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Best Evidence on Treatment of Elbow Fractures in the Elderly

Posted on: 02/29/2012
When it comes to treating elbow fractures in the elderly, surgeons are often between a rock and a hard place. If they perform an open reduction and internal fixation (ORIF) procedure (open incision, hardware to hold the broken bones together), there is the risk that the bones won't knit together, infection, and stiffness. In addition, sometimes the bones still drift apart resulting in loss of reduction. Patients end up with painful arthritis and elbow deformities that affect the use of that arm.

But if the surgeon replaces the joint with a total elbow arthroplasty (TEA) or joint replacement, then the risks are for loosening of the implant, infection, and fractures around the implant. Either way the treatment decision is difficult and the surgery is technically very challenging.

That's why three surgeons from three countries (United States, England, and New Zealand) got together and did a study to review the evidence around treatment of elbow fractures in the elderly. Specifically, they looked at displaced (separated) intra-articular (inside the joint) fractures of the distal humerus (bottom end of the upper arm bone/upper half of the elbow).

However, there were only two studies that met the study criteria. The surgeons present their findings from those two studies. But they say right up front that the evidence is insufficient to make a true recommendation for one treatment over the other (internal fixation versus joint replacement). The biggest finding of the study was to point out the need for a large, randomized, controlled trial to investigate this problem more thoroughly.

In the meantime, here's what they found from the two studies that were available. Older adults with displaced distal humeral fractures of the elbow regained more elbow/arm function with a joint replacement. And patients who had open reduction and internal fixation (ORIF) were more likely to need a second (revision) surgery.

The main advantage of ORIF is that it can be successful leaving the natural anatomy and bone intact. Should the procedure fail to reduce pain, increase motion, and improve function, then it is still possible to have a joint replacement later.

The two studies reviewed had several limitations. First, they were small in number. Second, in one study there were six different surgeons involved. The level of experience and expertise was not mentioned but could have been a factor in outcomes. When internal fixation was used with hardware, different types of devices were used (perpendicular plates, parallel plates, screws of different types) that could also affect the results.

In the second study, only women were included. In this study, the surgeons paid attention to comorbidities (other health problems present at the same time) that might have influenced the results. Alcoholism, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), and osteoporosis (brittle bones) were some of the problems reported. The surgeons felt that patients with comorbidities were more likely to have better results with total elbow arthroplasty (TEA). But whether the presence of any comorbidity (or only certain conditions) makes a difference remains unknown.

And finally, the period of follow-up for these two studies was only two years so no long-term results were available. The authors' final conclusion is that all of these study limitations reinforce the fact that further studies in this area are needed.

References:
Cyril Mauffrey, MD, FRCS, et al. Open Reduction and Internal Fixation Compared with Primary Total Elbow Arthroplasty for Displaced Intra-Articular Fractures of the Distal Humerus in the Elderly: A Systematic Review of the Literature. In Current Orthopaedic Practice. January/February 2012. Vol. 23. No. 1. Pp. 59-62.

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