Revision ORIF Successful for Nonunion of Distal Humerus Fracture in Older Patients with Bone Loss

When distal humerus fractures are complicated by nonunion, the standard treatment is revision open reduction internal fixation (ORIF), joint contracture release and autogenous bone grafting. However, for older patients who have poor bone quality or bone loss, total elbow arthroplasty (TEA) is also an option. For this patient subgroup, there have been multiple reports of similar outcomes of TEA and ORIF at short- to mid-term follow-up. However, the long-term results are unknown.

In a retrospective study with an average follow-up of 22 years, Abhiram R. Bhashyam MD, PhD, chief resident in Orthopaedics, and Jesse B. Jupiter MD, orthopaedic surgeon in the Hand and Arm Center in the Department of Orthopaedics at Massachusetts General Hospital, found good to excellent outcomes following revision ORIF in this setting. Their report appears in The Archives of Bone and Joint Surgery.

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Study Participants and Design

The researchers identified 13 older patients with poor bone quality or poor bone stock who underwent revision ORIF, joint contracture release and autogenous bone grafting for distal humerus fracture nonunion, but also had been considered viable candidates for TEA. Seven of those patients were available for follow-up and were studied.

The average age of the group was 53 at the time of revision (range, 41–75 years) and 75 at follow-up (range, 59–99 years). The evaluations reported here were performed by researchers uninvolved in the patients' care, an average of 22 years (range, 19–27) after revision surgery. Three patients returned for a clinic visit and the others were assessed by telephone.

Radiographic Results

By reviewing the most recently available films, the researchers determined that all seven patients demonstrated healing of the nonunion. The average arthrosis grade was 2 (moderate joint-space narrowing with moderate osteophyte formation). No patient had required conversion to TEA.

Pain

• One patient reported exertional discomfort, but none required narcotic or chronic pain medication
• Scores on the PROMIS (Patient-Reported Outcome Measurement Information System) Pain Interference scale and PROMIS Depression scale were no different than those in the general population
• On visual analog scales of pain in various scenarios, scores ranged from 0–6 at rest to 0–9 with activity

Patient-reported Function

• On a Likert scale from 0–10, the average satisfaction score was 9.6 (range, 7–10)
• On the Mayo Elbow Performance Index, functional outcome was rated excellent by five patients, good by one and poor by one
• The average PROMIS Physical Function – Upper Extremity score was worse in the affected extremity than in the general population

Clinical Evaluation of Three Patients

• On average, the arc of ulnohumeral motion was 80° and the affected elbow had a flexion contracture of 32°, terminal flexion of 112°, pronation of 67° and supination of 70°
• All patients had normal power in extension, flexion, pronation and supination
• Grip strength was similar between the affected and unaffected sides
• Pinch strength was decreased in the affected versus the unaffected elbow (13.9 vs. 16.9, P = .04)

Dr. Bhashyam and Dr. Jupiter conclude that revision ORIF is a viable treatment option for distal humerus fracture nonunion for older patients who demonstrate poor bone stock (due to comminution or loss) on preoperative radiography or are found to have poor bone quality intraoperatively.

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