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ORIGINAL ARTICLE
Year : 2016  |  Volume : 16  |  Issue : 1  |  Page : 53-56

Total elbow arthroplasty in grossly comminuted intercondylar fracture humerus in elderly population: Results and analysis


1 Department of Orthopaedic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of Paediatrics, R. G. KAR Medical College, Kolkata, West Bengal, India

Date of Web Publication7-Jan-2016

Correspondence Address:
Gopal Ghosh
Department of Orthopaedic Surgery, 12 C Garfa 4th Lane, Jadavpur, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-6308.165113

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  Abstract 

Purpose: The purpose was to evaluate short to medium term outcome of total elbow arthroplasty (TEA) in the grossly comminuted intercondylar fracture humerus in the elderly population. Patients and Methods: It is a prospective study. Data were collected from the patients attended with intercondylar fracture humerus in a tertiary care hospital from June 2009 to July 2014. Thirty-five patients attended with intercondylar fracture humerus in these periods. We had done 13 cases of primary TEA for comminuted intercondylar fracture of the distal humerus. Grossly comminuted fracture, osteoporotic bone and age more than 65 years were considered for TEA. All the patients were evaluated at 6 weeks after the operation, and then at 3, 6, 9, 12, 18, and 24 months. We used the Mayo score to assess the functional results. Results: Mean age of the patients was 70.84 years (range: 66–78 years). Of thirteen patients, nine patients were female, and four patients were male. The mean interval between the time of the accident and operation was 4.07 days (range: 2–10 days). The mean hospital stay was 12 days (range: 8–16 days). The mean follow-up was for 19.46 months (range: 18–31 months). All the elbows were stable. The mean flexion was to 115.38° (90°–140°). The mean arc of rotational movement was 161.53° (130°–180°). Eleven patients had no limitation of daily living, and two had some limitation of daily living. Mean Mayo score was 93.84 (range: 85–100). One patient developed osteolysis around the stem of the prosthesis in the humerus in follow-up radiograph, but the clinically patient had no complaint. Three patients had a surgical site infection, and two patients had ulnar nerve paresis but infection controlled after 7–10 days and nerve paresis completely cured after 3–4 months. Conclusion: The primary TEA in a case of grossly comminuted intercondylar fracture humerus in elderly population gives comparable short to medium term results.

  Abstract in Arabic 

الغرض: الغرض تقييم قصيرة المدى المتوسط نتيجة لتقويم مفاصل الكوع المجموع (الشاي) في عظم العضد كسر إينتيركونديلار المسحوقة صارخ في عدد السكان المسنين. المرضى والطرق: دراسة مستقبلية. تم جمع البيانات من أتينديد المرضى مع إينتيركونديلار كسر عظم العضد في مستشفى رعاية الثالثية من يونيو 2009 إلى يوليو عام 2014. خمسة وثلاثون مريضا أتينديد مع إينتيركونديلار كسر عظم العضد في هذه الفترات. وقد فعلنا 13 حالة من الشاي الأولية لكسر عظم العضد القاصي إينتيركونديلار المسحوقة. كسر صارخ المسحوقة والعظام هشاشة العظام والعمر أكثر من 65 عاماً واعتبرت للشاي. وتم تقييم جميع المرضى في 6 أسابيع بعد العملية، ومن ثم في 3، 6، 9 و 12 و 18 و 24 شهرا. قمنا باستخدام نقاط مايو كلينيك لتقييم النتائج الفنية. النتائج: يعني كان عمر المرضى سنة 70.84 (النطاق: سنة 66 - 78). المرضى الثلاثة عشر، تسعة مرضى من الإناث، وأربعة مرضى من الذكور. يعني الفاصل الزمني بين وقت وقوع الحادث وعملية وكان يوما 4.07 (النطاق: 2 - 10 أيام). الإقامة في المستشفى يعني كان 12 يوما (النطاق: أيام 8 - 16). تمت متابعة يعني لأشهر 19.46 (النطاق: الأشهر 18 - 31). وكانت جميع المرفقين مستقرة. وكان الانحناء يعني 115.38° (90 - 140°). وكان قوس متوسط حركة دورانية 161.53° (130 - 180°). أحد عشر مريضا أي تقييد للمعيشة اليومية، واثنتان منهن بعض القيود للمعيشة اليومية. يعني كانت النتيجة مايو كلينيك 93.84 (النطاق: 85 - 100). مريض واحد وضع عظام النهايات حول ساق الاصطناعية في عظم العضد في متابعة الأشعة، ولكن كان المريض سريرياً لا شكوى. كان ثلاثة مرضى عدوى موقع جراحية، واثنين من المرضى كان شلل العصب الزندي ولكن الإصابة التي تسيطر عفر 7 - 10 أيام وشلل العصب شُفي تماما بعد 3-4 أشهر. الاستنتاج: يعطي الشاي الأولية في حالة الكسر إينتيركونديلار المسحوقة صارخ عظم العضد في عدد السكان المسنين قصيرة قابلة للمقارنة إلى نتائج على المدى المتوسط. الكلمات الرئيسية: المسحوقة إينتيركونديلار كسر عظم العضد، عدد السكان المسنين، وتقويم مفاصل الكوع المجموع

