The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 1 suppl 1

Surgical Techniques | March 01, 2005

Distal Humeral Fractures Treated with Noncustom Total Elbow Replacement

S. Kamineni, FRCS(Orth)¹; Bernard F. Morrey, MD²

¹ Department of Orthopaedics and Biomechanics, Imperial College London and Hillingdon Hospital NHS Trust, South Kensington Campus, London SW7 2AZ, United Kingdom
² Department of Orthopedic Surgery, 128 Guggenheim Building, Mayo Clinic, Mayo Building, 200 First Street S.W., Rochester, MN 55905

View Disclosures and Other Information

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. One or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commerical entity (royalty for implant). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The line drawings in this article are the work of Joanne Haderer Müller of Haderer & Müller (biomedart@haderermuller.com).

Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 940-947, May 2004

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Mar 01;87(1 suppl 1):41-50. doi: 10.2106/JBJS.D.02871

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Abstract

BACKGROUND:

The purpose of this study was to review the cases of patients with a distal humeral fracture that was treated with a noncustom total elbow arthroplasty. We hypothesized that, on the basis of the functional and clinical outcome, total elbow replacement is a reliable option for the treatment of elderly patients with a severe, comminuted fracture of the distal part of the humerus.

METHODS:

We retrospectively reviewed forty-nine acute distal humeral fractures in forty-eight patients who were treated with total elbow arthroplasty as the primary option. The average age of the patients was sixty-seven years. Forty-three fractures were followed for at least two years. According to the AO classification, five fractures were type A, five were type B, and thirty-three were type C. The average age of the forty-three patients was sixty-nine years and the average duration of follow-up was seven years. Fourteen patients died during the review period. Postoperative clinical function was assessed with use of the Mayo elbow performance score, and anteroposterior and lateral radiographs made at follow-up examinations were reviewed.

RESULTS:

At the latest follow-up examination, the average flexion arc was 24° (range, 0° to 75°) to 131° (range, 100° to 150°) and the Mayo elbow performance score averaged 93 of a possible 100 points. Heterotopic ossification was present to some extent in seven elbows, with radiographic abutment noted in two. Thirty-two (65%) of the forty-nine elbows had neither a complication nor any further surgery from the time of the index arthroplasty to the most recent follow-up evaluation. Fourteen elbows (29%) had a single complication, and most of them did not require further surgery. Ten additional procedures, including five revision arthroplasties, were required in nine elbows; five were related to soft tissue and five were related to the implant or bone.

CONCLUSIONS:

Complex distal humeral fractures should be assessed primarily for the reliability with which they can be reconstructed with osteosynthesis. When osteosynthesis is not considered to be feasible, especially in patients who are physiologically older and place lower demands on the joint, total elbow arthroplasty can be considered. This retrospective review supports a recommendation for total elbow arthroplasty for the treatment of an acute distal humeral fracture when strict inclusion criteria are observed.

Figures in this Article

INTRODUCTION

INTRODUCTION | SURGICAL TECHNIQUE | AFTERCARE | References

A growing body of orthopaedic literature has demonstrated the value of joint replacement for certain types of distal humeral fractures^1-4. The improvement seen with regard to function, a lower rate of complications, and decreased morbidity is well documented^5-7. Surgical technique is critically important if the patient is to realize the full benefits of the procedure. Technical aspects of the surgery, with emphasis on those that have been less well recognized with regard to their effect on outcome and the ability to avoid complications, are described.

SURGICAL TECHNIQUE

INTRODUCTION | SURGICAL TECHNIQUE | AFTERCARE | References

The patient is placed supine on the operating table with the involved arm brought over a bolster and across the chest (Fig. 1). A pneumatic tourniquet is employed. A straight 18-cm posterior skin incision is centered just medial to the tip of the olecranon. The ulnar nerve is identified and is dissected distally. It is then released from the medial epicondyle and is exposed to its first motor branch (Fig. 2). The flexor-pronator attachment to the medial epicondylar fragment is sharply released. All medial fragments are then removed by releasing all soft-tissue attachments, including the capsule (Fig. 3). The skin flap is elevated laterally, and the lateral epicondyle is identified. The extensor muscle origins are released from the lateral fragments, which allows removal of the remaining lateral comminuted fracture fragments (Fig. 4). At this juncture, all comminuted fragments have been removed, and the distal part of the humerus is then "delivered" to the lateral aspect of the triceps (Fig. 5).

