Eur J Orthop Surg Traumatol (2014) 24:777–782 DOI 10.1007/s00590-013-1358-z
ORIGINAL ARTICLE
Does timing of surgery affect the outcome of open articular distal humerus fractures ˇ arko Dasˇic´ Dragan Radoicˇic´ • Ivan Micic´ • Z Milimir Kosˇutic
•
Received: 2 August 2013 / Accepted: 31 October 2013 / Published online: 13 November 2013 Ó Springer-Verlag France 2013
Abstract Background Open intraarticular distal humerus fractures classified as Orthopaedic Trauma Association (OTA) 13 C may have devastating consequences for patient’s quality of life, especially if leading arm in younger active patient is involved. We conducted a study to determine whether the timing of open reduction and internal fixation of open intraarticular distal humerus fractures affects the outcomes. Patients and methods Multicentric prospective study: In the first group, there were 15 patients, 10 men and 5 women, mean age 38.7 years, operated in\6 h of injury. In the second group 17 patients, 11 men and 6 women, mean age 42.3 years operatively treated in delayed settings, mean delay to operation 4.6 days of injury. In both groups, patients had open distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. Functional outcome was assessed with Mayo elbow performance score and Disabilities of Arm and Shoulder and Hand (DASH). Mean Mayo elbow performance (MEP) score in the first group was 71 (range 30–100); in the second, mean MEP was 64.3 (range 25–100). The mean DASH in the first group was 27.89 (range from 1.7 D. Radoicˇic´ (&) M. Kosˇutic Ortohopaedic Surgery and Traumatology Clinic, Military Medical Academy Belgrade, Crnotravska 17, Belgrade, Serbia e-mail: [email protected] M. Kosˇutic e-mail: [email protected] I. Micic´ Faculty of Medicine, Clinical Center Nis, Orthopaedic Surgery and Traumatology Clinic, University of Nis, Nis, Serbia e-mail: [email protected] Zˇ. Dasˇic´ Clinical Centre of Montenegro, Podgorica, Serbia e-mail: [email protected]
to 75.8), and in the second, mean DASH score was 32.6 (range 5.8–77.5). There were no statistically significant differences between two groups, MEP t(28) = 0.935, p \ 0.358; DASH t(28) = -0.636, p \ 0.530. Conclusion Our study shows that early open reduction and internal fixation of open distal articular humerus fractures reduces the hospital stay, but does not significantly affect the overall outcomes and complications. Keywords Open intraarticular Distal humerus fractures OTA 13 C Open reduction Bicolumnar fixation
Background Distal humeral fractures comprise approximately 2 % of all fractures and one-third of all humeral fractures [1]. The complex anatomy of distal humerus makes intraarticular distal humeral fractures quite challenging for open reduction and internal fixation, and in cases of open fractures, there is additional risk of infection [2]. Operative treatment is favored, and many surgical approaches and techniques are available [3–5], with increasing popularity of total elbow arthroplasty, especially in elderly patients [6–8]. Anatomic reduction, stable fixation, early mobilization and fracture union are the main premises for a satisfactory result [9, 10]. The question of timing of operation in regard to postoperative complications seems to raise differences in opinion. Some authors state that ORIF of distal humerus fractures is best undertaken during daylight hours, after adequate planning and with a rested, experienced surgical team and staff [11]. Others take open fractures emergently to the OR for irrigation, debridement and surgical fixation [2, 12].
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The purpose of our study was to determine whether immediate early total care concept (ETC) in treatment of open complex articular distal humerus fractures is more beneficial, with lower risks of complications related to damage control surgery (DCO) and delayed definitive operative treatment.
