Review Question - QID 219903

This 86-year-old female sustained a right intra-articular distal humerus fracture following a fall. When considering both surgeries in elderly patients over 65, total elbow arthroplasty (TEA) has been shown to facilitate improved short-term functional outcomes following surgery (Answer 3).

Distal humerus fractures are common injuries that display a continuum of complexity. They can appear as rather innocuous, simple extra-articular fractures, but also as complex, comminuted intra-articular fractures. The most appropriate treatment depends on several factors, namely the fracture type, the mechanism of injury, and the individual's age and health status. With an aging population, more individuals of advanced age and increasing medical complexity are sustaining these fractures, creating a therapeutic conundrum, particularly with complex fractures. The therapeutic milieu in these instances involves three options: nonoperative treatment with casting ("bag of bones"), open reduction internal fixation (ORIF), or TEA. A significant amount of literature has examined the outcomes between ORIF and TEA in the elderly population. In general, range of motion is similar between treatments, but studies suggest TEA recipients have better functional outcomes immediately following surgery. Meanwhile, reoperation rates appear to be similar in the short term; however, mid- to long-term reoperation rates are inconclusive, with some studies suggesting higher reoperation rates in TEA secondary to component loosening and bushing wear.

McKee et al. performed a multicenter, prospective, randomized controlled trial comparing the effectiveness of ORIF (n=15) versus primary TEA (n=25) in elderly patients (> 65 years) sustaining displaced, comminuted intra-articular distal humerus fractures. The authors noted shorter operative times and hospital stays in those undergoing TEA, as well as improved DASH scores at six weeks and six months. However, TEA and ORIF did result in a similar range of motion post-operatively at all time points out to two years, while complication rates were found to be similar. The authors conclude TEA portends better functional outcomes acutely following surgery and support its use in elderly patients sustaining complex intra-articular distal humerus fractures.

Githens et al. conducted a systematic review and meta-analysis of 27 studies (n=563) comparing functional outcomes, radiographic outcomes, and complication rates between ORIF and TEA in patients over 60 sustaining distal humerus fractures. The authors noted similar degrees of range of motion achieved between the two treatments. At the same time, overall complication rates were higher in the TEA group, which were attributed to the increased occurrence of minor complications, namely superficial infection, hematomas, or heterotopic ossification. In contrast, those undergoing ORIF had higher rates of major complications, which was considered anything necessitating a return to the operating theatre, although this difference was not significant. The authors conclude surgeons must consider the unique risks associated with each respective procedure and understand that both procedures provide good functional outcomes.

Figures A and B represent an AP and lateral of the right elbow demonstrating a 'Y Type' intra-articular distal humerus fracture.

Incorrect Answers:
Answer 1: While range of motion is similar between the two therapies, this does not necessarily correlate to similar degrees of function.
Answer 2: While the literature is largely inconclusive regarding the reoperation rates between the two procedures, some studies suggest reoperation rates to be higher in TEA.
Answer 4: Complication rates appear to be more frequent in TEA.
Answer 5: Operation time has been shown to be shorter with TEA.