ORIF or elbow arthroplasty for distal humeral fractures: The choice is patient-dependent

KOHALA COAST, Hawaii — New treatment options for open reduction and internal fixation and total elbow arthroplasty are increasing the ways surgeons can treat distal humeral fractures.

“This is an exciting topic because there are many new treatment options,” William N. Levine, MD, said at Orthopedics Today Hawaii 2009. “It is an ever-challenging topic to consider.”

Levine said these difficult-to-treat fractures are classified as being a one- or two-column fracture, either high or low on the distal humerus.

“It is often in the very low, shear fractures in the elderly, osteoporotic patient where you are going to start to consider elbow arthroplasty. That is where internal fixation has such a poor track record,” he said. Factors to consider when deciding between open reduction and internal fixation (ORIF) or total elbow arthroplasty are patient age, hand dominance, the mechanism of injury, patient activity level and lifestyle.

“Other issues are their ulnar nerve status, skin quality and any associated injuries that should be documented,” said Levine, who served as chair of the Sports Medicine Track at the meeting.

For single-column fractures, the goal is to restore the articular surface. For two column fractures, surgeons can use contoured recon plates.

“The new contoured plates come in many sizes and shapes to meet your needs, and locking plates can fit your needs as well,” he said. “These are a nice addition to our armamentarium for managing these difficult fractures.”

In many cases, the surgeon has to weigh the patient factors with the benefits and drawbacks of each procedure.

“Internal fixation is anatomic, and you do not have postoperative restrictions once you get healing,” Levine said. “The cons are that we worry about stiffness, hardware problems, ulnar nerve difficulties, and malunion and nonunion.”

The benefits of total elbow arthroplasty are increased range of motion and better outcomes, which have been docmented in studies. The cons are the lifetime functional limitations, concerns about loosening and bushing wear. Noted limitations include a permanent weight lifting and weight-bearing restriction of 5 lbs.

“Arthroplasty is an option for patients older than 65 years; that is in question, but that is the age that has been used in most of the series, [as well as] severe comminution and osteoporotic bone,” he said.

“If you accept the limitations of the total elbow, you can achieve some profound positive results for your patients,” Levine added.

McKee showed in a recent publication that all the parameters in a study of ORIF and total elbow arthroplasty indicated that patients were better off with the arthroplasty.

“In those patients in whom ORIF is not amenable, a total elbow is clearly superior,” Levine said. ?In some patients in whom you think ORIF is appropriate, you should be prepared to convert to a total elbow if you think the ORIF is going to fail, because a later conversion from ORIF to a total elbow has inferior outcomes compared to primary arthroplasties.”

Reference:

Levine WN. Distal humeral fractures: ORIF vs. arthroplasty. Presented at Orthopedics Today Hawaii 2009. Jan. 11-14, 2009. Kohala Coast, Hawaii.