Materials and methods We conducted a prospective study on one series of open distal humerus articular fractures classified by Orthopaedic Trauma Association (OTA) classification as types 13.C2 and 13.C3 [13], treated with open reduction and internal fixation within 6 h of injury compared to another series of patients with same type of open fracture treated in the same manner in delayed procedure. Patients who were not operated immediately were polytraumatized and/or with comorbidities that required additional preoperative tests and examinations or were admitted during hours when senior surgeons trained in this field of traumatology were not on call. Most of the patients in this group were politraumatized and required multidisciplinary surgical response (10 of them had besides orthopedic some kind of neurosurgical, vascular, thoracal or abdominal trauma), and in 7 cases, definitive ORIF procedure was delayed because staff on call was not proficient in this field of surgery. In both groups, there were only open fractures Gustilo type I and II [14]. In the first group were 15 patients, 10 men 5 women, mean age 38.7 years (from 23 to 67), with open Gustillo I or II type, distal humerus articular metaphyseal multifragmentary fractures. All fractures operated in \6 h of injury were classified according to OTA as 13.C2 or 13.C3. There were 8 patients with 13 C2 and 7 patients with 13 C3 type of fracture. Eight patients had Gustilo II and 7 patients had Gustilo I type of open fracture. All patients were available for follow-up. In the second group were 17 patients, 11 men and 6 women, mean age 42.3 years (from 27 to 64) with open Gustilo I or II type, distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. All fractures were treated operatively in delayed settings; mean delay to operation was 4.6 days from injury. There were 10 patients with 13 C2 and 7 patients with 13 C3 type of fracture. Open fracture Gustilo I type was indentified in 9 patients and Gustilo II in 8 patients. In this series, 15 patients were available for follow-up. None in both series had previous elbow fractures, and none had elbow arthritis. Mechanism of injury was falling from height in 11 cases, falling from standing in 8 cases, falling during sports in 5 and motor vehicle accident in 8 cases. In all cases, intraoperative wound cultures were obtained. All patients in both groups received same preoperative
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Fig. 1 Male 48 years old. ETC group (patient was operated in \6 h of admission). Open reduction internal fixation of open distal humerus intraarticular fracture with dual plating technique
antibiotic regimen preoperatively—ceftriaxone 2.0 gr i.v., amikacin 1.0 gr i.v. and metronidazole 1.5 g i.v.—with same dosages per day postoperatively. All antibiotics were discontinued 3 days after surgery. One patient in the first group and two patients in the second group received antibiotic a few more days as requested by the attending surgeon. Preoperatively anteroposterior and lateral elbow radiographs were obtained, and in 4 cases in the first and 5 cases in the second group, elbow 3D MSCT scans were obtained. In all cases, identical operative approach and similar technique were applied. Patients were placed prone or in lateral decubitus, with upper arm supported by a holder. Operative technique was open reduction internal fixation of distal humerus intraarticular multifragmentary fracture with bicolumnar plating technique [15–18] as depicted in Figs. 1 and 2. In all cases, posterior transolecranon approach was used [19]. Before and after olecranon osteotomy, thorough irrigation and careful debridement were performed, ulnar nerve released and protected, all fragments identified and small and devitalized fragments were removed. In some cases, intraoperative radiographs were obtained. Osteosynthesis was performed in most cases with two 3.5-mm straight and/ or curved pelvic reconstruction plates, and in two cases in both groups, distal humerus medial and lateral 3.5-mm LCP plates were used. Pelvic reconstruction plates were intraoperatively adapted to the columnar contours of the distal humerus. All olecranon osteotomies were reduced and fixed with two K-wires and figure-of-eight tension band wiring. Drains were removed on the second postoperative day. Postoperatively, most of the patients were immobilized in an arm sling, except in the two cases in the first and three cases in the second group, where plaster splint was used for 2 weeks, and arm sling afterward. Patients in both series underwent regular postoperative clinical, radiographical and laboratory evaluation. Infections were confirmed by positive intraoperative cultures
Eur J Orthop Surg Traumatol (2014) 24:777–782
Fig. 2 Male 48 years old. ETC group. Postoperative AP X-ray
and postoperative clinical signs and additional swabs. Elbow radiographs were obtained immediately postoperatively, and afterward according to follow-up scheme: 2 weeks after discharge, then 4 weeks after that, and usually followed by 6–8-week intervals up to fracture union. In cases of infection, follow-ups were more frequent. Range of motion was evaluated with a goniometer. Functional results were assessed with Mayo elbow performance score (MEP) [20, 21], and Disabilities of Arm and Shoulder and Hand (DASH) questionnaire [22, 23]. To obtain information regarding the effect of timing of ORIF of open intraarticular distal humerus fractures, independent samples t test was performed (IBM SPSS) on both series values of MEP and DASH score findings (data were previously tested for normal distribution). Series were insufficient for adequate statistical analysis of infection, nonunion and other noted complications. Each author certifies that his institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research and that informed consent for participation in the study was obtained.
