Total Elbow Arthroplasty for the Treatment of Distal Humerus Nonunions

  • Davide Aliani
  • Francesco Pogliacomi


Distal humerus fractures develop into nonunions in up to 20% of cases. The clinical pattern is characterized by pain, instability and loss of upper extremity function. The treatment is challenging and is influenced by the presence of residual degenerated articular surfaces, poor bone quality, joint contracture, dystrophic soft tissues and implants placed previously as well as small bone fragments.

In young demanding patients, osteosynthesis revision, with bone autograft or allograft in cases of bone loss, and take down of joint contractures are the first choice of treatment. When this procedure is not possible, salvage techniques such as interposition arthroplasty are valid alternatives. In selected older low-demand patients, where fixation is not possible, total elbow arthroplasty is a good option of treatment. Preoperative assessment of these patients must include exclusion of underlying infection which, if present, would require a different therapeutic approach. Amongst the variety of implant types available, linked implants are most frequently utilized because capsular and ligamentous insufficiency is frequently associated with nonunions.

The surgical technique is difficult, with a steep learning curve. Post-operative rehabilitation and lifetime restriction in terms of use and lifting are important for satisfying outcomes and long-lasting survival of the implants.

Outcomes reported in the literature are satisfying, both in terms of pain relief and in recovery of function, although a considerable rate of complications and implant revision has been reported.


Elbow Arthroplasty Older patients Nonunion Distal humerus 



Authors want to thank Dr Silvio Tocco for language support. Authors also want to thank Roberto Rotini, MD, and Maurizio Corradi, MD, for the teaching regarding surgery of the upper limb.


