Revision total elbow arthroplasty for aseptic and septic nonunion of distal humerus fractures: a case series.

BACKGROUND

Distal humerus fractures can be difficult to manage in older patients with poor bone quality and those with risk factors for failure of open reduction internal fixation. When nonunion occurs, there are limited repeat fixation options and conversion to total elbow arthroplasty (TEA) can be considered. The objective of this descriptive, retrospective case series is to compare the outcomes of TEA for aseptic vs. septic nonunion of distal humerus fractures.

METHODS

Seven cases were identified by 2 orthopedic surgeons that specialize in TEA. The inclusion criteria were as follows: (a) adult patients (≥18 years of age), (b) underwent TEA after distal humerus open reduction internal fixation complicated by aseptic or septic nonunion, (c) had clinical follow-up data ≥1 year after TEA, and (d) completed patient-reported outcome surveys ≥1 year after TEA. Charts were reviewed to extract the relevant data, and outcomes between aseptic and septic nonunion groups compared using range of motion, grip strength, x-rays, and patient-reported outcome measures.

RESULTS

After TEA, all average patient-reported outcome scores were better in the aseptic nonunion group compared to the septic nonunion group, indicating a more favorable recovery trajectory (Disabilities of the Arm, Shoulder and Hand score: 39.5 ± 9.3 vs. 58.4 ± 21.9; visual analog pain scale: 3.1 ± 2.1 vs. 4.4 ± 2.4). In addition, range of motion was better in the aseptic nonunion group compared to the septic nonunion group for most parameters (flexion: 127.3 ± 17.3 vs. 106.7 ± 18.8; supination: 73.3 ± 20.5 vs. 58.3 ± 28.4; pronation: 80.5 ± 9.9 vs. 69.0 ± 21.5), except elbow extension (27.5 ± 43.7 vs. -2.3 ± 8.7). Two patients in the aseptic nonunion group developed post-operative complications (ulnar neuropathy and periprosthetic fracture with osteolysis) compared to one patient in the septic nonunion group (periprosthetic infection).

CONCLUSION

TEA is a viable treatment option for patients with aseptic and septic nonunion of distal humerus fractures, although patient outcomes in septic nonunion tend to be worse. Conversion to TEA is best done in 2 stages to ensure infection is identified and treated appropriately.