Results Since January 2007 to December 2011, 32 patients with open distal humerus articular fractures classified by OTA as type 13.C2 and 13.C3 were treated with open reduction
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and internal fixation. Fifteen of them were operated within 6 h of injury, and 17 were treated operatively in the same manner in delayed procedure (mean 4.6 days of injury). All patients in the first and 15 patients in the second group were available for follow-up. Follow-up range was from 15 to 68 months; mean follow-up was 39.6 months. At the final follow-up (including time when performed arthrodesis in both groups healed), mean MEP score in the first group was 71 (range 30–100) and in the second was 64.3 (range 25–100). The mean DASH in the first group was 27.89 (range from 1.7 to 75.8), and in the second, mean DASH score was 32.6 (range 5.8–77.5). Independent sample t test revealed that there were no statistically significant differences between the group treated within 6 h of injury and the group treated in delayed procedure, neither when as outcome variable was used MEP score nor when as outcome variable was used DASH score. MEP t(28) = 0.935, p \ 0.358; DASH t(28) = 0.636, p \ 0.530. Only 4 patients, 2 in each group, at final follow-up had full elbow range of motion. All but these two patients had same degree of elbow flexion contracture. Mean flexion contracture in the first group was 33° and in the second group was 36°. Mean flexion/extension arc of motion was 86° in the first and 84° in the second group. Forearm pronation on average 75°, supination averaged 69° in the first group, 71° pronation and 70° supination in the second group. In the group of patients operated within 6 h of injury, there were 2 infections. In postoperative swabs from sinus tract, Staphylococcus aureus was isolated. The rest of the patients were infection free at first 2 weeks and all during other follow-ups as well. Infection required prolonged antibiotic therapy, and signs of infection subsided in 3 weeks postoperatively. No additional debridement surgery was needed. In one infected case, nonunion with bone loss was evident 6 months postoperatively. Reosteosynthesis with bone grafting was carried out, but 6 months postoperatively, implant loosening was evident and nonunion did not heal. In agreement with the patient, who was at that time 32 years old, after explanation of all treatment options, including re-reosteosynthesis with bone grafting and total elbow arthroplasty, decision was made to carry out elbow arthrodesis. Elbow arthrodesis was performed and afterward successfully healed. In all other cases in the first group, all operated fractures and olecranon osteotomies united. No patients had any signs of elbow varus/valgus instability. One patient, immediately postoperatively, in this group had transient radialis paresis, and one patient had ulnar nerve neuropathy, which fully resolved during physical therapy in 4 weeks after operation. Two patients in this group had heterotopic ossifications, Brooker grade I and II [24]. At
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the final follow-up in this group, there was radiographic evidence of posttraumatic elbow arthrosis in 3 cases. Average length of hospitalization in this group was 4.1 days. In series operated in delayed procedure, there were 3 infections that required additional surgical interventions including debridement and removal of implants. Consequently, 1 infected nonunion persisted during follow-up period. In this case, Klebsiella spp. was isolated from sinus tract and intraoperative cultures. In this case, elbow arthrodesis was performed 8.5 months since primary operation, but signs of chronic infection persisted. After another debridement, implants removal hinged elbow brace was applied as permanent solution. One patient in this group had early loss of fixation and re-fracture 4 weeks postoperatively, all cultures in this case were negative, reORIF with bone grafting was performed and fracture union was achieved. Besides those patients, all other operated fractures and olecranon osteotomies united primarily. Three patients in this group had heterotopic ossifications, two were Brooker I and one Brooker grade II. Radiographic evidence of posttraumatic elbow arthrosis was noted in 3 cases in this group. Average length of hospitalization in this group was 9.4 days.
