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Journal of Orthopaedics, Trauma and Rehabilitation 24 (2018) 60e65

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Journal of Orthopaedics, Trauma and Rehabilitation

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Case Report

Total Elbow Arthroplasty Gives Good Functional Outcome in DistalHumerus Fracture with Pre-existing Chronic Elbow Dislocation全肘關節置換對患有長期肘關節脫位的遠端肱骨骨折提供良好的功能結果

Chan Hing Shing*, Ho Sheung TungDepartment of Orthopaedics and Traumatology, Caritas Medical Centre, Kowloon, Hong Kong

a r t i c l e i n f o

Article history:Received 13 December 2016Received in revised form22 March 2017Accepted 11 April 2017

Keywords:chronic elbow dislocationdistal humerus fractureelderlytotal elbow arthroplasty

* Corresponding author. E-mail: henrychs@gmail.co

http://dx.doi.org/10.1016/j.jotr.2017.04.0022210-4917/Copyright© 2017, HongKongOrthopaedic AssociatCC BY-NC-ND license (http://creativecommons.org/licenses/by

a b s t r a c t

Distal humerus fracture with concomitant chronic elbow dislocation is difficult to manage by openreduction and internal fixation, while total elbow arthroplasty (TEA) is an effective treatment for acutefracture or failed internal fixation of distal humerus fracture in elderly patients with osteoporosis. Wepresent a case of an 86-year-old woman who suffered from acute distal humerus fracture in the presenceof chronic elbow deformity from elbow dislocation since childhood at the age of 10 years. This wastreated with TEA using Coonrad/Morrey prosthesis with long stem and long flange humerus componentsand cerclage wiring of humeral condyle. Postoperatively, elbow mobilization was started early within ahinged elbow brace. There was no operative complication. At the last follow-up 22 months after surgery,there was no pain and good elbowmotion (20e130� flexioneextension arc, full supination and pronationto neutral) was obtained. The Mayo Elbow Performance Score was 100. There was incorporation of thebone graft at the anterior flange with no radiographic loosening of the prosthesis. This case shows thatTEA can yield a gratifying clinical result and efficiently resolves two problems with one solution.

中 文 摘 要

遠端肱骨骨折並伴有長期肘關節脫位是難以開放復位及內固定處理，而全肘關節置換是一個用於老年及骨質

疏鬆症患者的急性遠端肱骨骨折或骨折內固定失敗的有效治療。我們報告一位從10歲 起患有長期肘關節脫位

及畸形，86歲時發生急性遠端肱骨骨折。使用長桿和長凸緣肱骨組件的Coonrad/Morrey人工假體和利用金

屬線環紥肱骨髁進行肘關節置換。術後使用鉸鏈肘護托展開早期肘關節活動。手術後沒有併發症。術後22個月的最後隨訪中，沒有疼痛，肘活動良好 (20�-130� 屈曲伸展弧度、完全前旋、後旋至中立位置) 。梅奧肘關

節功能評分為100分。放射線造影見到凸緣處移植骨的結合而假體沒有鬆動。這個案例表明肘關節置換可提

供令人滿意的臨床效果，並且可以用一個方案很好地解決两個問題。

Introduction

Distal humerus fracture in the elderly is a surgical challengewhen there is gross displacement, metaphyseal comminution, orvery low fracture of the trochlea or capitellum. Even with openreduction using the gold standard internal fixation by dual columnplate osteosynthesis, complications like hardware failure,nonunion, malunion, and elbow stiffness remain common in theelderly. Total elbow arthroplasty (TEA) is increasingly andcommonly used for the primary treatment of selected distal hu-merus fractures in elderly patients. TEA is also indicated when

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ion and theHongKong College ofOrthop-nc-nd/4.0/).

there is pathological fracture, degenerative elbow disease, post-traumatic arthritis, and nonunion of the distal humerus.1 Chronicelbow dislocation may be another pre-existing condition of theelbow that favours TEA for distal humerus fracture. To the best ofour knowledge, this is the first report regarding the use of TEA totreat an elderly patient who presentedwith distal humerus fracturewith chronic elbow dislocation.

