Subscribe to RSS
DOI: 10.1055/s-0043-121893
Ellenbogenfraktur im Alter – Erhalt oder Ersatz?
Die distale Humerusfraktur im AlterDistal Humerus Fracture in the ElderlyPublication History
Publication Date:
11 January 2018 (online)
![](https://www.thieme-connect.de/media/zfo/201801/lookinside/thumbnails/10-1055-s-0043-121893_ou5206-1.jpg)
Zusammenfassung
Distale Humerusfrakturen zeigen im geriatrischen Patientenkollektiv eine zunehmende Inzidenz. Aufgrund der häufig vorbestehenden osteoporotischen Knochenverhältnisse ist der Chirurg regelhaft mit komplexen intraartikulären mehrfragmentären Frakturen konfrontiert.
Der Erhalt der Selbstständigkeit und das Vermeiden von Pflegebedürftigkeit ist ein Dogma in der Versorgung geriatrischer Patienten. Gerade beim betagten Patienten ist folglich eine stabile postoperative Situation und eine frühfunktionelle Nachbehandlung anzustreben. Die offene anatomische Reposition und stabile Retention mittels Doppelplattenosteosynthese ist der osteosynthetische Versorgungsstandard. Moderne anatomische, winkelstabile Implantate sollen die stabile Retention erleichtern und die Operationsdauer verkürzen. Die wenigen zur Verfügung stehenden Daten mit modernen Plattensystemen zeigen beim geriatrischen Patienten zwar gute funktionelle Ergebnisse, jedoch auch hohe Komplikationsraten.
Wie an anderen großen Gelenken hat sich auch am Ellenbogen die Frakturendoprothetik aufgrund der direkten Primärstabilität als wertvolle therapeutische Alternative beim älteren Patienten etabliert. So zeigen die Register in den letzten Jahrzehnten eine Vervielfachung der Implantationszahlen.
Das Standardimplantat in der Frakturendoprothetik des geriatrischen Patienten ist die zementierte „semi-constrained“ Prothese. Als Nachteile einer primär endoprothetischen Versorgung werden die lebenslange Belastungsrestriktion sowie potenzielle prothesenassoziierte Langzeitkomplikationen wie aseptische Lockerung und periprothetische Frakturen genannt.
Vergleichende Studien mit kurz- und mittelfristigen Nachuntersuchungszeiträumen zeigen gegenüber der Osteosynthese vergleichbare funktionelle Ergebnisse, jedoch weniger Komplikationen und Revisionen sowie eine verkürzte Operationsdauer. Langzeitergebnisse, die potenzielle prothesenassoziierte Komplikationen suffizient erfassen, fehlen jedoch.
In der rekonstruierbaren und für eine frühfunktionelle Beübung stabil retinierbaren Fraktursituation des distalen Humerus bleibt die Osteosynthese folglich auch beim geriatrischen Patienten das Verfahren der ersten Wahl.
Abstract
Distal humerus fractures show increasing incidence with age. Due to preexisting osteoporosis, the surgeon is regularly confronted with complex comminuted intraarticular fractures.
The maintenance of autonomy in daily life and avoidance of permanent care dependency is a dogma in the care of geriatric patients. Accordingly, a stable post-operative situation that allows early functional post-operative treatment is mandatory, especially in the elderly patient. Open reduction and stable internal fixation using double plate osteosynthesis are the current osteosynthetic standard of treatment. Modern precontoured systems with angular stability facilitate stable fixation and reduce surgery time. However, complication rates are high, despite the good functional outcomes in the few available studies which use modern plate systems in a geriatric patient population.
Due to the high rate of primary stability, elbow arthroplasty has become an established treatment option for complex distal humerus fractures in elderly patients. Consequently arthroplasty registry data report a growing number of elbow replacements for fracture in recent decades.
The standard implant design in the fractures in geriatric patients is the cemented “semi-constrained” total elbow arthroplasty. The disadvantages of total elbow replacement are the lifelong stringent weight restriction patients must adhere to, as well as potential long-term complications associated with arthroplasty, such as aseptic loosening and periprosthetic fractures.
Comparative studies with short- and medium-term follow-up show overall comparable functional results for elbow arthroplasty and double plate osteosynthesis, with fewer complications and revisions as well as a shorter duration of surgery within the arthroplasty group. However, long-term outcome studies are necessary to identify potential long-term complications associated with arthroplasty and are pending.
Therefore, in reconstruction of fractures of the distal humerus which allow stable fixation and early functional post-operative treatment, open reduction and double plate internal fixation with modern locking plate systems remains the gold standard even for geriatric patients.