  1. 1.
    Brinker MR, O’Connor DP. The incidence of fractures and dislocations referred for orthopaedic services in a capitated population. J Bone Joint Surg Am. 2004;86:290–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am. 2011;93(7):686–700.CrossRefPubMedGoogle Scholar
  3. 3.
    Robinson CM, Hill RM, Jacobs N, Dall G, Court-Brown CM. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma. 2003;17(1):38–47.CrossRefPubMedGoogle Scholar
  4. 4.
    Kinik H, Atalar H, Mergen E. Management of distal humerus fractures in adults. Arch Orthop Trauma Surg. 1999;119(7–8):467–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Smith GC, Hughes JS. Unreconstructable acute distal humeral fractures and their sequelae treated with distal humeral hemiarthroplasty: a two-year to eleven-year follow-up. J Should Elb Surg. 2013;22(12):1710–23.CrossRefGoogle Scholar
  6. 6.
    Min W, Ding BC, Tejwani NC. Staged versus acute definitive management of open distal fractures. J Trauma. 2011;71(4):944–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Min W, Ding BC, Tejwani NC. Comparative functional outcome of AO/OTA type C distal humerus fractures: open injuries do worse than closed fractures. J Trauma Acute Care Surg. 2012;72(2):E27–32.CrossRefPubMedGoogle Scholar
  8. 8.
    Allende C, Allende BT. Post-traumatic distal humerus non-union. Int Orthop. 2009;33(5):1289–94.CrossRefPubMedGoogle Scholar
  9. 9.
    Claessen FM, Braun Y, Peters RM, Kolovich GP, Ring D. Plate and screw fixation of bicolumnar distal humerus fractures: factors associated with loosening or breakage of implants or nonunion. J Hand Surg Am. 2015;40(10):2045–51.CrossRefPubMedGoogle Scholar
  10. 10.
    Haralsson S. The intra-osseous vasculature of the distal end of the humerus with special reference to capitulum; preliminary communication. Acta Orthop Scand. 1957;27:81–93.Google Scholar
  11. 11.
    Brouwer KM, Jupiter JB, Ring D. Nonunion of operatively treated capitellum and throclear fractures. J Hand Surg Am. 2011;36(5):804–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Mitsunaga MM, Bryan RS, Linscheid RL. Condylar nonunions of the elbow. J Trauma. 1982;22:787–91.CrossRefPubMedGoogle Scholar
  13. 13.
    El-Maghraby TA, Moustafa HM, Pauwels EK. Nuclear medicine methods for evaluation of skeletal infection among other diagnostic modalities. Q J Nucl Med Mol Imaging. 2006;50:167–92.PubMedGoogle Scholar
  14. 14.
    Stucken C, Olszewski DC, Creevy WR, Murakami AM, Tornetta P III. Preoperative diagnosis of infection in patients with nonunions. J Bone Joint Surg Am. 2013;95(15):1409–12.Google Scholar
  15. 15.
    Ahmad SS, Shaker A, Saffarini M, Chen F, Hirschmann MT, Kohl S. Accuracy of diagnostic tests for prosthetic joint infection: a systematic review. Knee Surg Traumatol Arthrosc. 2016;24(10):3064–74.CrossRefGoogle Scholar
  16. 16.
    Yang F, Yang Z, Feng J, Zhang L, Ma D, Yang J. Three phase bone scintigraphy with (99m)Tc-MDP and serological indices in detecting infection after internal fixation in malunion or nonunion traumatic fractures. Hell J Nucl Med. 2016;19(2):130–4.PubMedGoogle Scholar
  17. 17.
    Ballani NS, Al-Huda FA, Khan HA, Al-Mohannadi S, Mahmood H, Al-Enezi F. The value of quantitative 99m 99m uptake of Tc-MDP and Tc-HMPAO white blood cells in detecting osteomyelitis in violated peripheral bones. J Nucl Med Technol. 2007;35:91–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Wenter V, Albert NL, Brendel M, Fendler WP, Cyran CC, Bartenstein P, Friederichs J, Müller JP, Militz M, Hacker M, Hungerer S. [18F]FDG PET accurately differentiates infected and non-infected non-unions after fracture fixation. Eur J Nucl Med Mol Imaging. 2017;44(3):432–40.CrossRefPubMedGoogle Scholar
  19. 19.
    Sanchez-Sotelo J. Nonunion and malunion of distal humerus fractures. In: Morrey BF, Sanchez-Sotelo J, editors. The elbow and its disorders. 4th ed. Philadelphia: Saunders Elsevier; 2009. p. 349–58.CrossRefGoogle Scholar
  20. 20.
    Cil A, Veillette CJH, Sanchez-Sotelo J, Morrey BF. Linked elbow replacement: a salvage procedure for the distal humerus non-union. J Bone Joint Surg Am. 2008;90:1939–50.CrossRefPubMedGoogle Scholar
  21. 21.