Discussion There is no dilemma whether the treatment of open comminuted distal humerus fractures should be operative. In our study, most of the patients were under 50 years of age. In younger active patients, open reduction internal fixation of Gustilo type I/II distal articular humerus fractures is favored option [2, 15, 17]. It seems that those fractures in young active patients do not acquire much attention, and additionally, open type of distal humerus articular fractures gets even less coverage. Most of the published series on the topic of distal humerus articular fractures concern the fractures in the elderly; in our series in both groups, most of the patients were under 50 years of age. On the other hand, in the elderly, total elbow arthroplasty is as viable or even better treatment option as open reduction internal fixation [4, 5, 25, 26]. To our knowledge, there is not much available data on the subject of TEA immediately after open distal humeral fractures. We present a unique series of patients operated immediately versus series of patients with delayed ORIF of open distal articular humerus fractures; to our knowledge, the topic has not previously been much discussed in the literature. Elbow has unique and complex anatomic features; besides elbow is mostly just under the skin, no big muscles cover the joint, prone to stiffness and other complications after traumatic events. Major complications after open
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reduction internal fixation of distal humerus articular fractures regardless of type of implant used are elbow contracture, ulnar neuropathy, infection, heterotopic ossifications and delayed or nonunion [27, 28]. Postoperative elbow contracture seems to be almost inevitable complication. Only two patients of 24 (both were women) at the final follow-up in our both series had full elbow range of movement. In relation to similar series [2, 15, 17, 29] considering same measuring tools (MEP and DASH), our functional results were within ranges published in those series. We treated operatively 24 patients and registered three postoperative infections. In the group of patients operated in \6 h of injury, there was one infection, early postoperatively, and in the series operated in delayed procedure, there were 2 infections that required additional surgical interventions, debridement and/or removal of implants. At the end of follow-up, one patient in both series had elbow arthrodesis due to infection and consequential nonunion. Considering damage control surgery (DCO) concept versus early total care (ETC), our research showed that there was no difference in overall outcomes in two groups. This result supports DCO. This means that in the critical situations, where delay is expected or inevitable, like second group, we do not always have to operate for the open distal articular humerus fracture. Given the risk of infection, open reduction and internal fixation of open distal humerus fractures seem to be a relatively safe procedure, whether it is performed as soon as possible or in delayed settings. After comparison of the results between the two groups, since there was no increase in infection incidence, postoperative hospitalization was shorter and there were mildly better functional results in the first group; we would give a slight advantage to the early operation wherever and whenever possible to carry out. Helfet et al. [30] reported excellent results in treatment of nonunions of distal humerus; fifty-one of the fifty-two patients had healing after ORIF of delayed unions and nonunions of distal humeral fractures, but only some of their patients with nonunions had previous operations or postoperative infection. Ring et al. [31] in their series of unstable distal humerus nonunions note that in some cases, internal fixation with plates, screws and autogenous bone grafting may not be sufficient for nonunion treatment, and in some of their cases with large defects after debridement at the site of previous infection, supplemental external fixation and vascularized fibular grafts were needed. In our series, we performed elbow arthrodesis in both nonunion cases due to chronic infection and bone defects. In those circumstances, it was surgeons who preferred treatment option. Although we presented and explained to the patients in question other operative possibilities including reosteosynthesis with bone grafting and arthrolysis, total
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elbow arthroplasty and possible complications and limitations of those treatment options, both patients after consideration of all suggested options have chosen elbow arthrodesis. Douglas et al. [32] have found that heterotopic ossifications occurred in 22 % of patients with OTA type C distal humerus fractures. Incidence of heterotopic ossifications in our series was similar to their findings. The main weakness of the study is small series of patients. Moreover, the investigated groups were relatively heterogenic, considering patients’ age and gender (21 males/11 females, age from 23 to 67 years). On the other side, some consistency in conclusion was to be expected since all patients had same type of injury and underwent the same preoperative, operative and postoperative management algorithm by a small group of orthopedic surgeons.
Conclusion Open intraarticular distal humerus fractures classified as OTA 13 C may have devastating consequences for patient’s quality of life, especially if leading arm in younger active patient is involved. Successful treatment demands operative approach. There is consensus that for the best outcome, this type of fractures should be operated on as soon as possible. But at the moment, not much data is available on the subject. The study might be underpowered to be able to demonstrate a difference in functional outcome, but it shows that early surgery may have positive effect on hospital stay, without significant impact on the overall outcomes and complications. Longer-term research and larger series of patients are required to confirm the implications of this study. Conflict of interest Each author certifies that he has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research and that informed consent for participation in the study was obtained.