Case Report

In 2002, an elderly woman presented to our orthopaedic clinicfor her elbow deformity. She was known to have long-standingright elbow deformity after an injury to her elbow since the ageof 10 years. She attended our clinic since 2002. Plain X-ray (Figure 1)

aedic Surgeons. Publishedby Elsevier (Singapore) Pte Ltd. This is an open access article under the

Figure 1. X-ray image taken during follow-up in 2008.

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showed dislocation of the right ulnohumeral joint, nonunion oflateral condyle of humerus, dome shaped trochlea and slenderdistal humerus shaft, and degenerative changes at the radio-capitellar joint. Although she had on and off right elbow pain, thiscould be relieved with analgesics. She enjoyed good elbow functionwith independent activities of living. She could use chopsticks well,and her right hand could reach the occiput and mouth. Her elbowrangewas 0e130� with full supination and pronation butwith grossinstability. There were no symptoms or signs of ulnar neuropathy.In view of satisfactory upper limb function, she was managedconservatively with analgesics for her intermittent elbow pain.

In October 2014, the 86-year-old lady had a slip and fall accidentand was admitted for right elbow injury. Physical examinationshowed that there was right elbow swelling and diffuse tenderness.The elbow range was limited. No neurovascular deficit was noted.Plain X-ray (Figure 2) showed a fracture at the slender portion ofthe distal humerus with the pre-existing chronic elbow dislocationand an ill-defined lateral condyle of humerus. Plaster of Paris slabwas given with gentle reduction for immobilization (Figure 3). Theelbow anatomy was studied using three-dimensional computedtomography (Figure 4). It showed a fracture at the slender pencil-shaped sclerotic segment at the diaphyseal-metaphyseal region.

Figure 2. Postinjur

The lateral condyle was almost absent. A full range of Coonrad-Morrey prosthesis from Zimmer (Warsaw, IN), including extra-small ulnar components and long humerus prosthesis with longanterior flange was arranged.

TEAwas performed 2 weeks after the injury to allow subsidenceof the elbow swelling while waiting for the availability of theprosthesis. The patient was put in a supine position with theinvolved upper limb brought over a towel roll across the chest. Theelbow was approached from posterior using a posterior straightmidline incision with a bilaterotricepital “triceps-on” approach.Instead of resection of distal fragments of the humerus anddetachment of collateral ligaments, flexorepronator and exten-soresupinator to medial and lateral condyles, the condyles werepreserved for later fixation to preserve the integrity of the collateralligaments. The olecranonwas eroded with the loss of olecranon tip.The radial head was enlarged. The distal humerus shaft was thin-nedwith the obliteration of themarrow canal. The thinned scleroticdistal part of the humerus was excised and retained as bone graft.The humerus medullary cavity was reamed and could accept asmall humerus prosthesis. The flat spot of the proximal ulna wasused to guide the orientation of the ulnar component in the sig-moid notch and proximal ulna. A long flange humerus prosthesiswas used to bridge the distal humerus bone loss to allow the cap-ture of the bone graft in between the anterior humerus cortex andanterior flange. A 6-inch small humerus component with longflange and a small 3-inch ulnar component were inserted for trialreduction. The proper depth of insertion of humerus prosthesis wasdetermined by the muscle tension with the elbow in 90� flexionunder axial load. Full elbow flexion and extension was obtained ontable. Antibiotics-loaded cement (Palacos with gentamicin(Zimmer, Warsaw, IN)) was used. The remnants of medial andlateral condyles were wired back to the distal shaft of the humerus,and the bone graft was packed under the long anterior flange.Partial excision of the radial head was done to eliminate impinge-ment during rotation. Subcutaneous anterior transposition of theulnar nerve was done. A long arm plaster of Paris slab with theelbow at 50� flexionwas applied in the operating theatre (Figure 5).Prophylaxis against heterotopic ossification was not given in thispatient. Indomethacin was contraindicated in this patient as shehad a history of duodenal bleeding in 2005.

y X-ray image.

