OTA 2008 Posters

Scientific Poster #117 Upper Extremity OTA-2008

Is Primary Total Elbow Arthroplasty Safe for the Treatment of Open Intraarticular Distal Humerus Fractures

Bethany Gallagher, MD (n); William M. Ricci, MD (a,b-AO, Synthes; a,b,c,e-Smith + Nephew;
a,b,e-Wright Medical Technology, Inc.; e-OrthoVita);
Washington University School of Medicine, St. Louis, Missouri, USA

Purpose: Total elbow arthroplasty (TEA) has become a viable treatment alternative for elderly patients with a distal humerus fracture. These elderly patients often have very minute soft-tissue coverage around the elbow, “paper-thin” skin, and not infrequently present with low-grade open fractures. In these situations, theoretically, TEA has an increased risk of wound and deep infectious complications. This study evaluated the results of a protocol of serial irrigation and débridement (I & D) followed by primary TEA for the treatment of open intraarticular distal humerus fractures.

Methods: Seven elderly patients (2 male, age 72 years [range, 63-86]) with open (2 grade I, 5 grade 2) distal humerus fractures (OTA 13C) were treated between 2001 and 2007 with a standard staged protocol that included TEA (Coonrad-Morrey, Zimmer). The protocol included emergent operative I&D upon presentation followed by repeat I&D and TEA at approximately 48 hours after presentation. Antibiotics were administered upon presentation and continued until 48 hours after TEA. Elbows were splinted for 1 to 2 weeks to facilitate wound healing, then physical therapy for range of motion (ROM) and strengthening was initiated. Baseline (preinjury) functional outcome scores (Disabilities of the Arm, Shoulder and Hand [DASH]) were obtained during the initial hospitalization and again at the 6- and 12-month follow-up visits. Elbow ROM measurements were obtained at each follow-up visit.

Results: Patients were evaluated with routine postoperative follow-up for an average of 7.9 months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture and one olecranon fracture. The olecranon fracture occurred after a secondary fall, was minimally displaced, and was successfully treated nonoperatively, while the contracture required formal operative capsular release. The average ROM at most recent postoperative evaluation averaged 15° short of full extension (range, –5° to 30°) to 121° flexion (range, 100°-130°). DASH outcome scores averaged 25 at preinjury baseline and 48 at the most recent follow-up visits.

Conclusions: Arthroplasty has been used commonly for the treatment of fractures of the femoral neck and proximal humerus for decades. Fortunately, open fractures of the hip and proximal humerus are rare, yielding exceedingly little evidence for the safety of performing an arthroplasty in the setting of open fracture. TEA, over the past decade, has become a mainstream option for the treatment of distal humerus fractures. Such fractures are not uncommonly open, especially in the elderly. Aside from the open nature of the fracture, TEA may be the best surgical option for these patients. However, there may be hesitation in using arthroplasty in an open fracture setting due to potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.