-
Literatur
- 1 Robinson CM, Hill RMF, Jacobs N. et al. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma 2003; 17: 38-47
- 2 Palvanen M, Kannus P, Niemi S. et al. Secular trends in distal humeral fractures of elderly women. Bone 2010; 46: 1355-1358
- 3 Korner J, Lill H, Müller LP. et al. Distal humerus fractures in elderly patients: results after open reduction and internal fixation. Osteoporos Int 2005; 16 (Suppl. 02) S73-S79
- 4 Nauth A, McKee MD, Ristevski B. et al. Distal humeral fractures in adults. J Bone Joint Surg Am 2011; 93: 686-700
- 5 Liu JJ, Ruan HJ, Wang JG. et al. Double-column fixation for type C fractures of the distal humerus in the elderly. J Shoulder Elbow Surg 2009; 18: 646-651
- 6 Srinivasan K, Agarwal M, Matthews SJE. et al. Fractures of the distal humerus in the elderly. Clin Orthop Relat Res 2005; 434: 222-230
- 7 Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997; 79: 826-832
- 8 Zagorski JB, Jennings JJ, Burkhalter WE. et al. Comminuted intraarticular fractures of the distal humeral condyles: surgical vs. nonsurgical treatment. Clin Orthop Relat Res 1986; 202: 197-204
- 9 Papaioannou N, Babis GC, Kalavritinos J. Operative treatment of type C intra-articular fractures of the distal humerus: the role of stability achieved at surgery on final outcome. Injury 1995; 26: 169-173
- 10 Park JS, Kim YT, Choi SJ. Crisscross-type screw fixation for transcondylar fractures of distal humerus in elderly patients. Arch Orthop Trauma Surg 2014; 135: 1-7
- 11 Walz M, Auerbach F. Die distale intraartikuläre Humerusfraktur beim alten Menschen. Unfallchirurg 2006; 109: 940-947
- 12 Schuster I, Korner J, Arzdorf M. et al. Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma 2008; 22: 113-120
- 13 Korner J, Diederichs G, Arzdorf M. et al. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma 2004; 18: 286-293
- 14 Voigt C, Rank C, Waizner K. et al. Biomechanical testing of a new plate system for the distal humerus compared to two well-established implants. Int Orthop 2013; 37: 667-672
- 15 Hungerer S, Wipf F, von Oldenburg G. et al. Complex distal humerus fractures–comparison of polyaxial locking and nonlocking screw configurations – a preliminary biomechanical study. J Orthop Trauma 2014; 28: 130-136
- 16 Caravaggi P, Laratta JL, Yoon RS. et al. Internal fixation of the distal humerus: a comprehensive biomechanical study evaluating current fixation techniques. J Orthop Trauma 2014; 28: 222-226
- 17 Schmidt-Horlohé K, Hoffmann R. Die Gelenkfraktur des alten Menschen: to fix or to replace? – Distaler Humerus. Z Orthop Unfall 2015; 153: 597-606
- 18 Dietz SO, Nowak TE, Burkhart KJ. et al. Distale Humerusfraktur beim älteren Menschen. Unfallchirurg 2011; 114: 801-815
- 19 Zalavras CG, Vercillo MT, Jun BJ. et al. Biomechanical evaluation of parallel versus orthogonal plate fixation of intra-articular distal humerus fractures. J Shoulder Elbow Surg 2011; 20: 12-20
- 20 Stoffel K, Cunneen S, Morgan R. et al. Comparative stability of perpendicular versus parallel double-locking plating systems in osteoporotic comminuted distal humerus fractures. J Orthop Res 2008; 26: 778-784
- 21 Park SH, Kim SJ, Park BC. et al. Three-dimensional osseous micro-architecture of the distal humerus: implications for internal fixation of osteoporotic fracture. J Shoulder Elbow Surg 2010; 19: 244-250
- 22 Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elbow Surg 2010; 19: 2-9
- 23 OʼDriscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005; 14: S186-S194
- 24 Dubberley JH, Faber KJ, MacDermid JC. et al. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am 2006; 88: 46-54
- 25 Ashwood N, Verma M, Hamlet M. et al. Transarticular shear fractures of the distal humerus. J Shoulder Elbow Surg 2010; 19: 46-52
- 26 Giannicola G, Sacchetti FM, Greco A. et al. Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures. Acta Orthop 2010; 81: 228-233
- 27 Burkhart KJ, Müller LP, Schwarz C. et al. Behandlung der komplexen intraartikulären Fraktur des distalen Humerus mittels Latitude-Ellenbogenprothese. Oper Orthop Traumatol 2010; 22: 279-298
- 28 McKee MD, Veillette CJH, Hall JA. et al. A multicenter, prospective, randomized, controlled trial of open reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg 2009; 18: 3-12
- 29 Müller LP, Kamineni S, Rommens PM. et al. Primäre totale Ellenbogenprothese zur Versorgung distaler Humerusfrakturen. Oper Orthop Traumatol 2005; 17: 119-142
- 30 Müller LP, Wegmann K, Burkhart KJ. Frakturendoprothetik der distalen Humerusfraktur. Unfallchirurg 2013; 116: 708-715
- 31 Ellwein A, Lill H, Voigt C. et al. Arthroplasty compared to internal fixation by locking plate osteosynthesis in comminuted fractures of the distal humerus. Int Orthop 2015; 39: 747-754