Figure 3. Postslab X-ray image.

Figure 4. Three-dimensional computed tomogrpahy reconstruction.

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After removal of the drain and after the swelling of elbow sub-sided with high elevation, a hinged elbow brace was applied toallow free range of motion. The wound healed well, and there wasno ulnar nerve symptoms. There was no infection or heterotopicossification. She was pain-free with good elbow flexioneextensionof 10e100� at 3-month follow-up. She had a femoral neck fracturein July 2016 (9 months after TEA) with dynamic hip screw fixationdone. She recovered well and could walk outdoors with a stick. Thelast follow-up at 22 months (after TEA) showed satisfactory elbowmotion (flexioneextension arc of 20e130�, full supination andpronation to neutral) with no pain. X-ray showed incorporation ofthe bone graft at the anterior flange with no radiographic looseningof the prosthesis (Figure 6). The Mayo Elbow Performance Scorewas 100 (pain 45, motion 20, stability 10, and daily function 25).

Discussion

This is a challenging clinical problem to solve as it combinesacute fracture on top of the chronic elbow instability withnonunion fracture dislocation. Treatment options include conser-vative treatment, open reduction internal fixation, TEA, and elbowarthrodesis. The authors believe that this is the first reportregarding the use of TEA for the treatment of this rare presentation.

Conservative treatment is reserved for very frail elderly patientswith contraindication to anaesthesia. For this healthy patient withgood pre-injury function, there is a high risk of nonunion, pain, andstiff elbow after conservative treatment. Stable fixation of thefracture is difficult and reduction of the chronic elbow dislocation isimpossible due to the gross joint incongruity related to aberrant

Figure 5. X-ray image taken im

development of the elbow articulating bones after dislocation atthe age of 10 years. Elbowarthrodesis gives a poor function not onlyfrom the loss of elbow motion but also from the altered mechanicsof wrist flexors and extensors due to excessive bone shortening toachieve fusion. Also, solid fusion is technically difficulty to obtainwith a low fusion rate.

Our goal is to achieve a stable, pain-free, and good functionalelbow with one-stage surgery without significant additional risksor future complications to the patient. TEA is the most logicaltreatment as it solves both the problem of acute fracture andchronic elbow instability. In the only prospective randomisedstudy of 40 patients, TEA had a significantly better Mayo ElbowPerformance Score (96 vs. 73), better flexioneextension arc (107�

vs. 95�), with less complications and a lower revision rate (12% vs.27%) than open reduction and internal fixation.2 Primary TEA hasbeen increasingly considered as an alternative treatment forselected elderly patients with comminuted distal humerus frac-tures. Its use is limited by life-long activity restriction and theconcern of long-term survival. Furthermore, complications afterTEA may be more severe and more difficult to treat than thoseafter internal fixation.

Computed tomography scan was done to delineate the anatomyand determine the necessity of the long humerus prosthesis, withthe long anterior flange as the prosthesis having to be seated moreproximally because the thinned segment of the distal humeruscould not accommodate the humeral stem. Preoperative templat-ing has not been found useful in the prediction of the size ofimplant. A local study showed that the size of implant could bepredicted accurately by the planning template in only 24% (4/17) of

mediately postoperatively.

Figure 6. X-ray image taken during follow-up at 15 months postoperatively.