Keywords: Comminuted intercondylar fracture humerus, elderly population, total elbow arthroplasty


How to cite this article:
Ghosh G, Roy S. Total elbow arthroplasty in grossly comminuted intercondylar fracture humerus in elderly population: Results and analysis. Saudi J Sports Med 2016;16:53-6

How to cite this URL:
Ghosh G, Roy S. Total elbow arthroplasty in grossly comminuted intercondylar fracture humerus in elderly population: Results and analysis. Saudi J Sports Med [serial online] 2016 [cited 2023 Feb 8];16:53-6. Available from: https://www.sjosm.org/text.asp?2016/16/1/53/165113


  Introduction Top


The fracture of the distal humerus in adults are relatively uncommon comprising approximately 2% of all fractures, and one-third of all humerus fractures.[1] More than 60% of distal humerus fracture in elderly occur from low energy injuries, such as a fall from standing height.[1] Intercondylar fracture of the distal humerus is the most common fracture pattern. The fracture fragments are often displaced by an unopposed muscle pull at the medial and lateral epicondyles and sometimes grossly comminuted due to osteoporosis of the bone in the elderly population. The treatment for intercondylar fracture of the distal humerus depends on the patients' age, bone quality, and the degree of comminution. Surgical treatment options are open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA). Intra-articular fractures require precise anatomical reduction and fixation which will provide rigid stability in order to allow early mobilization.[2],[3] The frequent multifragmentary nature of the fracture, with comminution of the articular surface and the metaphysis makes accurate reduction and fixation very difficult.[4] Osteopenic bone, which is always present to some degree in the elderly population, predisposes to increased comminution and inadequate fixation.[5],[6] TEA may be considered in markedly comminuted fractures and fractures in the osteoporotic bone.[7],[8],[9] There are a few papers available on primary TEA for comminuted intercondylar fracture of the osteopenic distal humerus in the elderly population.[8],[9] In our institution, we have done thirteen cases of primary TEA for comminuted intercondylar fracture of the distal humerus in the elderly population for last 5 years. In the present study, we analysis the short to medium term results and outcome of this operation.


  Patients and Methods Top


It is a prospective study. Data were collected from the Patients attended with intercondylar fracture humerus in a tertiary care hospital from June 2009 to July 2014. Thirty-five patients attended with intercondylar fracture humerus in these periods. We had done 13 cases of primary TEA for comminuted intercondylar fracture of the distal humerus. Grossly comminuted fracture, osteoporotic bone and age more than 65 years were considered for TEA. The mean age of the patients were 70.84 years (range: 66–78 years). Of 13 patients, nine patients were female, and four patients were male. All patients had osteopenia. Five patients sustained this injury due to minor fall, and three patients had a high velocity injury. Twelve patients had fracture pattern AO13C, and one had AO13B. We used baksis sloppy hinge prosthesis for our patients.[10] This prosthesis has 7°–10° varus-valgus laxity with limited rotation at the hinge section. Varus – valgus laxity at the hinge section of sloppy hinge prosthesis allows the forces across the prosthesis to dissipate primarily to the surrounding soft tissues, this protecting the bone cement interface.[11]

