Primary vs. secondary total elbow arthroplasty for distal humerus fractures

All patients undergoing TEA were identified by electronically screening our database for cases of linked and unlinked TEA between August 2008 and May 2014. On the basis of patient records and radiographs, the indication for implantation in TEA was retrospectively reviewed. All patients who underwent TEA for an acute trauma with fracture of the distal humerus (primary TEA; Fig. 1) or for failed reconstruction or nonoperative treatment after a distal humerus fracture (secondary TEA; Fig. 2) were included in this study. A minimum follow-up of 6 months was set as the inclusion criterion. Exclusion criteria were previous injury at the fractured elbow, neuromuscular disease, cortisone or other immune-suppressive therapy, and an open fracture of grade II or higher according to the Tscherne and Ostern classification [19]. After excluding one patient because of pre-existing hemiplegia of the affected arm, 35 patients met the inclusion criteria. The patient records were reviewed for demographic and perioperative data. If the initial treatment was not conducted in our department, radiographs and patient records were requested.

All patients received a semiconstrained, cemented total elbow prosthesis (Latitude, Tornier, Bloomington, IN, USA), which was implanted using a modified Campbell approach. The posterior split of the triceps muscle in the midline was extended to the proximal ulna with a radial and ulnar periosteal flap. The ulnar nerve was exposed in all cases. Transposition of the nerve was necessary in four cases after secondary TEA. Postoperatively, all patients were treated according to a standardized protocol. After 2 days of immobilization and radiological assessment, early functional treatment was started to prevent elbow stiffness [20], as even a small loss of motion can substantially reduce the patient’s quality of life [21]. Owing to the extended approach, elbow flexion was limited to 90° for 6 weeks. Weight-bearing was not allowed for the same time.

All patients were invited to a one-time follow-up examination, which included evaluation of range of motion and stability of the elbow, actual pain assessed via the Visual Analog Scale for Pain (VAS), and patient satisfaction (satisfied vs. dissatisfied). To objectify the functional result, the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand Score (DASH) were analyzed. Additionally, complications and revision surgeries were recorded. Complications were categorized as minor (nerve irritation or postoperative hematoma) and major (those that required a revision of the prosthesis). Postoperative radiographs of all patients and further follow-up radiographs, if available, were analyzed.

Perioperative data, functional results (range of motion and MEPS and DASH scores), and postoperative complications were described for each group. Subsequently, these results were statistically compared using the Mann–Whitney U test as a two-way analysis of variance for independent factors. A p value of ≤0.05 was considered statistically significant. Since the study was purely exploratory in design, and only a small group of patients was compared, the p values reported can be interpreted only descriptively. All statistical analyses were performed using SPSS for Mac (IBM SPSS Statistics 22, Chicago, IL, USA).

Of 35 patients who met the inclusion criteria, six died from unrelated causes. After losing six patients to follow-up, 23 patients finally participated in the study (follow-up rate, 79%; mean follow-up, 28 months; range, 6–47 months; mean age, 66 years; range, 41–85 years). Nine of the 23 patients (39%; mean age: 70 years; 8 women) underwent treatment with primary TEA. The remaining 14 patients (61%; mean age: 63 years; 11 women) underwent secondary TEA implantation. Secondary TEA implantation resulted after loss of reduction following double-plate osteosynthesis in four patients, nonunion in two (one after reconstruction and one after nonoperative therapy), nonunion with an additional partial necrosis of the distal humerus in a further three, posttraumatic arthritis after internal fixation in two, and posttraumatic arthritis after nonoperative treatment in three patients. After initial joint-preserving therapy, we observed two peaks regarding the time between trauma and secondary TEA implantation. The mean time between trauma and TEA was 227 ± 226 days (range, 14–760) for failed internal fixation, nonunion, partial necrosis, or posttraumatic elbow arthritis after reconstruction. Patients with arthritis after nonoperative treatment required TEA on average 29 ± 7.8 years (range, 20–35) after trauma. Further baseline information is listed in Table 1.

