periprosthetic olecranon fracture; at the time of reoperation, the patient underwent revision of both components and internal fixation of the olecranon fracture. There were 2 additional loose ulnar components requiring a revision surgical procedure. The ulnar component fractured in 2 more elbows (at 11 months and 19 years postoperatively). Both fractured ulnar components were porous-coated and were successfully revised.
There were 5 additional periprosthetic fractures after falls. One was a fracture of the ulna distal to the component and 1 was a fracture proximal to the humeral component; both were in patients with rheumatoid arthritis, occurred within the first year after the index operation, and were treated nonoperatively. One elbow sustained an ulnar periprosthetic fracture 16 years after the index procedure that was treated with open reduction and internal fixation. Another elbow sustained a humeral periprosthetic fracture that was also treated operatively with internal fixation. One additional elbow sustained an undisplaced ulnar periprosthetic fracture; internal fixation was offered but declined, with poor function at the time of the latest follow-up.
At the time of the most recent follow-up, radiographic loosening was evident in the 3 elbows (7%) requiring ulnar component revision. Six additional elbows showed radiolucent lines (humeral side in 2 elbows, ulnar side in 2 elbows, and both sides in 2 elbows). All of these patients had lines that were type I or II (type I is indicated by a 1-mm radiolucent line that involves <50% of the interface, whereas type II is indicated by a 1-mm radiolucent line that involves ≥50% of the interface); all these elbows with radiolucent lines provided a good functional outcome with no pain, except for 1 patient who reported mild pain with activity but did not seek further treatment. Bushing wear was appreciated in 5 elbows; in 4 elbows, there were no other radiographic changes, whereas 1 of these elbows had asymptomatic, nonprogressive, incomplete ulnar radiolucent lines at 10 years.
Survivorship Analysis and Risk Factors
At the time of the most recent follow-up, 8 of the 19 surviving patients had undergone a reoperation or revision. Patients without revision or reoperation had a mean Mayo Elbow Performance Score of 95 points at the time of the latest follow-up after a mean time of 11.6 years.
The revision-free rates were 85% at 5 years and 76% at 10 years for elbows with rheumatoid arthritis and 92% at both 5 years and 10 years for elbows without rheumatoid arthritis (Fig. 2); these rates were not significantly different between patients with rheumatoid arthritis and those without rheumatoid arthritis (HR, 2.5 [95% confidence interval (CI), 0.6 to 11.4]; p = 0.223) (Table III). Because the patients with rheumatoid arthritis were younger and had a higher proportion of males, the effect of rheumatoid arthritis on revision was further analyzed in a multivariable model adjusted for age and sex. In this multivariable model, the effect of rheumatoid arthritis remained nonsignificant (p > 0.05), and the HR was attenuated (HR, 0.96 [95% CI, 0.1 to 7.3]; p = 0.963) (Table IV). Male sex was the only significant risk factor for revision (HR, 12.6 [95% CI, 1.7 to 93.6]; p = 0.013). After adjusting for age and sex, the risk of death was higher in patients with rheumatoid arthritis, but this was not significant (HR, 2.7 [95% CI, 0.9 to 8.0]; p = 0.071).
Total elbow arthroplasty has become an accepted alternative for selected elderly patients with distal humeral fracture. Although initially the procedure was restricted to fractures with associated inflammatory arthropathy, currently, arthroplasty is considered for elbows without rheumatoid arthritis. Short-term outcomes have proven that total elbow arthroplasty is a successful treatment, but in several previous studies, the mean follow-up is 3 years5,7,12,15,16. Thus, long-term follow-up studies are needed to understand if implant failure occurring later offsets the early benefits of elbow arthroplasty in this population.