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Eur J Orthop Surg Traumatol (2014) 24:777–782 humerus fractures in women older than age 65. J Orthop Trauma 17:473–480 Kamineni S, Morrey BF (2004) Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 86:940–947 Nauth A, McKee MD, Ristevski B et al (2011) Distal humeral fractures in adults. J Bone Joint Surg Am 93(7):686–700 Ilyas AM, Jupiter JB (2008) Treatment of distal humerus fractures. Acta Chir Orthop Traumatol Cech 75(1):6–15 Greiner S, Haas NP, Bail HJ (2008) Outcome after open reduction and angular stable internal fixation for supra-intercondylar fractures of the distal humerus: preliminary results with the LCP
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distal humerus system. Arch Orthop Trauma Surg 128(7):723–729 30. Helfet DL, Kloen P, Anand N, Rosen HS (2003) Open reduction and internal fixation of delayed unions and non-unions of fractures of the distal part of the humerus. J Bone Joint Surg 17A:473–480 31. Ring D, Gulotta L, Jupiter JB (2003) Unstable nonunions of the distal part of the humerus. J Bone Joint Surg Am 85-A(6):1040–1046 32. Douglas K, Cannada LK, Archer KR et al (2012) Incidence and risk factors of heterotopic ossification following major elbow trauma. Orthopedics 35(6):e815–e822
ORIGINAL ARTICLE
Does timing of surgery affect the outcome of open articular distal humerus fractures ˇ arko Dasˇic´ Dragan Radoicˇic´ • Ivan Micic´ • Z Milimir Kosˇutic
•
Received: 2 August 2013 / Accepted: 31 October 2013 / Published online: 13 November 2013 Ó Springer-Verlag France 2013
Abstract Background Open intraarticular distal humerus fractures classified as Orthopaedic Trauma Association (OTA) 13 C may have devastating consequences for patient’s quality of life, especially if leading arm in younger active patient is involved. We conducted a study to determine whether the timing of open reduction and internal fixation of open intraarticular distal humerus fractures affects the outcomes. Patients and methods Multicentric prospective study: In the first group, there were 15 patients, 10 men and 5 women, mean age 38.7 years, operated in\6 h of injury. In the second group 17 patients, 11 men and 6 women, mean age 42.3 years operatively treated in delayed settings, mean delay to operation 4.6 days of injury. In both groups, patients had open distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. Functional outcome was assessed with Mayo elbow performance score and Disabilities of Arm and Shoulder and Hand (DASH). Mean Mayo elbow performance (MEP) score in the first group was 71 (range 30–100); in the second, mean MEP was 64.3 (range 25–100). The mean DASH in the first group was 27.89 (range from 1.7 D. Radoicˇic´ (&) M. Kosˇutic Ortohopaedic Surgery and Traumatology Clinic, Military Medical Academy Belgrade, Crnotravska 17, Belgrade, Serbia e-mail: [email protected] M. Kosˇutic e-mail: [email protected] I. Micic´ Faculty of Medicine, Clinical Center Nis, Orthopaedic Surgery and Traumatology Clinic, University of Nis, Nis, Serbia e-mail: [email protected] Zˇ. Dasˇic´ Clinical Centre of Montenegro, Podgorica, Serbia e-mail: [email protected]
to 75.8), and in the second, mean DASH score was 32.6 (range 5.8–77.5). There were no statistically significant differences between two groups, MEP t(28) = 0.935, p \ 0.358; DASH t(28) = -0.636, p \ 0.530. Conclusion Our study shows that early open reduction and internal fixation of open distal articular humerus fractures reduces the hospital stay, but does not significantly affect the overall outcomes and complications. Keywords Open intraarticular Distal humerus fractures OTA 13 C Open reduction Bicolumnar fixation
Background Distal humeral fractures comprise approximately 2 % of all fractures and one-third of all humeral fractures [1]. The complex anatomy of distal humerus makes intraarticular distal humeral fractures quite challenging for open reduction and internal fixation, and in cases of open fractures, there is additional risk of infection [2]. Operative treatment is favored, and many surgical approaches and techniques are available [3–5], with increasing popularity of total elbow arthroplasty, especially in elderly patients [6–8]. Anatomic reduction, stable fixation, early mobilization and fracture union are the main premises for a satisfactory result [9, 10]. The question of timing of operation in regard to postoperative complications seems to raise differences in opinion. Some authors state that ORIF of distal humerus fractures is best undertaken during daylight hours, after adequate planning and with a rested, experienced surgical team and staff [11]. Others take open fractures emergently to the OR for irrigation, debridement and surgical fixation [2, 12].
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Eur J Orthop Surg Traumatol (2014) 24:777–782
The purpose of our study was to determine whether immediate early total care concept (ETC) in treatment of open complex articular distal humerus fractures is more beneficial, with lower risks of complications related to damage control surgery (DCO) and delayed definitive operative treatment.