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elbows, and extra-small ulnar prostheses might be used in Chineserheumatoid patients.3 Even with digital templating, the predictivevalue was only 53% for both implants.4

A “triceps-on” approach was used for TEA in this patient andother patients with distal humerus fracture by the senior author. Bysparing the triceps muscle and its insertion, extensor weakness anddisruption is prevented as the entire elbow extensor mechanism isleft in continuity. Early free flexion and extension exercises can bestarted. A comparative study of 83 primary TEAs of 73 patients forinflammatory arthropathy showed that the “triceps-on” approachgave a lower complication rate in the triceps (8.1% vs. 32.6%) and ahigher rate of adequate cementation (92% vs. 70%) than the “tri-ceps-off” approach, while there was no difference in the final rangeof motion.5

Linked semiconstrained prosthesis was used in distal humerusfractures to ensure joint stability in the presence of bone loss andligamentous insufficiency after resection of fracture fragments indistal humerus fracture. The anterior flange and bone graft in thefloppy hinge prosthesis is designed to resist the torsional andposterior directed forces associated with loosening of the con-strained prosthesis. The floppy hinge prosthesis allows 5e10� ofvarus/valgus which reduces the constraint and lessens the risk ofwear, loosening, and mechanical failure. With the Coonrad-Morreysystem, the commonly used 4-inch humerus prosthesis is insertedto the proximal aspect of olecranon fossa of humerus after excisionof the comminuted fracture fragments of distal humerus. This al-lows the bone graft to be captured by the intact anterior humeralcortex and the anterior flange. Additional bone loss, like in thispatient, required a 6-inch long humerus prosthesis with longanterior flange to bypass bone defect and to engage diaphysis. Suchnoncustom, long flange prosthesis can address up to a total of 8 cmof distal humeral bone loss.6 The proper depth of insertion of thehumerus prosthesis is guided by themuscle tension of intact bicepsand triceps with the elbow in 90� flexion on axial loading. Full

extension should be obtained on trial reduction; an extensiondeficit may be corrected by deeper insertion of the humerusprosthesis in TEA for distal humerus fracture as tight ligament oranterior capsular complex does not exist as in TEA for rheumatoidarthritis. There should be no contact between the anterior flangeand a prominent coronoid process or the cement on full flexion.Otherwise, anterior impingement prosthesis loosening caused byulnar prosthesis pistoning on flexion may occur.

The risk of wound complication and infection is higher in TEAthan in total joint arthroplasty in lower limbs. Deep infection be-tween 2% and 10% was reported after TEA. Prophylactic systematicantibiotics are routine and most surgeons use antibiotics-loadedcement in TEA. Antibiotics cement was used in 86% of cases in aseries of 87 TEAs done for acute distal humerus fractures in patientsaged > 65 years.7 The use of antibiotics-loaded cement in TEA isindirectly supported by its use in lower limb total joint arthroplastyand reverse total shoulder arthroplasty. Antibiotics-loaded cementwas found effective in the prevention of deep infection after pri-mary reverse total shoulder arthroplasty in a retrospective cohortstudy of 501 consecutive shoulders at 37-month follow-up. Thedifference in deep infection rate (0% vs. 3.0%, p < 0.001) wassignificant.8

Transient or even permanent sensory and motor ulnar nervecomplications may occur in 3e5% of TEAs.9 Anterior ulnar trans-position was done in 47% of 87 TEAs done for acute distal humerusfractures in patients aged > 65 years.7 A recent study advocates insitu release rather than routine transposition of ulnar nerve.10 In acentre which routinely performed an in situ release of ulnar nervewithout transposition, ulnar nerve symptoms occurred in 5% (4 of78 patients); of the four patients with ulnar nerve symptoms, twohad resolution of symptoms, whereas the remaining two requiredsubsequent transposition for continued symptoms. Ulnar nervetransposition should be considered when there is abnormaltracking or increased tension of the nerve after insertion of the

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prosthesis, particularly in those with marked limitation of preop-erative elbow flexion less than 100�.

Conclusion

Acute humerus fracture with concomitant chronic elbow frac-ture dislocation associated with significant elbow instability isdifficult to manage by open reduction and internal fixation. TEAgives a gratifying clinical result as shown in the present patient andresolves two difficult problems with one solution.

Conflicts of interest

The authors declare no conflicts of interest.

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