AO/OTA B and C articular fractures of the distal humerus: What are the boundaries between Total Elbow Arthroplasty and ORIF?

Introduction

Distal humerus fractures represent about 2% of all fractures and approximately 30% of all humerus fractures [1], furthermore, these are relatively common injuries in the elderly population. With the ever-aging population, the incidence of these injuries is on the rise. Currently, there is debate as to whether to treat elderly patients with significantly comminuted intra-articular fractures of the distal humerus with open reduction–internal fixation (ORIF) or total elbow arthroplasty (TEA). Despite improvements in internal fixation techniques, a high percentage of elbows require reintervention after ORIF surgeries for distal humerus fractures. [2]
Generally, osteosynthesis of distal humeral fractures in the elderly has been proven to be one of the technically most difficult operations in orthopedics, especially in the setting of osteoporosis [3].
For many orthopedic surgeons, such fractures represent a challenge scenario due to a lack of familiarity stemming from their infrequent occurrence in the adult demographic [4].
Complications including malunion, nonunion, failure of fixation, ulnar neuropathy, and elbow stiffness plague patients sustaining these injuries, with complication rates up to 35% being reported in the literature [5,6].
The frequency of distal humerus fragility fractures is increasing significantly. The mechanisms of injuries are mainly bimodal, with a clear distinction mostly between young men (high-energy trauma) and older women (osteoporotic fractures) [7].
Regression analysis predicted a 3-fold increase in their incidence by 2030, which is far faster than the anticipated expansion in this second population category [8].
Although osteosynthesis with double-plate fixation is the recommended treatment in adults, the presence of osteoporotic bone, metaphyseal comminution, poor-quality soft tissue, and intolerance for joint immobilization increases the challenge in the elderly. In the presence of osteopenia, internal fixation which is sufficiently stable to allow early mobilization is often difficult [5,9,10].
Although there is substantial evidence of the benefits of ORIF in younger patients, the results have been highly variable in the elderly, with a significant failure/poor outcome rate. Several studies suggest that primary TEA is a reliable treatment for severe intra-articular distal humeral fractures in the elderly [11,12].
In recent years more TEA surgeries are being chosen as the primary treatment in joint fractures of the distal humerus reporting good results in the elderly and osteoporotic patients and showing reduced complications and stiffness when compared to ORIF surgeries [13].
The novelty of our study concerns the benefits of the use of TEA in distal humerus joint fractures of the frail elderly as a valuable treatment option and not reserved only for complex cases not suitable for internal fixation.