Treatment of distal humerus fractures in osteoporotic elderly patients is often challenging. For non-reconstructible fractures with open reduction and internal fixation, total elbow arthroplasty (TEA) is an acceptable alternative. However, the relatively high complication rates and lifelong activity restrictions make TEA less ideal for elderly or low-demand patients. Efforts to identify or develop alternate procedures that benefit relatively young, high-demand patients have resulted in increased interest in hemiarthroplasty. This systematic review reports the clinical outcomes of hemiarthroplasty for distal humeral fractures.
We systematically reviewed the databases of PubMed, Ovid MEDLINE, and Cochrane Library. All English-language studies published before June 2017 were considered for possible inclusion. Search terms included ‘distal humerus fracture’ and ‘hemiarthroplasty’. Studies reporting outcomes (and a minimum of 1 year clinical follow-up) in human subjects after hemiarthroplasty (Latitude system) for distal humeral fractures were assessed for inclusion. Patient demographics, clinical and radiographic outcomes, and complications were recorded, and homogenous outcome measures were analyzed.
Nine studies with a total of 115 patients met the inclusion criteria. Among the included studies, the weighted mean follow-up time was 35.4 months. Furthermore, the weighted mean of the postoperative range of motion (107.6° flexion-extension, 157.5° for pronation-supination) and functional outcomes (Mayo elbow performance scores: 85.8, Disabilities of the Arm, Shoulder and Hand score: 19.6) were within the acceptable range.
Our study indicates that hemiarthroplasty is a viable option for comminuted distal humerus fracture. Satisfactory functional outcomes were observed in most patients.
Open reduction and internal fixation (ORIF) to restore the articular surface is the conventional treatment for distal humerus fractures [
Mellen and Phalen [
The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist and algorithm [
This review included studies of human subjects, with original data published in the English language that reported outcomes of hemiarthroplasty for distal humerus fractures, with a minimum follow-up of 1 year. Included studies were required to report clinical outcomes or complications after using the Latitude system for distal humerus fracture. Review articles and case reports were excluded.
Data regarding study characteristics, patient demographics, indications and contraindications, inclusion and exclusion criteria, and outcome measures were extracted from each study that met the inclusion criteria. The literature search and data extraction were performed by 4 blinded reviewers. Articles published on or before June 15, 2017 were considered. Only papers published in peer-reviewed journals were eligible, and relevance was established on the basis of article titles and abstracts. After article selection, bibliographies were assessed by the reviewers to identify further relevant articles. Three reviewers (GBL, EK, and JMK) reviewed each paper independently and discussed and resolved any disagreements on the inclusion or exclusion of any articles. The inclusion and exclusion of studies were also discussed with an expert orthopedic surgeon (IHJ). Study characteristics of interest included author names, year of publication, study design, number of patients at the final follow-up, and length of follow-up. Patient demographics included sex and age. Outcomes of interest included postoperative functional outcome scores, radiographic assessment, complications, reoperations, and conversion to TEA. Descriptive statistics were used to report study characteristics, patient demographics, and outcomes.
The methodologic quality of the included studies was analyzed with the modified Coleman Methodology Score [
We also conducted a meta-analysis, for which the results using the random-effects model took into account the possible clinical diversity and methodological variations between studies. Specific analyses considering confounding factors were not possible due to unavailability of raw data. Categorical variables were expressed as frequencies with percentages, and continuous variables were expressed as mean values with ranges. Functional outcome and range of motion data were presented using standardized mean deviation calculations. All statistical analyses were performed with the IBM SPSS ver. 21.0 (IBM Co., Armonk, NY, USA). A pooling data analysis was performed using randomeffect models, which assumed that there were variations between studies. The chi-square tests studied the heterogeneity between trials. The I2 statistic was used to estimate the percentage of total variation across studies, owing to heterogeneity rather than chance, with values greater than 50% being considered as substantial heterogeneity. I2 was calculated using the following formula: I2=100%×(Q-df)/Q, where Q is defined as Cochrane’s heterogeneity statistic and df is defined as degree of freedom. The possible clinical and methodological reasons in cases of substantial heterogeneity were qualitatively explored.