Materials and methods We conducted a prospective study on one series of open distal humerus articular fractures classified by Orthopaedic Trauma Association (OTA) classification as types 13.C2 and 13.C3 [13], treated with open reduction and internal fixation within 6 h of injury compared to another series of patients with same type of open fracture treated in the same manner in delayed procedure. Patients who were not operated immediately were polytraumatized and/or with comorbidities that required additional preoperative tests and examinations or were admitted during hours when senior surgeons trained in this field of traumatology were not on call. Most of the patients in this group were politraumatized and required multidisciplinary surgical response (10 of them had besides orthopedic some kind of neurosurgical, vascular, thoracal or abdominal trauma), and in 7 cases, definitive ORIF procedure was delayed because staff on call was not proficient in this field of surgery. In both groups, there were only open fractures Gustilo type I and II [14]. In the first group were 15 patients, 10 men 5 women, mean age 38.7 years (from 23 to 67), with open Gustillo I or II type, distal humerus articular metaphyseal multifragmentary fractures. All fractures operated in \6 h of injury were classified according to OTA as 13.C2 or 13.C3. There were 8 patients with 13 C2 and 7 patients with 13 C3 type of fracture. Eight patients had Gustilo II and 7 patients had Gustilo I type of open fracture. All patients were available for follow-up. In the second group were 17 patients, 11 men and 6 women, mean age 42.3 years (from 27 to 64) with open Gustilo I or II type, distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. All fractures were treated operatively in delayed settings; mean delay to operation was 4.6 days from injury. There were 10 patients with 13 C2 and 7 patients with 13 C3 type of fracture. Open fracture Gustilo I type was indentified in 9 patients and Gustilo II in 8 patients. In this series, 15 patients were available for follow-up. None in both series had previous elbow fractures, and none had elbow arthritis. Mechanism of injury was falling from height in 11 cases, falling from standing in 8 cases, falling during sports in 5 and motor vehicle accident in 8 cases. In all cases, intraoperative wound cultures were obtained. All patients in both groups received same preoperative
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Fig. 1 Male 48 years old. ETC group (patient was operated in \6 h of admission). Open reduction internal fixation of open distal humerus intraarticular fracture with dual plating technique
antibiotic regimen preoperatively—ceftriaxone 2.0 gr i.v., amikacin 1.0 gr i.v. and metronidazole 1.5 g i.v.—with same dosages per day postoperatively. All antibiotics were discontinued 3 days after surgery. One patient in the first group and two patients in the second group received antibiotic a few more days as requested by the attending surgeon. Preoperatively anteroposterior and lateral elbow radiographs were obtained, and in 4 cases in the first and 5 cases in the second group, elbow 3D MSCT scans were obtained. In all cases, identical operative approach and similar technique were applied. Patients were placed prone or in lateral decubitus, with upper arm supported by a holder. Operative technique was open reduction internal fixation of distal humerus intraarticular multifragmentary fracture with bicolumnar plating technique [15–18] as depicted in Figs. 1 and 2. In all cases, posterior transolecranon approach was used [19]. Before and after olecranon osteotomy, thorough irrigation and careful debridement were performed, ulnar nerve released and protected, all fragments identified and small and devitalized fragments were removed. In some cases, intraoperative radiographs were obtained. Osteosynthesis was performed in most cases with two 3.5-mm straight and/ or curved pelvic reconstruction plates, and in two cases in both groups, distal humerus medial and lateral 3.5-mm LCP plates were used. Pelvic reconstruction plates were intraoperatively adapted to the columnar contours of the distal humerus. All olecranon osteotomies were reduced and fixed with two K-wires and figure-of-eight tension band wiring. Drains were removed on the second postoperative day. Postoperatively, most of the patients were immobilized in an arm sling, except in the two cases in the first and three cases in the second group, where plaster splint was used for 2 weeks, and arm sling afterward. Patients in both series underwent regular postoperative clinical, radiographical and laboratory evaluation. Infections were confirmed by positive intraoperative cultures
Eur J Orthop Surg Traumatol (2014) 24:777–782
Fig. 2 Male 48 years old. ETC group. Postoperative AP X-ray
and postoperative clinical signs and additional swabs. Elbow radiographs were obtained immediately postoperatively, and afterward according to follow-up scheme: 2 weeks after discharge, then 4 weeks after that, and usually followed by 6–8-week intervals up to fracture union. In cases of infection, follow-ups were more frequent. Range of motion was evaluated with a goniometer. Functional results were assessed with Mayo elbow performance score (MEP) [20, 21], and Disabilities of Arm and Shoulder and Hand (DASH) questionnaire [22, 23]. To obtain information regarding the effect of timing of ORIF of open intraarticular distal humerus fractures, independent samples t test was performed (IBM SPSS) on both series values of MEP and DASH score findings (data were previously tested for normal distribution). Series were insufficient for adequate statistical analysis of infection, nonunion and other noted complications. Each author certifies that his institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research and that informed consent for participation in the study was obtained.