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FIG. 1: The patient is placed supine on the operating table. The arm is brought over a bolster, and a straight posterior skin incision is made with the apex just medial to the tip of the olecranon. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 2: After the ulnar nerve has been protected and released to the first motor branch, the medial fracture fragments are released by sharp excision. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 3: After the soft tissue has been released from the fracture fragments medially, those fragments amenable to removal are removed from the medial aspect of the joint. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 4: Sharp dissection releases the extensor and capsular muscular attachments to the lateral fragments, and these are excised. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 5: The humerus is "delivered" to the lateral aspect of the margin of the triceps. The canal is readily prepared with intramedullary rasps. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

CRITICAL CONCEPTSINDICATIONS:Highly comminuted distal humeral fractures that are not amenable to open reduction and internal fixation in patients over the age of sixty-five years or in any patient with pre-existing arthrosis of the elbow are considered indications for joint replacementClosed or Gustilo type-I open fractures are amenable to acute joint replacementCONTRAINDICATIONS:The major contraindication is infection. Open Gustilo type-II or III fractures are treated in a staged fashion by first débriding the wound and then inserting the total elbow prosthesis at a later date. When the wound is débrided, all of the osseous elements are excised to lessen the likelihood of ectopic bone formation. The triceps muscle is typically not detached from the ulna unless leaving it attached results in a very difficult exposure. This eliminates problems of triceps insufficiency.PITFALLS:Delay for a custom stem to be designed. As a result of the flexibility of this system, no delay was necessary for any of the fractures in our original series³. The device is normally inserted to the proximal aspect of the olecranon fossa of the humerus. If the fracture extends more proximally, a larger flange is used to bridge the additional bone loss. Furthermore, shortening of up to 7 cm can be accepted, with minimal resulting weakness. Hence, up to 8 cm of the distal part of the humerus may be removed and still be managed with an off-the-shelf implant (Figs. 15-A, 15-B, and 15-C).Ulnar neuropathy. The ulnar nerve is always identified and mobilized, and this has resulted in virtually no ulnar nerve symptoms after the surgery in our patients.Canal preparation. In order to leave the triceps attached to the ulna and still obtain adequate exposure for preparation of the canal, it is important to peel away the medial corner of the triceps attachment to the olecranon.Inadequate exposure. Preparation of the ulna requires clear access to the base of the coronoid and clear recognition of the orientation of the ulnar shaft referable to the base of the coronoid. This lessens the likelihood of violating the ulnar cortex with the rasp.Inadequate cement technique. It is important to use a cement-delivery system thatprovides a complete and adequate bone-cement interface for both components⁹. Hence, we use an injection system with a nozzle that fits into the ulna as well as into the humerus.Soft-tissue impingement. Care should be taken not to insert the humeral component too proximally as this will result in soft-tissue impingement during flexion that will place tension or shear stress on the bone-cement interface of the ulnar component during flexion (Fig. 6).Grip weakness. Repair of the flexor and extensor common tendons to the medial and lateral aspects of the triceps has resulted in virtually no alteration in wrist or grip strength (Fig. 14).AUTHOR UPDATE:There have been no changes in surgical techniques since the time of publication of the original paper.

CRITICAL CONCEPTS

INDICATIONS:

Highly comminuted distal humeral fractures that are not amenable to open reduction and internal fixation in patients over the age of sixty-five years or in any patient with pre-existing arthrosis of the elbow are considered indications for joint replacementClosed or Gustilo type-I open fractures are amenable to acute joint replacement

Closed or Gustilo type-I open fractures are amenable to acute joint replacement

CONTRAINDICATIONS:

The major contraindication is infection. Open Gustilo type-II or III fractures are treated in a staged fashion by first débriding the wound and then inserting the total elbow prosthesis at a later date. When the wound is débrided, all of the osseous elements are excised to lessen the likelihood of ectopic bone formation. The triceps muscle is typically not detached from the ulna unless leaving it attached results in a very difficult exposure. This eliminates problems of triceps insufficiency.

PITFALLS:

Delay for a custom stem to be designed. As a result of the flexibility of this system, no delay was necessary for any of the fractures in our original series³. The device is normally inserted to the proximal aspect of the olecranon fossa of the humerus. If the fracture extends more proximally, a larger flange is used to bridge the additional bone loss. Furthermore, shortening of up to 7 cm can be accepted, with minimal resulting weakness. Hence, up to 8 cm of the distal part of the humerus may be removed and still be managed with an off-the-shelf implant (Figs. 15-A, 15-B, and 15-C).Ulnar neuropathy. The ulnar nerve is always identified and mobilized, and this has resulted in virtually no ulnar nerve symptoms after the surgery in our patients.Canal preparation. In order to leave the triceps attached to the ulna and still obtain adequate exposure for preparation of the canal, it is important to peel away the medial corner of the triceps attachment to the olecranon.Inadequate exposure. Preparation of the ulna requires clear access to the base of the coronoid and clear recognition of the orientation of the ulnar shaft referable to the base of the coronoid. This lessens the likelihood of violating the ulnar cortex with the rasp.Inadequate cement technique. It is important to use a cement-delivery system thatprovides a complete and adequate bone-cement interface for both components⁹. Hence, we use an injection system with a nozzle that fits into the ulna as well as into the humerus.Soft-tissue impingement. Care should be taken not to insert the humeral component too proximally as this will result in soft-tissue impingement during flexion that will place tension or shear stress on the bone-cement interface of the ulnar component during flexion (Fig. 6).Grip weakness. Repair of the flexor and extensor common tendons to the medial and lateral aspects of the triceps has resulted in virtually no alteration in wrist or grip strength (Fig. 14).