Our results indicate that total elbow arthroplasty is associated with 76% to 92% survival free of revision at 10 years. Nine patients in our study died in the first 5 years after their index procedure of unrelated causes, because of the selection of this procedure for elderly patients; thus, many patients did not live long enough to experience mechanical failure. Although the implant survivorship rates were higher in the patients without rheumatoid arthritis at 5 and 10 years despite the potential for higher functional demands on the arthroplasty20, these differences were not significant. The risk of failure, including revision, was progressive in patients with rheumatoid arthritis, and patients without rheumatoid arthritis had an early risk of reoperation related to soft-tissue problems and a late risk related to periprosthetic fractures. Male sex had a significant negative impact on survival of the arthroplasty (HR, 12.6). Hypothetically, this could be related to a higher functional demand or failure to comply with postoperative limitations.
Ulnar stem loosening and bushing wear were previously stated as the main long-term failure mode in semiconstrained total elbow arthroplasty for posttraumatic arthritis24, but this was not reproduced in our study. Despite some authors reporting an association between wear and osteolysis25, 4 of 5 patients with evidence of bushing wear showed no signs of osteolysis. Osteolysis may be related to the behavior of precoated ulnar stems26, with only 1 case needing a reoperation due to associated humeral osteolysis. A low rate of bushing wear may be a reflection of the selective indications in our study. Loosening was observed in 2 precoated ulnar stems and 1 patient had marked ulnar osteolysis and an olecranon fracture. Two patients had a fracture of a porous-coated ulnar stem, but none of these events have been observed after the introduction of the plasma-sprayed modification, in agreement with prior studies26.
Complications have been frequent and diverse in nature with continuous follow-up of these patients and have required a reoperation, including implant revision, in 12 of 44 patients. Early complications mainly included wound problems in 5 patients, 3 of whom needed 6 additional procedures, including a muscle flap. Infection was observed early in the postoperative period, which resolved after 2 debridements and a humeral stem and bushing exchange, and at a later period, both requiring excisional arthroplasty. In our study, periprosthetic fractures occurred early in patients with rheumatoid arthritis, which was probably a reflection of the poor bone stock present; in patients without rheumatoid arthritis, fractures occurred after the 10-year follow-up and increased at the 15-year and 20-year follow-ups. In our study, we could not correlate periprosthetic fractures with osteolysis or stem loosening, as suggested by others17-27; the periprosthetic fractures reported in our study more likely reflect the increased rate of falls that occurs in patients of advanced age. Although this complication is not implant-related, it often needs complex surgical treatment including different fixation methods, allografts, and revision implants.
The strengths of this study include the long duration of prospective follow-up for all patients, the confirmation of a different outcome for patients with rheumatoid arthritis and those without rheumatoid arthritis, and the difference in the rate and timing of complications. The limitations of this study included that it was a single-institution study, so the results may not have been generalizable. A different patient-selection strategy might have led to a different rate of observed events28. Other limitations were the existence of missing data for some variables, the loss of patients due to death, and the low event rate that limited statistical precision. The event of death during the long-term follow-up occurred in 25 of the 44 patients, the majority of whom had the implant in place. Prasad et al. reported that 18 of 40 patients without rheumatoid arthritis who were treated for fracture with a semiconstrained total elbow arthroplasty had died by the time of the 10-year follow-up20. Similarly, Bigsby et al. reported the long-term results of semiconstrained total elbow arthroplasty, mainly for rheumatoid arthritis; at 10 years, 18 of 40 patients had died, with an overall survival of 13.1 years29. Our results show that patients with rheumatoid arthritis lived longer and more of them were alive at the time of the latest follow-up, but this may be related to the fact that they were surgically managed at a younger age (62.8 years compared with 74.8 years).
In summary, total elbow arthroplasty is an effective mode of treatment for unreconstructible distal humeral fractures of the elderly or severely affected joints and the majority of patients will die with a useful joint and the implant in place. Complications after this procedure are frequent, and although the rate and timing of complications were different in patients with rheumatoid arthritis and patients without rheumatoid arthritis, the surgeons treating this kind of injury should follow their patients over time and should be prepared to manage a wide array of complications using complex techniques. This information may prove useful for patients and surgeons in making a preoperative decision, managing expectations, and defining potential complications after total elbow arthroplasty for distal humeral fractures.
Investigation performed at the Mayo Clinic, Rochester, Minnesota
Disclosure: There was no external source of funding for this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this work (http://links.lww.com/JBJS/E332).
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