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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
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
彰基骨科
Distal Humeral Fracture -- Complications --
• Stiffness of elbow joint• Post-traumatic arthritis• Ulnar neuropathy• Heteroptic ossification• Nonunion or Malunion
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
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
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
彰基骨科
MATERIALS AND METHODS
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)
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
彰基骨科
Implants Selection Stryker’s Solar Total Elbow
Zimmer’s Coonrad-Morrey Total Elbow
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
彰基骨科
Assessment• Clinical assessment
– Complication– Mayo Elbow Performance Score (MEPS)– Prosthesis survival
• Radiographic assessment– Implants position – Loosening
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
彰基骨科
Implant Loosening
Type 0A radiolucent line <1mm thick, involves < 50% of the interface
Type 1A radiolucent line is 1 mm thick, involves < 50% of the interface
Type 2A radiolucent line >1mm thick, involves > 50% of the interface
Type 3A radiolucent line >2mm thick, involves 100% of the interface
Type 4Gross loosening
彰基骨科
RESULTS
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
彰基骨科
Mayo Elbow Performance Score (MEPS)
彰基骨科
Implant Loosening
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
彰基骨科
CASE PRESENTATION
彰基骨科
65 Y/O Male Post-OP 49 Mons
彰基骨科
78 Y/O Female Post-OP 25 Mons
彰基骨科
72 Y/O Male Post-OP 13 Mons
彰基骨科
DISCUSSION
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
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
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
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
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
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 survivalF/U Years Survival
2 years 96%
5 Years 82%
10~15 Years 65%
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
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
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
彰基骨科
THANK YOU