Ulnar neuropathy. The ulnar nerve is always identified and mobilized, and this has resulted in virtually no ulnar nerve symptoms after the surgery in our patients.

Canal preparation. In order to leave the triceps attached to the ulna and still obtain adequate exposure for preparation of the canal, it is important to peel away the medial corner of the triceps attachment to the olecranon.

Inadequate exposure. Preparation of the ulna requires clear access to the base of the coronoid and clear recognition of the orientation of the ulnar shaft referable to the base of the coronoid. This lessens the likelihood of violating the ulnar cortex with the rasp.

Inadequate cement technique. It is important to use a cement-delivery system thatprovides a complete and adequate bone-cement interface for both components⁹. Hence, we use an injection system with a nozzle that fits into the ulna as well as into the humerus.

Soft-tissue impingement. Care should be taken not to insert the humeral component too proximally as this will result in soft-tissue impingement during flexion that will place tension or shear stress on the bone-cement interface of the ulnar component during flexion (Fig. 6).

Grip weakness. Repair of the flexor and extensor common tendons to the medial and lateral aspects of the triceps has resulted in virtually no alteration in wrist or grip strength (Fig. 14).

AUTHOR UPDATE:

There have been no changes in surgical techniques since the time of publication of the original paper.

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FIG. 15:: Fig. 15-A The implant sits in the nominal location with the absence of all of the distal humeral articulation, approximately 3 cm of bone loss. Use of the long flange allows engagement of the native bone even in the presence of an additional 3 cm of bone loss by allowing the implant not to be fully seated across the deficient 3 cm of distal humeral bone. A total of 8 cm of distal humeral bone loss can be addressed with a noncustom long-flange version of the implant by allowing shortening of 2 cm. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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Fig. 15-B: Radiograph of a seventy-two-year-old patient who had an AO type-C3 fracture with intact bone, measuring approximately 1 cm, proximal to the olecranon fossa. Fig. 15-C At five years, the patient had a well-seated implant with no evidence of loosening.

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FIG. 6: In patients with substantial distal humeral bone loss, placement of the elbow in 90° of flexion with application of an axial load allows estimation of the proper depth of insertion of the humeral implant. d = distance short of full insertion. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 14: The flexor and extensor musculotendinous origins are repaired to the medial and lateral aspects of the triceps, respectively. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

The humeral preparation is straightforward. Typically, no cuts are necessary because of the fracture, so the canal is simply prepared by rasping it to the appropriate size according to the size of the implant (Fig. 5). If the proximal part of the humerus has residual bone that interferes with the placement of the implant, a trial prosthesis is inserted and the distal part of the humerus is trimmed as necessary. It is unlikely that a patient with a normal shoulder will subsequently need a shoulder prosthesis, so a 15-cm stem is employed in such a patient. If there is pre-existing shoulder pathology and a proximal humeral implant may be considered in the future, the 10-cm stem is inserted since it allows at least 4 cm of separation between the tips of the two stems. Normally, the depth of insertion of the humeral component is defined by the flange of the implant resting on the roof of the coronoid fossa. If the fracture is proximal to this landmark, the trial implant is inserted and an axial load is placed on the forearm to estimate the proper depth of insertion of the humeral component (Fig. 6).

The ulna is most appropriately exposed from the medial aspect of the triceps. The ulnar nerve is identified and is protected anteriorly. Twenty to 25% of the medial aspect of the triceps tendon attachment, to the tip of the olecranon, is then released, allowing the medial margin of the triceps to be reflected (Fig. 7). Flexing and rotating the forearm allows exposure of the olecranon and coronoid. The tip of the olecranon is removed. A high-speed burr is then used to enter the proximal part of the ulnar canal at the base of the coronoid (Fig. 8). Care is taken to orient the rasp properly down the canal to avoid penetration of the cortex. Proper orientation of the ulnar component is assessed by confirming that the rasp handle is perpendicular to the flat plane of the proximal part of the ulna⁸ (Fig. 9). The ulna is then prepared by serial reaming and rasping of the canal. A trial reduction of the ulnar component is carried out and, importantly, the maneuver by which the elbow can be reduced is tested.

