Total Elbow Arthroplasty for the Treatment of Distal Humerus Nonunions
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.
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.
KeywordsElbow 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.
- 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
- 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
- 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
- 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
- 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.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
- 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.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
- 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.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.Bryan RS, Morrey BF. Extensive posterior exposure of the elbow. A triceps-sparing approach. Clin Orthop Relat Res. 1982;166:188–92.Google Scholar
- 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
- 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