A Multi-center Prospective Randomized Controlled Trial of Open Reduction-Internal Fixation vs. Total Elbow Arthroplasty for Displaced Intra-articular Distal Humeral Fractures in Elderly Patients

Author(s): McKee M, et al. (Members of the Canadian Orthopaedic Trauma Group)

Source: J Shoulder Elbow Surg 18(1): 3-12, 2009.

Summary:

This is a prospective randomized controlled trial comparing the results of ORIF to total elbow arthroplasty in elderly patients with displaced intra-articular distal humerus fractures.  The entry criteria were men and women over the age of 65 years with displaced comminuted intra-articular fractures of the distal humerus.  Extra-articular or partial articular fractures were excluded.  In addition they excluded patients with diaphyseal extension.  It is of note that they did not include patients with rheumatoid arthritis in contradistinction to previous studies.

A total of 42 patients were enrolled in the study.  Data was collected on 40 of these.  Twenty were randomized to open reduction internal fixation and 20 were randomized to total elbow arthroplasty.  The mean age of these patients was 77 years.  Five of the patients randomized to open reduction internal fixation had to be converted to total elbow arthroplasty intra-operatively because of extensive comminution.   This then resulted in a total of 15 patients treated with ORIF and 25 patients treated with total elbow arthroplasty.

 Re-operation was required after the index procedure in 7 patients, 4 who had open reduction internal fixation and 3 who had total elbow arthroplasty.  The most significant finding was that the MEPS (Mayo Elbow) score was statistically significantly improved in the TEA group, compared with the ORIF group.  There was a trend towards improved motion in the TEA group, but this was not statistically significant.  The DASH scores showed significant improvement in the TEA group compared to the ORIF group early, but not at 1 year follow-up.

The most common complication in both groups was ulnar nerve symptoms.  This was higher in the open reduction internal fixation group (5 patients) compared with the total elbow arthroplasty group (3 patients).  It is of note that radiographic evaluation in the TEA group indicated 1 loose ulnar component at 2 years in 1 patient with a deep infection.

The significance of this study is that it reinforces the need to keep the total elbow arthroplasty as a reasonable alternative in elderly patients.  One note of caution is that the mean age in these patients was 77 years.  In addition, the authors had 1 loose (infected) ulnar component at 2 year follow-up.  These results are consistent with the literature and care should be exercised before entertaining this as an option in the younger, more active elderly patient.