Outcomes of distal humerus fractures in patients above 65 years of age treated by plate fixation.

INTRODUCTION: Distal humerus fractures in elderly patients are often complex fractures that are difficult to treat. The goal of this study was to report on the results of a multicentre series of internal fixation of AO type A, B and C distal humerus fractures in elderly patients and to identify the pros and cons of various fixation constructs. PATIENTS AND METHODS: Two studies were performed. One was a prospective multicentre study with 53 patients and the other was a retrospective multicentre study with 289 patients, all above 65 years of age and with a recent distal humerus fracture. Patients were evaluated based on clinical criteria (history, health condition, joint range of motion, Mayo Elbow Performance Score) and radiological criteria (fracture type, union of fracture, presence of malunion, hardware condition). RESULTS: Based on the MEPS, the clinical and functional results were relatively satisfactory: average of 92 points for type A, 82 points for type B and 88 points for type C. In both series, type B fractures were the most difficult to treat and had less good clinical, functional and radiological outcomes. Most of the complications occurred with type C fractures; these consisted mainly of nerve injuries and fixation failure/non-union. DISCUSSION: Although these fractures are difficult to treat and have an appreciable number of complications, the functional recovery was fairly satisfactory. One of the most challenging aspects of surgical treatment is the existence of osteoporosis in these patients. This must be carefully analysed to determine if an indication exists for total elbow arthroplasty. LEVEL OF EVIDENCE: IV.

Minimally invasive fixation of type B and C interprosthetic femoral fractures.

INTRODUCTION: Interprosthetic femoral fractures are rare and raise unresolved treatment issues such as the length of the fixation material that best prevents secondary fractures. Awareness of the advantages of locked-plate fixation via a minimally invasive approach remains limited, despite the potential of this method for improving success rates. HYPOTHESIS: Femur-spanning (from the trochanters to the condyles) locked-plate fixation via a minimally invasive approach provides high healing rates with no secondary fractures. MATERIALS AND METHODS: From January 2004 to May 2011, all eight patients seen for interprosthetic fractures were treated with minimally invasive locked-plate fixation. Mean time since hip arthroplasty was 47.5 months and mean time since knee arthroplasty was 72.6 months. There were 12 standard primary prostheses and four revision prostheses; 11 prostheses were cemented and a single prosthesis showed femoral loosening. Classification about the hip prostheses was Vancouver B in one patient and Vancouver C in seven patients; about the knee prosthesis, the fracture was SoFCOT B in three patients and SOFCOT C in five patients, and a single fracture was SoFCOT D. Minimally invasive locking-plate fixation was performed in all eight patients, with installation on a traction table in seven patients. RESULTS: Healing was obtained in all eight patients, after a mean of 14 weeks (range, 12-16 weeks). One patient had malalignment with more than 5° of varus. There were no general or infectious complications. One patient died, 32 months after surgery. The mean Parker-Palmer mobility score decreased from 6.2 pre-operatively to 2.5 at last follow-up. Early construct failure after 3 weeks in one patient required surgical revision. There was no change in implant fixation at last follow-up. No secondary fractures were recorded. DISCUSSION: In patients with type B or C interprosthetic fractures, femur-spanning fixation not only avoids complications related to altered bone stock and presence of prosthetic material, but also decreases the risk of secondary fractures by eliminating stress riser zones. The minimally invasive option enhances healing by preserving the fracture haematoma. Thus, healing was obtained consistently in our patients, with no secondary fractures, although the construct failed in one patient. LEVEL OF EVIDENCE: Level IV.

Distal femur fractures. Surgical techniques and a review of the literature.

Fractures of the distal femur are rare and severe. The estimated frequency is 0.4% with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak for men in their 30s and a peak for elderly women; however, at present it is found predominantly in women and in the elderly with more than 50% of patients who are over 65. The most common mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing. The anatomy of the distal femur explains the three major types of fracture. Because of the anatomy of the distal femur, only surgical treatment is indicated to stabilize the fracture. A non-surgical treatment is a rare option. The aim of this report was to provide an update on the existing surgical solutions for the management of these fractures and describe details of the surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical data published in the literature are reported to compare different surgical options.

Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years.