Our literature search and references scan identified 231 relevant articles; of these, 218 were excluded for various reasons as indicated (
A total of 115 patients from the 9 articles were included in the study, most of whom were female (
Most studies reported good or excellent outcomes, flexion-extension range of motion, and pronation-supination range of motion (
The weighted mean flexion-extension and pronation-supination arcs were 107.6° (I2=57.24%; heterogeneity) and 157.5° (I2=95.58%; heterogeneity), respectively (
Overall, there were 85 complications among the 115 patients evaluated. Cartilage wear (n=45) was the most common complication reported, followed by heterotopic ossification (n=39), loosening (n=13), and neuropathy (n=11). Other lesser complications included fracture (either intra- or postoperative) (n=7), stiffness (n=6), posterolateral rotatory instability (n=4), continuous pain (n=2), peri-prosthetic infection (n=1) and wound breakdown (n=1) (
This systematic review focused solely on employing the Latitude system for hemiarthroplasty for distal humerus fracture. All the studies included are classified as level IV evidence. The generally accepted optimal treatment for distal humerus fractures is ORIF, which is able to achieve stable fixation in majority of fractures; however, once attempts at fixation have failed, conversion to hemiarthroplasty avoids suboptimal fixation leading to poor outcomes. Distal humerus hemiarthroplasty is most typically used for intra-articular fractures of the distal humerus in geriatric populations. It also serves as a salvage procedure in younger patients with rheumatoid arthritis or tumors. To the best of our knowledge, by investigating the data of 115 patients who underwent distal humerus hemiarthroplasty, our work represents the most complete analysis for this specific indication.
Our analysis revealed that patients undergoing distal humerus hemiarthroplasty were more likely female and mostly in their seventh decade of age (mean, 66.41 years). Functional outcomes were summarized by means of 85.84 and 19.57 for MEPS and DASH scores, respectively. These outcomes are comparable with results associated with TEA [
Distal humerus hemiarthroplasty offers several benefits when compared to TEA, including preservation of the bone stock as well as minimization of postoperative restriction or revision surgery. Distal humerus hemiarthroplasty also preserves the native collateral ligaments, which helps preserve elbow proprioception. As for any other hemiarthroplasty, cartilage wear remains the most common challenge.
Despite the advantages of distal humerus hemiarthroplasty, complication rates remain higher than TEA. The most common complication in our review was cartilage wear (39.1%), followed by heterotopic ossification (33%), loosening (11.3%), neuropathy (9.6%), and stiffness (5.2%). Others less reported complications were periprosthetic fracture (4.34%), instability (3.47%), wound necrosis (1.73%), hardware irritation (0.86%), and triceps muscle weakness (0.86%). A common concern with any hemiarthroplasty is wearing of the native joint at the articulation point, resulting from a disparity in elasticity and surface roughness between the articular cartilage and prosthesis lining. With altered loading, the cartilage wears with time, eventually manifesting as and later causing instability and inducing the toggling movements. Loosening is also a worrisome and frequent complication of arthroplasty. We postulate that the cementing technique specifically contributes to this complication. In this situation, the prosthesis pullout is perpetuated by the pistoning movement of the cement mantle. However, the loosening rate of hemiarthroplasty was lower than that observed in TEA [
The lack of standardized outcome measurements and consistent follow-up are limitations to our analysis. Published literature on distal humerus arthroplasty for distal humerus fracture is limited, and therefore our analysis lacks power. The case series that do exist are short, often with limited and irregular follow-up. We were unable to utilize certain statistical analysis methods, such as correlation testing, since the power of the test depends on the number of studies included. In a meta-analysis that includes less than 25 studies, the correlation test will be unable to withstand biases in the literature search.
This systematic review highlights the favorable outcomes of distal humerus arthroplasty for distal humerus fracture with the Latitude system. We propose that prospective analysis should be directed at forming regimented physical therapy to reduce complication rates.
Our study indicates that hemiarthroplasty is a viable option for comminuted distal humerus fracture. Satisfactory functional outcomes were observed in most patients.
This meta-analysis does not need an IRB approval document.
None.
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Flowchart of the search strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
Clinical outcomes (Mayo elbow performance scores).
df: degree of freedom.
Clinical outcomes (Disabilities of the Arm, Shoulder and Hand).
df: degree of freedom.
Range of motion (flexion-extension).
df: degree of freedom.
Range of motion (supination-pronation).
df: degree of freedom.