Surgical technique

The operation was performed under general anesthesia with the patients supine and a tourniquet applied to the upper arm. A posteromedial incision was made followed by subfacial dissection first medially then laterally. Through medial dissection, the ulnar nerve is isolated and mobilized with flexor carpi ulnaris erased from the proximal ulna. The medial epicondyle, coronoid, olecranon process, and the lower end of the humerus were exposed by subperiosteal dissection and detachment of the soft tissue. Further dissection exposed the posterior surface of lower triceps, the lateral supracondylar ridge, and the lateral epicondyle. Initially, the head of the radius is excised at the level of the annular ligaments and then the distal humerus is sectioned transversely just proximal to the olecranon fossa. A subarticular L-shaped bone resection at the upper end of the ulna preserving the triceps and brachialis. Reaming of the medullary cavity of humerus and ulna were done. The ulnar stem followed by the humeral stem of the prosthesis were fixed with bone cement. The hinge components of the humeral and ulnar stem were assembled with the help of main hinge screw. Before wound closure, full flexion, and extension of the elbow were tested. Any block in extension due to projecting the tip of olecranon process was trimmed off. Tourniquet was deflated at this stage and hemostasis secured; wound closed in layers. Well-padded compression bandage followed by plaster of Paris (POP) back slab applied in the extension of the elbow.

Postoperative care

Dressing change done on 5th postoperative day and POP back slab removed. Elbow was retained in an adjustable splint in maximum flexion and extension alternatively for 6 h. Passive movement of elbow and forearm were started from the 14th postoperative day. The splint was removed 3–5 weeks after the operation. All the patients were evaluated at 6 weeks after the operation, the band then at 3, 6, 9, 12, 18, and 24 months. We used the Mayo score 35 to assess the functional results. At each visit, we recorded the range of movement of the elbow and forearm rotation. The degree of stability of the elbow was noted, and we questioned each patient about pain, the ability to carry out daily activities, and the overall subjective assessment of the outcome. Radiographs of the elbow were also taken at each follow-up visit.


  Results Top


Results are summarized in [Table 1]. [Figure 1] and [Figure 2] shows pre and post operative X-Ray. [Figure 3] shows osteolysis of humerus after total elbow arthroplasty. The mean interval between the time of the accident and operation was 4.07 days (range: 2–10 days). Mean hospital stay was 12 days (range: 8–16 days). The mean follow-up was for 19.46 months (range: 18–31 months). One patient had deep soft tissue infection, and other one had a superficial surgical site infection. After through wound debridement and followed by an intravenous antibiotic application for 14 days deep infection healed. Superficial surgical site infection healed by intravenous antibiotic application for 7 days. One patient had tourniquet palsy which completely recovered after 3 months. Two patients had ulnar nerve palsy which was completely cured 3–4 months after the operation. All the elbows were stable. The mean flexion was to 115.38° (900°–1400°). The mean arc of rotational movement was 161.53° (130°–180°). Eleven patients had no limitation of daily living, and two had some limitation of daily living. Mean Mayo score was 93.84 (range: 85–100). One patient developed osteolysis around the stem of the prosthesis in the humerus in follow-up radiograph, but the clinically patient had no complaint.
Table 1: Results of a follow-up for the 13 patients who had total elbow arthroplasty in grossly comminuted intercondylar fracture humerus

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Figure 1: Preoperative X-ray (intercondylar fracture humerus)

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Figure 2: Postoperative X-ray after total elbow arthroplasty

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Figure 3: Osteolysis of humerus after total elbow arthroplasty