INTRODUCTION: Fractures of the distal humerus are often complex and therefore challenging to treat. In elderly patients with decreased bone strength due to osteoporosis, strong fixation is crucial to allow resuming early motion that guarantees a good functional outcome as well as minimising mechanical complications. Locked implants meet these requirements. Here, we report outcomes in a uniform series of patients older than 65 years with distal humerus fractures managed with LCP DHP(®) (Synthès) fixation. Our objective was to evaluate the efficacy and limitations of this technique. HYPOTHESIS: LCP DHP provides strong fixation of osteoporotic bone and leads to good clinical and radiological outcomes. MATERIALS AND METHODS: We retrospectively studied 46 consecutive patients (2004-2010) with a mean age of 80 years including 15 with extra-articular and 31 with articular distal humerus fractures. At presentation, 11 complications were noted in nine patients (compound fractures and trauma-related nerve injuries). The transolecranon approach was used in 31 patients. Mean duration of immobilisation was 2.7 weeks in 33 patients. RESULTS: Forty-three patients were re-evaluated after a mean follow-up of 25 months (range, 10-64 months); two patients died and one was lost to follow-up. Flexion was 127° and loss of extension was 23°, producing an average range of motion of 104°. Functional recovery was highly satisfactory with a Mayo Clinic Performance Score of 87 (70-100) and 95% of good and very good results. Postoperative complications consisted of infection (n=3), metaphyseal non-union (n=2), ulnar nerve injury (n=6), transient radial nerve palsy (n=1), and peri-articular ossification (n=4). Compound fracture and worse AO fracture type were associated with worse functional outcomes. DISCUSSION: Despite the high complication rate, functional recovery was similar to that reported in previous case series, including after arthroplasty. Furthermore, the rate of mechanical complications was lower. Thus, our working hypothesis was confirmed. LEVEL OF EVIDENCE: Level IV retrospective non-comparative study.

Complex fractures of the distal humerus in the elderly: is primary total elbow arthroplasty a valid treatment alternative? A series of 20 cases.

INTRODUCTION: Distal humerus fractures are fairly rare. But as our population ages, these fractures become more complex and the choice of treatment more delicate. Poor bone quality results in many technical problems and the fixation hardware stability remains at risk. The goal of this study was to evaluate the functional recovery and morbidity of complex distal humerus fractures in elderly patients when treated with elbow prosthesis. HYPOTHESIS: Good functional recovery can be achieved with a total joint replacement. PATIENTS AND METHODS: This series consisted of 20 patients (18 women and two men) having an average age of 80years (range 65-93, median 80). Based on the AO classification, there were two Type A2 fractures, two Type B fractures, 15 Type C fractures and one fracture that could not be classified because of previous rheumatoid disease history at this elbow. Two fractures were open. In two cases, the olecranon was also fractured. Treatment consisted of the implantation of a Coonrad-Morrey, hinge-type total elbow prosthesis (Zimmer(®), Warsaw, IN, USA). The Mayo Clinic surgical approach was used 17 times and the transolecranon approach was used three times. Primary arthroplasty was performed in 19 cases and the surgery was performed after six weeks of conservative treatment (diagnostic delay) in one case. Unrestricted motion was allowed after surgery, but a maximum of 0.5kg could be carried during the first 3months; this was subsequently increased to 2.5kg. RESULTS: Fifteen of the 20 patients were available for reevaluation with an average follow-up of 3.6years (range 1.7-5.5, median 3.4). Four patients had died and one was lost to follow-up. The average range of motion was 97° (range 60-130°), comprising an average flexion of 130° (range 110-140°) and average loss of extension of 33° (range 0-80°). Pronation and supination were normal. The average Mayo Elbow Performance Score (MEPS) was 83 (range 60-100, median 80). X-rays revealed seven cases of radiolucent lines, with two being progressive. There was no visible wear of the polyethylene bushings at the hinge. Six patients had moderate periarticular heterotopic ossification. The two cases of olecranon osteotomy and one case of olecranon fracture had healed. There were no surgical site infections but two cases of ulnar compression, one of which required neurolysis. There was one case of humeral component loosening after 6years, but the implant was not changed. DISCUSSION: The clinical range of motion results were comparable to published data. The functional scores were slightly lower, mainly because of the pain factor. The initial results were encouraging and consistent with published data as long as the indications were well-chosen. Based on this retrospective study, total elbow arthroplasty can be a valid alternative in the surgeon's treatment armamentarium for complex distal humerus fractures in elderly patients who have moderate functional demands. Our results support our hypothesis, since we found good functional recovery without associated morbidity. LEVEL OF EVIDENCE: Level IV retrospective study without comparator.