    Helfet DL, Kloen P, Anand N, Rosen HS. Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. J Bone Joint Surg Am. 2003;85:33–40.CrossRefPubMedGoogle Scholar
  22. 22.
    Jupiter JB. The management of nonunion and malunion of the distal humerus – a 30-year experience. J Orthop Trauma. 2008;22:742–50.CrossRefPubMedGoogle Scholar
  23. 23.
    Dawson J, Kiner D, Gardner W 2nd, Swafford R, Nowotarski PJ. The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications. J Orthop Trauma. 2014;28(10):584–90.CrossRefPubMedGoogle Scholar
  24. 24.
    Ismail HD, Phedy P, Kholinne E, Djaja YP, Kusnadi Y, Merlina M, Yulisa ND. Mesenchymal stem cell implantation in atrophic nonunion of the long bones: a translational study. Bone Joint Res. 2016;5(7):287–93.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Morrey BF. Post-traumatic contracture of the elbow. Operative treatment including distraction arthroplasty. J Bone Joint Surg Am. 1990;72:601–18.CrossRefPubMedGoogle Scholar
  26. 26.
    Hausman MR, Birnbaum PS. Interposition elbow arthroplasty. Tech Hand Up Extrem Surg. 2004;8:181.CrossRefPubMedGoogle Scholar
  27. 27.
    Larson N, Morrey BF. Interposition arthroplasty as a salvage procedure of the elbow using an Achilles tendon allograft. J Bone Joint Surg Am. 2008;90(12):2714–23.CrossRefPubMedGoogle Scholar
  28. 28.
    Chauhan A, Palmer BA, Baratz ME. Arthroscopically assisted elbow interposition arthroplasty without hinged external fixator: surgical technique and patient outcomes. J Should Elb Surg. 2015;24(6):947–54.CrossRefGoogle Scholar
  29. 29.
    Triplet JJ, Kurowicki J, Momoh E, Law TY, Niedzielak T, Levy JC. Trends in total elbow arthroplasty in the Medicare population: a nationwide study of records from 2005 to 2012. J Should Elb Surg. 2016;25(11):1848–53.CrossRefGoogle Scholar
  30. 30.
    Jenkins PJ, Watts AC, Norwood T, Duckworth AD, Rymaszewski LA, McEachan JE. Total elbow replacement: outcome of 1146 arthroplasties from the Scottish Arthroplasty Project. Acta Orthop. 2013;84:119–23.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Gay DM, Lyman S, Do H, Hotchkiss RN, Marx RG, Daluiski A. Indications and reoperation rates for total elbow arthroplasty: an analysis of trends in New York State. J Bone Jont Surg Am. 2012;94:110–7.CrossRefGoogle Scholar
  32. 32.
    Sanchez-Sotelo J. Total elbow arthroplasty. Open Orthop J. 2011;5:115–23.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Platschke HC, Thrillemann TM, Brorson S, Olsen BS. Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008. J Should Elb Surg. 2014;23:829–36.CrossRefGoogle Scholar
  34. 34.
    Inagaki K. Current concepts of elbow-joint disorders and their treatment. J Orthop Sci. 2013;18:1–7.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    McKee MD, Veillette CJ, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I. A multicenter, prospective, randomized, controlled trial of open reduction – internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Should Elb Surg. 2009;18(1):3–12.CrossRefGoogle Scholar
  36. 36.
    Frankle MA, Herscovici D Jr, DiPasqaule TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total arthroplasty in the treatment of intraarticular distal humerus fractures in women older than 65. J Orthop Trauma. 2003;17:473–80.CrossRefPubMedGoogle Scholar
  37. 37.
    Ackerman G, Jupiter JB. Non-union of fractures of the distal end of the humerus. J Bone Joint Surg Am. 1988;70(1):75–83.Google Scholar
  38. 38.
    Morrey BF, Brian RS, Dobyns JH, Linscheid RL. Total elbow arthroplasty. A five year experience in patients who have rheumatoid arthritis. J Bone Joint Surg. 1998;80A:1327–35.Google Scholar
  39. 39.
    Sanchez-Sotelo J, Ramsey ML. Total elbow arthroplasty for distal humerus nonunion and dysfunctional instability. In: Morrey BF, Sanchez-Sotelo J, editors. The elbow and its disorders. 4th ed. Philadelphia: Saunders Elsevier; 2009. p. 835–42.CrossRefGoogle Scholar
  40. 40.
    Lowe LW, Miller AJ, Allum RL, Higginson DW. The development of an unconstrained elbow arthroplasty. J Bone Joint Surg. 1984;66B:243–7.CrossRefGoogle Scholar
  41. 41.
    Hastings H II, Theng CS. Total elbow replacement for distal humerus fractures and traumatic deformity: results and complications of semiconstrained implants and design rationale for the Discovery Elbow System. Am J Orthop (Belle Mead NJ). 2003;32(9 Suppl):20–8.Google Scholar