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  Discussion Top


The treatment of grossly comminuted intercondylar fracture humerus in an elderly population with osteoporosis is very difficult. The first option treats the patients conservatively with cast immobilization but disadvantages are inadequate fracture reduction and it needs prolonged immobilization, so this mode of treatment is not popular or appropriate for these patients. However, in elderly patients with a significant comorbid condition, which contraindicates operative management may be treated with cast immobilization. The second option is ORIF. The goal of ORIF are a stable fixation and to restore articular congruity. ORIF in young patients is satisfactory. However, in elderly patients with grossly comminution and osteoporosis reconstruction of articular geometry is very difficult, and these category patients are more prone to the postoperative collapse of fixation. According to some researchers, ORIF in elderly patients with grossly comminution and osteoporosis results were good to excellent. Other authors, however, report less satisfactory results in this elderly population [12],[13],[14] which has led some surgeons to consider TEA to be the primary method of treatment. Morrey et al.[15] reported very good results in a retrospective review of TEA in 20 patients with 21 fractures. Our study shows that primary TEA in grossly comminuted intercondylar fracture humerus in elderly population gives well to excellent results, while a mean follow-up of 19.46 months (8–33 months) may be considered to be a deficiency of our study. Another limitation is that the study was not randomized.


  Conclusion Top


Finally, our study does not emphasize that primary TEA is the treatment of choice in grossly comminuted intercondylar fracture humerus in elderly population but it proves that Primary TEA is an another option, which gives comparable short to medium term results to ORIF.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Egol KA, Koval KJ, Zuckerman JD. Handbook of Fracture. 4th ed. Philadelphia, USA: Lippincott Williams and Wilkins; 2010. p. 214.  Back to cited text no. 1
    
2.
M¨uller M, Allg¨ower M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Germany: Springer; 1991.  Back to cited text no. 2
    
3.
Ring D, Jupiter JB. Complex fractures of the distal humerus and their complications. J Shoulder Elbow Surg 1999;8:85-97.  Back to cited text no. 3
    
4.
Jupiter JB, Neff U, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. J Bone Joint Surg Am 1985;67:226-39.  Back to cited text no. 4
    
5.
John H, Rosso R, Neff U, Bodoky A, Regazzoni P, Harder F. Operative treatment of distal humeral fractures in the elderly. J Bone Joint Surg Br 1994;76:793-6.  Back to cited text no. 5
    
6.
Luppino T, Fiocchi R, Salsi A, Stefanini T. Stable osteosynthesis by the AO method in comminuted intra-articular fractures of the distal humerus. Ital J Orthop Traumatol 1989;15:165-70.  Back to cited text no. 6
    
7.
Behrman MJ, Bigliani LU. Distal humeral replacement after failed continuous passive motion in a T-condylar fracture. J Orthop Trauma 1993;7:87-9.  Back to cited text no. 7
    
8.
Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-32.  Back to cited text no. 8
    
9.
Ray PS, Kakarlapudi K, Rajsekhar C, Bhamra MS. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. Injury 2000;31:687-92.  Back to cited text no. 9
    
10.
Baksi DP. Total replacement of elbow joint. Indian J Orthop 1980;14:129-42.  Back to cited text no. 10
  Medknow Journal  
11.
Baksi DP. Evaluation of physical properties of authors elbow prosthesis with the help of a newly designed elbow joint simulator. Indian J Orthop 1989;23:61-9.  Back to cited text no. 11
    
12.
Korner J, Lill H, Müller LP, Hessmann M, Kopf K, Goldhahn J, et al. Distal humerus fractures in elderly patients: Results after open reduction and internal fixation. Osteoporos Int 2005;16 Suppl 2:S73-9.  Back to cited text no. 12
    
13.
Frankle MA, Herscovici D Jr, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003;17:473-80.  Back to cited text no. 13
    
14.
Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: A comparison of primary surgery and surgery after failed internal fixation or conservative treatment. J Bone Joint Surg Br 2008;90:343-8.  Back to cited text no. 14
    
15.
Morrey BF, An KN, Chao ET. The Elbow and Its Disorders. 2nd ed. Philadelphia: Saunders; 1993. p. 648-64.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


This article has been cited by
1 Total Elbow Arthroplasty from Indian Perspective: A Systematic Review
Vivek Tiwari, Samir Dwidmuthe
Indian Journal of Orthopaedics. 2022;
[Pubmed] | [DOI]



 

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