Results Since January 2007 to December 2011, 32 patients with open distal humerus articular fractures classified by OTA as type 13.C2 and 13.C3 were treated with open reduction
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and internal fixation. Fifteen of them were operated within 6 h of injury, and 17 were treated operatively in the same manner in delayed procedure (mean 4.6 days of injury). All patients in the first and 15 patients in the second group were available for follow-up. Follow-up range was from 15 to 68 months; mean follow-up was 39.6 months. At the final follow-up (including time when performed arthrodesis in both groups healed), mean MEP score in the first group was 71 (range 30–100) and in the second was 64.3 (range 25–100). The mean DASH in the first group was 27.89 (range from 1.7 to 75.8), and in the second, mean DASH score was 32.6 (range 5.8–77.5). Independent sample t test revealed that there were no statistically significant differences between the group treated within 6 h of injury and the group treated in delayed procedure, neither when as outcome variable was used MEP score nor when as outcome variable was used DASH score. MEP t(28) = 0.935, p \ 0.358; DASH t(28) = 0.636, p \ 0.530. Only 4 patients, 2 in each group, at final follow-up had full elbow range of motion. All but these two patients had same degree of elbow flexion contracture. Mean flexion contracture in the first group was 33° and in the second group was 36°. Mean flexion/extension arc of motion was 86° in the first and 84° in the second group. Forearm pronation on average 75°, supination averaged 69° in the first group, 71° pronation and 70° supination in the second group. In the group of patients operated within 6 h of injury, there were 2 infections. In postoperative swabs from sinus tract, Staphylococcus aureus was isolated. The rest of the patients were infection free at first 2 weeks and all during other follow-ups as well. Infection required prolonged antibiotic therapy, and signs of infection subsided in 3 weeks postoperatively. No additional debridement surgery was needed. In one infected case, nonunion with bone loss was evident 6 months postoperatively. Reosteosynthesis with bone grafting was carried out, but 6 months postoperatively, implant loosening was evident and nonunion did not heal. In agreement with the patient, who was at that time 32 years old, after explanation of all treatment options, including re-reosteosynthesis with bone grafting and total elbow arthroplasty, decision was made to carry out elbow arthrodesis. Elbow arthrodesis was performed and afterward successfully healed. In all other cases in the first group, all operated fractures and olecranon osteotomies united. No patients had any signs of elbow varus/valgus instability. One patient, immediately postoperatively, in this group had transient radialis paresis, and one patient had ulnar nerve neuropathy, which fully resolved during physical therapy in 4 weeks after operation. Two patients in this group had heterotopic ossifications, Brooker grade I and II [24]. At
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the final follow-up in this group, there was radiographic evidence of posttraumatic elbow arthrosis in 3 cases. Average length of hospitalization in this group was 4.1 days. In series operated in delayed procedure, there were 3 infections that required additional surgical interventions including debridement and removal of implants. Consequently, 1 infected nonunion persisted during follow-up period. In this case, Klebsiella spp. was isolated from sinus tract and intraoperative cultures. In this case, elbow arthrodesis was performed 8.5 months since primary operation, but signs of chronic infection persisted. After another debridement, implants removal hinged elbow brace was applied as permanent solution. One patient in this group had early loss of fixation and re-fracture 4 weeks postoperatively, all cultures in this case were negative, reORIF with bone grafting was performed and fracture union was achieved. Besides those patients, all other operated fractures and olecranon osteotomies united primarily. Three patients in this group had heterotopic ossifications, two were Brooker I and one Brooker grade II. Radiographic evidence of posttraumatic elbow arthrosis was noted in 3 cases in this group. Average length of hospitalization in this group was 9.4 days.
