Total Elbow Arthroplasty As The Salvage procedure of Nonunion or Malunion of Distal Humeral Fracture
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This document discusses the use of total elbow arthroplasty as a salvage procedure for nonunion or malunion of distal humeral fractures. It summarizes that distal humeral fractures are challenging to treat due to the complex anatomy and common comminution. Nonunion or malunion can occur in 2-10% of cases after open reduction and internal fixation and result in pain, instability and loss of function. Total elbow arthroplasty can be considered for cases with poor bone stock or articular destruction when revision fixation is not possible. The document presents results from 12 patients who underwent total elbow arthroplasty with generally good pain relief, range of motion and function, though complication rates were high.
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Total Elbow Arthroplasty As The Salvage procedure of Nonunion or Malunion of Distal Humeral Fracture
- 1. 彰基骨科 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
- 2. 彰基骨科 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
- 3. 彰基骨科 Distal Humeral Fracture -- Complications -- • Stiffness of elbow joint • Post-traumatic arthritis • Ulnar neuropathy • Heteroptic ossification • Nonunion or Malunion
- 4. 彰基骨科 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
- 5. 彰基骨科 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
- 6. 彰基骨科 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
- 8. 彰基骨科 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)
- 9. 彰基骨科 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
- 10. 彰基骨科 Implants Selection Stryker’s Solar Total Elbow Zimmer’s Coonrad-Morrey Total Elbow
- 11. 彰基骨科 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
- 12. 彰基骨科 Assessment • Clinical assessment – Complication – Mayo Elbow Performance Score (MEPS) – Prosthesis survival • Radiographic assessment – Implants position – Loosening
- 13. 彰基骨科 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
- 14. 彰基骨科 Implant Loosening Type 0 A radiolucent line <1mm thick, involves < 50% of the interface Type 1 A radiolucent line is 1 mm thick, involves < 50% of the interface Type 2 A radiolucent line >1mm thick, involves > 50% of the interface Type 3 A radiolucent line >2mm thick, involves 100% of the interface Type 4 Gross loosening
- 15. 彰基骨科 RESULTS
- 16. 彰基骨科 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
- 17. 彰基骨科 Mayo Elbow Performance Score (MEPS)
- 19. 彰基骨科 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
- 21. 彰基骨科 65 Y/O Male Post-OP 49 Mons
- 22. 彰基骨科 78 Y/O Female Post-OP 25 Mons
- 23. 彰基骨科 72 Y/O Male Post-OP 13 Mons
- 24. 彰基骨科 DISCUSSION
- 25. 彰基骨科 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
- 26. 彰基骨科 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
- 27. 彰基骨科 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
- 28. 彰基骨科 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
- 29. 彰基骨科 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
- 30. 彰基骨科 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 survival F/U Years Survival 2 years 96% 5 Years 82% 10~15 Years 65%
- 31. 彰基骨科 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
- 32. 彰基骨科 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
- 33. 彰基骨科 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
- 34. 彰基骨科