Regarding primary TEA, two patients were initially treated with an external fixator on the day of trauma. The indication was a damage-control strategy because of critical soft-tissue swelling or a traumatic irritation of the ulnar and radial nerve. While all nine primary TEA implants were performed without removal or replacement of the radial head, the radial head was resected in seven patients with secondary TEA. In addition to the secondary TEA implantation, the initially inserted internal fixation had to be removed in all ten cases during the same surgery. Therefore, the duration of surgery for secondary TEA was significantly longer than for primary TEA (p = 0.007). While patients after primary TEA were hospitalized on average for 18 days, patients with secondary TEA were discharged after 17 days (p = 0.57).

At the time of the final follow-up, three minor complications and one major complication after primary TEA were recorded (Table 2). An 81-year-old woman suffered an infection of the operated elbow with septic loosening of the prosthesis 1 month after implantation, and the prosthesis had to be removed. While treating the infection, the elbow was stabilized with an external fixator. One month later, the infection was dominated and the elbow was arthrodesed in 90° flexion. A rotation of the forearm with supination/pronation of 60/0/90° was still possible. Because of the limited range of motion and persisting moderate pain, the patient was dissatisfied with the result. Objective and subjective scores confirmed the poor outcome (MEPS: 30 points; DASH: 88 points). Since the poor functional result was due to a change in therapy with consecutive loss of extension and flexion in the elbow, this patient was not considered in the comparison of the functional results, but in the complication analysis.

Regarding secondary TEA, there were seven patients with minor and four patients with major complications (Table 2). Two patients required complication-related revision, both due to an aseptic loosening. A 50-year-old woman had to undergo revision 21 months after TEA. The ulnar and humeral component had loosened without any signs of infection. Both components were replaced. A 56-year-old woman initially suffered an aseptic loosening of the ulnar component with replacement of the same after 10 months. After another 10 months, the ulnar and humeral components had loosened and both were replaced. Two patients suffered a periprosthetic fracture after a renewed trauma of the elbow. Both were stabilized with additional locked plating.

Four patients with primary TEA had a follow-up radiograph within a mean of 5.8 ± 5.9 months (range, 1–13). Three patients showed a proper integration of the wedged ventral bone graft without any signs of TEA loosening. Even the patient with the postoperative infection did not show definite signs of loosening, although the humeral and ulnar component were loose intraoperatively. After secondary TEA, one postoperative radiograph showed cement passed up to neck of the proximal humerus. Seven patients had a follow-up radiograph within a mean of 16 ± 14 months (range, 3–47). Five patients showed a proper integration of the wedged ventral bone graft without any signs of TEA loosening. In one patient, signs of humeral and ulnar loosening were seen after 20 months. Another patient showed radiological signs of loosening of the ulnar component after 10 months. After another 9 months after revision with replacement of the ulnar component, again signs of humeral and ulnar loosening were seen. An infection was excluded intraoperatively in both patients.

Comparing the clinical outcome measures between primary and secondary TEA, the mean extension/flexion arcs after primary and secondary TEA were 111° and 96°, respectively (p = 0.14). The MEPS (94 vs. 70 points, p = 0.051) and DASH score (26 vs. 48 points, p = 0.007) showed better results for primary TEA than for secondary TEA. In the primary group, one out of nine patients complained about moderate or severe pain. For the secondary group, five out of 14 patients reported moderate or severe pain (Table 3).

No significant differences in the clinical and functional results were found upon comparing secondary TEA after operative and nonoperative treatment. The extension–flexion arc was 95° vs. 98°, MEPS was 78 vs. 80 points, and the DASH score was 48 vs. 49 points, respectively.

The limitations of our study include the retrospective design and small number of patients, which is comparable to previous studies but might have underpowered the study. Although a radiological evaluation was performed, the follow-up was shorter than the clinical follow-up and radiographs were only available for 11 of 23 patients (47%). Furthermore, a mean follow-up of only 28 months is not sufficient for presenting long-term results and complications after TEA.