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FIG. 7: Release of the medial portion of the attachment of the triceps allows the forearm to be flexed and rotated, permitting exposure of the olecranon and coronoid. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 8: After the tip of the olecranon has been removed, the medullary canal is entered at the base of the coronoid with a high-speed burr. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 9: Proper axial orientation of the ulna is ensured by placing the rasp handle perpendicular to the flat portion of the proximal part of the ulna. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

After the canals have been lavaged and dried, 2 g of vancomycin is mixed with 80 g of cement, which is vacuum-mixed and placed in an injection gun. The cement is first inserted down the humeral canal with an injector system⁹. A medullary restrictor is inserted at the end of the injector tube and is deployed down the humerus with the injector gun (Fig. 10). The cement is then injected down the proximal part of the ulna. The ulnar component is inserted to a depth midway between the olecranon and the coronoid (Fig. 11). A 3-mm-thick sliver of bone is harvested from the excised trochlear fracture fragments at the time of exposure. This bone graft is now placed behind the anterior aspect of the distal part of the humerus, and the humeral component is inserted down the humerus and is tapped into place (Fig. 12). The joint is then reduced and is articulated with a "pin-within-the-pin" articulation (Fig. 13). Since there is no distal part of the humerus, the ulna is readily articulated with the humerus. At this junction, the typical arc of motion should be full extension to 150° of flexion. The ulnar nerve is brought anteriorly and is secured in a soft-tissue envelope with a 2-0 Vicryl suture. The extensors are sewn to the lateral margin of the triceps, and the flexors are sewn to the medial margin of the triceps (Fig. 14). A routine closure is carried out. Use of a drain is optional. The elbow is brought into extension, and an anterior splint is applied.

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FIG. 10: A cement restrictor is deployed with the injector system. The nozzle is cut to the length of the planned implant. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 11: The ulnar component is inserted to a depth such that the articulation rests approximately midway between the tips of the olecranon and the coronoid. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 12: The bone graft is placed anterior to the anterior humeral cortex and is captured by the flange as the humeral component is driven into place. (Redrawn and modified with permission of the Mayo Foundation for Medical Education and Research. All rights reserved.)

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FIG. 13: The implant is articulated by a pin-within-the-pin mechanism. Both implants are inserted to the appropriate depth prior to the coupling of the device.

AFTERCARE

INTRODUCTION | SURGICAL TECHNIQUE | AFTERCARE | References

The arm is elevated for twenty-four hours, after which free motion is allowed. The patient is discharged from the hospital on the second or third postoperative day. Typically, physical therapy is not employed. The patient is allowed to use the arm as tolerated.

References

INTRODUCTION | SURGICAL TECHNIQUE | AFTERCARE | References

Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am.1997;79: 826-32.79826 1997 [PubMed]

Gambirasio R, Riand N, Stern R, Hoffmeyer P. Total elbow replacement for complex fractures of the distal humerus. An option for the elderly patient. J Bone Joint Surg Br.2001;83: 974-8.83974 2001 [CrossRef]

Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am.2004;86: 940-7.86940 2004

Morrey BF. Total elbow arthroplasty for traumatic conditions. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: WB Saunders; 2000. 2000

Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone Joint Surg Am.1998;80: 1327-35.801327 1998 [PubMed]

Hargreaves D, Emery R. Total elbow replacement in the treatment of rheumatoid disease. Clin Orthop.1999;366: 61-71.36661 1999 [CrossRef]

Ray PS, Kakarlapudi K, Rajsekhar C, Bhamra MS. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. Injury.2000;31: 687-92.31687 2000 [PubMed][CrossRef]

Duggal N, Dunning CE, Johnson JA, King GJ. The flat spot of the proximal ulna: a useful anatomic landmark in total elbow arthroplasty. J Shoulder Elbow Surg.2004;13: 206-7.13206 2004 [PubMed][CrossRef]

Faber KJ, Cordy ME, Milne AD, Chess DG, King GJ, Johnson JA. Advanced cement technique improves fixation in elbow arthroplasty. Clin Orthop.1997;334: 150-6.334150 1997 [PubMed]

Topics

fracture ; education, medical ; elbow region ; fractures, comminuted ; humerus ; ulna ; olecranon ; elbow replacement arthroplasty ; triceps brachii ; humeral fractures, distal

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S. Kamineni, Bernard F. Morrey; Distal Humeral Fractures Treated with Noncustom Total Elbow Replacement. The Journal of Bone & Joint Surgery. 2005 Mar;87(1_suppl_1):41-50.

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