  42. 42.
    Giannicola G, Scacchi M, Polimanti D, Cinotti G. Discovery elbow system: 2- to 5-year results in distal humerus fractures and posttraumatic conditions: a prospective study on 24 patients. Journal of Hand Surgery. 39(9):1746–56.Google Scholar
  43. 43.
    Lingenfelter EJ, Adams RA, Morrey B. Management of the radial head and linked total elbow arthroplasty. J Should Elb Surg. 2011;20:625–30.CrossRefGoogle Scholar
  44. 44.
    Gramstad GD, King GJ, O’Driscoll SW, Yamaguchi K. Elbow arthroplasty using a convertible implant. Tech Hand Up Extrem Surg. 2005;9:153–63.CrossRefPubMedGoogle Scholar
  45. 45.
    Wagener ML, de Vos MJ, Hannink G, van der Pluijm M, Verdonschot N, Eygendaal D. Mid-term clinical results of a modern convertible total elbow arthroplasty. Bone Joint J. 2015;97-B(5):681–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Brinkman JM, de Vos MJ, Eygendaal D. Failure mechanisms in uncemented Kudo type 5 elbow prosthesis in patients with rheumatoid arthritis: 7 of 49 ulnar components revised because of loosening after 2–10 years. Acta Orthop. 2007;78(2):263–70.Google Scholar
  47. 47.
    van der Heide HJ, de Vos MJ, Brinkman JM, Eygendaal D, van den Hoogen FH, de Waal Malefijt MC. Survivorship of the KUDO total elbow prosthesis – comparative study of cemented and uncemented ulnar components: 89 cases followed for an average of 6 years. Acta Orthop. 2007;78(2):258–62.Google Scholar
  48. 48.
    Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188–92.Google Scholar
  49. 49.
    Morrey BF, Adams RA. Semiconstrained elbow replacement for distal humeral non-union. J Bone Joint Surg Br. 1995;77:67–72.CrossRefPubMedGoogle Scholar
  50. 50.
    Bain GI, Mehta JA, Lim YW. Surgical approaches for total elbow arthroplasty. In: Yamaguchi K, King GJW, editors. Advanced reconstruction elbow. Rosemont: American Academy of Orthopaedic Surgeons; 2007. p. 207–18.Google Scholar
  51. 51.
    Figgie MP, Inglis AE, Mow CS, Figgie HE 3rd. Salvage of non-union supraconylar fracture of the humerus by total elbow arthroplasty. J Bone Joint Surg Am. 1989;71:1058–65.CrossRefPubMedGoogle Scholar
  52. 52.
    Pogliacomi F, Aliani D, Cavaciocchi M, Corradi M, Ceccarelli F, Rotini R. Total elbow arthroplasty in distal humeral nonunion: clinical and radiographic evaluation after a minimum follow-up of three years. J Should Elb Surg. 2015;24:1998–2007.CrossRefGoogle Scholar
  53. 53.
    Kho JY, Adams BR, O’Rourke H. Outcome of semi-constrained total elbow arthroplasty in posttraumatic conditions with analysis of bushing wear on stress radiographs. Iowa Orthop J. 2015;35:124–9.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Sanchez-Sotelo J, Sperling JW, Morrey BF. Ninety-day mortality after total elbow arthroplasty. J Bone Joint Surg Am. 2007;89:1449–51.PubMedGoogle Scholar
  55. 55.
    Sanchez-Sotelo J, Morrey BF. Linked elbow replacement: a salvage procedure for distal humeral non-union. Surgical technique. J Bone Joint Surg Am. 2009;(91 Suppl 2):200–12.Google Scholar
  56. 56.
    Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63:872–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Brinker MR, O’Connor DP, Crouch CC, Melhoff TL, Bennet JB. Ilizarov treatment of infected nonunions of the distal humerus after failure of internal fixation: an outcome study. J Orthop Trauma. 2007;21(3):178–84.CrossRefPubMedGoogle Scholar
  58. 58.
    Sala F, Catagni M, Pili D, Capitani P. Elbow arthrodesis for post-traumatic sequelae: surgical tactics using the Ilizarov frame. J Should Elb Surg. 2015;24:1757–63.CrossRefGoogle Scholar
  59. 59.
    Gruber JS, Hageman M, Neuhaus V, Mugdal CS, Jupiter JB, Ring D. Patient activation and disability in upper extremity illness. J Hand Surg Am. 2014;39:1378–83.CrossRefPubMedGoogle Scholar
  60. 60.
    Nagy SM III, Szabo RM, Sharkey NA. Unilateral elbow arthrodesis: the preferred position. J South Orthop Assoc. 1999;8:80–5.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Davide Aliani
    • 1
  • Francesco Pogliacomi
    • 1
  1. 1.Orthopedic Clinic, Department of Medicine and SurgeryUniversity Hospital of ParmaParmaItaly

Personalised recommendations