Discussion There is no dilemma whether the treatment of open comminuted distal humerus fractures should be operative. In our study, most of the patients were under 50 years of age. In younger active patients, open reduction internal fixation of Gustilo type I/II distal articular humerus fractures is favored option [2, 15, 17]. It seems that those fractures in young active patients do not acquire much attention, and additionally, open type of distal humerus articular fractures gets even less coverage. Most of the published series on the topic of distal humerus articular fractures concern the fractures in the elderly; in our series in both groups, most of the patients were under 50 years of age. On the other hand, in the elderly, total elbow arthroplasty is as viable or even better treatment option as open reduction internal fixation [4, 5, 25, 26]. To our knowledge, there is not much available data on the subject of TEA immediately after open distal humeral fractures. We present a unique series of patients operated immediately versus series of patients with delayed ORIF of open distal articular humerus fractures; to our knowledge, the topic has not previously been much discussed in the literature. Elbow has unique and complex anatomic features; besides elbow is mostly just under the skin, no big muscles cover the joint, prone to stiffness and other complications after traumatic events. Major complications after open
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reduction internal fixation of distal humerus articular fractures regardless of type of implant used are elbow contracture, ulnar neuropathy, infection, heterotopic ossifications and delayed or nonunion [27, 28]. Postoperative elbow contracture seems to be almost inevitable complication. Only two patients of 24 (both were women) at the final follow-up in our both series had full elbow range of movement. In relation to similar series [2, 15, 17, 29] considering same measuring tools (MEP and DASH), our functional results were within ranges published in those series. We treated operatively 24 patients and registered three postoperative infections. In the group of patients operated in \6 h of injury, there was one infection, early postoperatively, and in the series operated in delayed procedure, there were 2 infections that required additional surgical interventions, debridement and/or removal of implants. At the end of follow-up, one patient in both series had elbow arthrodesis due to infection and consequential nonunion. Considering damage control surgery (DCO) concept versus early total care (ETC), our research showed that there was no difference in overall outcomes in two groups. This result supports DCO. This means that in the critical situations, where delay is expected or inevitable, like second group, we do not always have to operate for the open distal articular humerus fracture. Given the risk of infection, open reduction and internal fixation of open distal humerus fractures seem to be a relatively safe procedure, whether it is performed as soon as possible or in delayed settings. After comparison of the results between the two groups, since there was no increase in infection incidence, postoperative hospitalization was shorter and there were mildly better functional results in the first group; we would give a slight advantage to the early operation wherever and whenever possible to carry out. Helfet et al. [30] reported excellent results in treatment of nonunions of distal humerus; fifty-one of the fifty-two patients had healing after ORIF of delayed unions and nonunions of distal humeral fractures, but only some of their patients with nonunions had previous operations or postoperative infection. Ring et al. [31] in their series of unstable distal humerus nonunions note that in some cases, internal fixation with plates, screws and autogenous bone grafting may not be sufficient for nonunion treatment, and in some of their cases with large defects after debridement at the site of previous infection, supplemental external fixation and vascularized fibular grafts were needed. In our series, we performed elbow arthrodesis in both nonunion cases due to chronic infection and bone defects. In those circumstances, it was surgeons who preferred treatment option. Although we presented and explained to the patients in question other operative possibilities including reosteosynthesis with bone grafting and arthrolysis, total
Eur J Orthop Surg Traumatol (2014) 24:777–782
elbow arthroplasty and possible complications and limitations of those treatment options, both patients after consideration of all suggested options have chosen elbow arthrodesis. Douglas et al. [32] have found that heterotopic ossifications occurred in 22 % of patients with OTA type C distal humerus fractures. Incidence of heterotopic ossifications in our series was similar to their findings. The main weakness of the study is small series of patients. Moreover, the investigated groups were relatively heterogenic, considering patients’ age and gender (21 males/11 females, age from 23 to 67 years). On the other side, some consistency in conclusion was to be expected since all patients had same type of injury and underwent the same preoperative, operative and postoperative management algorithm by a small group of orthopedic surgeons.
Conclusion Open intraarticular distal humerus fractures classified as OTA 13 C may have devastating consequences for patient’s quality of life, especially if leading arm in younger active patient is involved. Successful treatment demands operative approach. There is consensus that for the best outcome, this type of fractures should be operated on as soon as possible. But at the moment, not much data is available on the subject. The study might be underpowered to be able to demonstrate a difference in functional outcome, but it shows that early surgery may have positive effect on hospital stay, without significant impact on the overall outcomes and complications. Longer-term research and larger series of patients are required to confirm the implications of this study. Conflict of interest Each author certifies that he has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research and that informed consent for participation in the study was obtained.
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