Patient Demographics
Year | Author | Level of study | Country | No. of case | Mean age (yr) | Male/Female | Mean F/U (mo) |
---|---|---|---|---|---|---|---|
2017 | Schultzel et al. [ |
IV | USA | 10 | 71.7 ± 9.17 | NA | 73.2 |
2016 | Smith et al. [ |
IV | Australia | 3 | 39 ± 11.7 | NA | 44 |
2015 | Phadnis et al. [ |
IV | UK | 16 | 78.7 ± 8.06 | 3/13 | 35 |
2015 | Nestorson et al. [ |
IV | Sweden | 42 | 67.36 ± 17.36 | 3/39 | 34.29 |
2015 | Heijink et al. [ |
IV | Netherland | 6 | 67.1 ± 8.41 | 0/6 | 54 |
2014 | Hohman et al. [ |
IV | USA | 7 | 63.42 ± 14.7 | 2/5 | 36 |
2013 | Smith and Hughes [ |
IV | Australia | 11 | 61.81 ± 17.37 | NA | 63.27 |
2012 | Argintar et al. [ |
IV | USA | 10 | 73.4 ± 8.8 | 1/9 | 12 |
2011 | Burkhart et al. [ |
IV | Germany | 10 | 75.2 ± 8.29 | 0/10 | 12.1 |
Values are presented as number only, mean ± standard deviation, or mean only.
F/U: follow-up, NA: not available.
Functional Scores and ROM Data from Included Studies
Year | Author | No. of case | Mean F/U (mo) | ROM (°) (FE) | ROM (PS) | MEPS | DASH score |
---|---|---|---|---|---|---|---|
2017 | Schultzel et al. [ |
10 | 73.2 | 122.5 ± 30.48 | 135 ± 17.15 | 82.22 ± 15.63 | 32.07 ± 26 |
2016 | Smith et al. [ |
3 | 44 | 93.33 ± 22.54 | 121.6 ± 96.73 | 80 ± 22.91 | 14 ± 10.81 |
2015 | Phadnis et al. [ |
16 | 35 | 115.6 ± 14.3 | 171.5 ± 8.7 | 89.56 ± 5.18 | 11.23 ± 5.77 |
2015 | Nestorson et al. [ |
42 | 34.29 | 105.24 ± 22.21 | 178.29 ± 5.43 | 90 ± 14.36 | 20.26 ± 16.63 |
2015 | Heijink et al. [ |
6 | 54 | 95.8 ± 16.5 | 165 ± 13.78 | 78.33 ± 25.43 | 18.48 ± 22.82 |
2014 | Hohman et al. [ |
7 | 36 | 96.42 ± 22.11 | 160.7 ± 13.7 | 72.43 ± 17.97 | 33.42 ± 25.15 |
2013 | Smith and Hughes [ |
11 | 63.27 | 118.45 ± 17.58 | 159 ±52.58 | 88.33 ± 16.39 | 20.9 ± 19.6 |
2012 | Argintar et al. [ |
10 | 12 | 102 ± 25 | 133.3 ± 15 | 77 ± 16 | 35.1 ± 24 |
2011 | Burkhart et al. [ |
10 | 12.1 | 107 ± 15.49 | 160 ± 17.63 | 91.3 ± 11.49 | 11.2 ± 10.66 |
Values are presented as number only, mean only, or mean ± standard deviation.
ROM: range of motion, F/U: follow-up, FE: flexion-extension, PS: pronation-supination, MEPS: Mayo elbow performance scores, DASH: Disabilities of the Arm, Shoulder and Hand.
Associated Complications
Year | Author | Complication (no. of case) |
---|---|---|
2017 | Schultzel et al. [ |
Intraoperative olecranon fracture (1), implant irritation (1) |
2016 | Smith et al. [ |
Stiffness (1), aseptic loosening (2) |
2015 | Phadnis et al. [ |
Ulnar nerve neurapraxia (1), radial head wear (3), ulnar wear (10), heterotopic ossifications (11) |
2015 | Nestorson et al. [ |
Limited range of movement (4), partial instability (1), loosening (1), sensory ulnar nerve symptoms (2), mild olecranon wear (5) |
2015 | Heijink et al. [ |
Some degree of instability (3), motoric and sensory sequelae of a partially recovered traumatic ulnar nerve lesion (1) |
2014 | Hohman et al. [ |
Postoperative ulnar neuropathy (1), intraoperative fracture of the humeral diaphysis (1), loosening (6), olecranon wear mild (2) moderate (3) severe (2), radial head wear mild (5), moderate (2) |
2013 | Smith and Hughes [ |
Ulnar neuritis (4), stiffness (1), wound necrosis (1), ulnar wear (13), periprosthetic fractures (2), loosening (2), heterotopic ossifications (13) |
2012 | Argintar et al. [ |
Symptomatic olecranon hardware (1), olecranon fracture intraoperatively after osteotomy (1), ulnar nerve numbness (1) |
2011 | Burkhart et al. [ |
Triceps weakness (1), transient ulnar nerve irritation (1), superficial wound infection (1), heterotopic ossifications (2) |