- 32 Plaschke HC, Thillemann TM, Brorson S. et al. Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008. J Shoulder Elbow Surg 2014; 23: 829-836
- 33 Gay DM, Lyman S, Do H. et al. Indications and reoperation rates for total elbow arthroplasty: an analysis of trends in New York State. J Bone Joint Surg Am 2012; 94: 110-117
- 34 Day JS, Lau E, Ong KL. et al. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010; 19: 1115-1120
- 35 Morrey BF, Bryan RS. Complications of total elbow arthroplasty. Clin Orthop Relat Res 1982; 170: 204-212
- 36 Morrey BF. Fractures of the distal humerus: role of elbow replacement. Orthop Clin North Am 2000; 31: 145-154
- 37 OʼDriscoll SW, An KN, Korinek S. Kinematics of semi-constrained total elbow arthroplasty. J Bone Joint Surg Br 1992; 74: 797-799
- 38 Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992; 74: 479-490
- 39 Voloshin I, Schippert DW, Kakar S. et al. Complications of total elbow replacement: a systematic review. J Shoulder Elbow Surg 2011; 20: 158-168
- 40 Wagener ML, de Vos MJ, Hannink G. et al. Mid-term clinical results of a modern convertible total elbow arthroplasty. Bone Joint J 2015; 97-B: 681-688
- 41 Fevang B-TS, Lie SA, Havelin LI. et al. Results after 562 total elbow replacements: a report from the Norwegian Arthroplasty Register. J Shoulder Elbow Surg 2009; 18: 449-456
- 42 Choo A, Ramsey ML. Total elbow arthroplasty: current options. J Am Acad Orthop Surg 2013; 21: 427-437
- 43 Schultzel M, Scheidt K, Klein CC. et al. Hemiarthroplasty for the treatment of distal humeral fractures: midterm clinical results. J Shoulder Elbow Surg 2017; 26: 389-393
- 44 Mehlhoff TL, Bennett JB. Distal humeral fractures: fixation versus arthroplasty. J Shoulder Elbow Surg 2011; 20: S97-S106
- 45 Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg 2010; 18: 20-30
- 46 Pooley J, Salvador Carreno J. Total elbow joint replacement for fractures in the elderly–functional and radiological outcomes. Injury 2015; 46: S37-S42
- 47 Adolfsson L, Hammer R. Elbow hemiarthroplasty for acute reconstruction of intraarticular distal humerus fractures: a preliminary report involving 4 patients. Acta Orthop 2009; 77: 785-787
- 48 Chalidis B, Dimitriou C, Papadopoulos P. et al. Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature. Injury 2009; 40: 582-590
- 49 Burkhart KJ, Nijs S, Mattyasovszky SG. et al. Distal humerus hemiarthroplasty of the elbow for comminuted distal humeral fractures in the elderly patient. J Trauma 2011; 71: 635-642
- 50 Linn MS, Gardner MJ, McAndrew CM. et al. Is primary total elbow arthroplasty safe for the treatment of open intra-articular distal humerus fractures?. Injury 2014; 45: 1747-1751
- 51 Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly: a comparison of primary surgery and surgery after failed internal fixation or conservative treatment. J Bone Joint Surg Br 2008; 90: 343-348
- 52 Huang JI, Paczas M, Hoyen HA. Functional outcome after open reduction internal fixation of intra-articular fractures of the distal humerus in the elderly. J Orthop Trauma 2011; 25: 259-265
- 53 Ducrot G, Bonnomet F, Adam P. et al. Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years. Orthop Traumatol Surg Res 2013; 99: 145-154
- 54 Mansat P, Nouaille Degorce H, Bonnevialle N. et al. Total elbow arthroplasty for acute distal humeral fractures in patients over 65 years old – results of a multicenter study in 87 patients. Orthop Traumatol Surg Res 2013; 99: 779-784
- 55 Argintar E, Berry M, Narvy SJ. et al. Hemiarthroplasty for the treatment of distal humerus fractures: short-term clinical results. Orthopedics 2012; 35: 1042-1045
- 56 Frankle MA, Herscovici jr. D, DiPasquale TG. et al. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003; 17: 473-480
- 57 Githens M, Yao J, Sox A. Open reduction and internal fixation versus total elbow arthroplasty for the treatment of geriatric distal humerus fractures: a systematic review and meta-analysis. J Orthop Trauma 2014; 28: 481-488
- 58 Weber O, Burger C, Kabir K. et al. Primäre Alloarthroplastik des frakturierten Ellenbogens beim hochbetagten Patienten. Unfallchirurg 2009; 112: 778-784
- 59 Gambirasio R, Riand N, Stern R. Total elbow replacement for complex fractures of the distal humerus. J Bone Joint Surg Br 2001; 83: 974-978
- 60 Kraus E, Harstall R, Borisch N. et al. Primärer endoprothetischer Ellenbogengelenkersatz bei komplexen intraartikulären distalen Humerusfrakturen. Unfallchirurg 2009; 112: 692-698
- 61 Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. J Bone Joint Surg Br 2002; 84: 812-816
- 62 Ray PS, Kakarlapudi K, Rajsekhar C. et al. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. Injury 2000; 31: 687-692
- 63 Ali A, Shahane S, Stanley D. Total elbow arthroplasty for distal humeral fractures: indications, surgical approach, technical tips, and outcome. J Shoulder Elbow Surg 2010; 19: 53-58