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. Incidence, management, and prognosis of early ulnar nerve dysfunction in type C fractures of distal humerus. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures.
We conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Forty-two patients were randomized by sealed envelope. Inclusion criteria were age greater than 65 years; displaced, comminuted, intra-articular fractures of the distal humerus (Orthopaedic Trauma Association type 13C); and closed or Gustilo grade I open fractures treated within 12 hours of injury. Both ORIF and TEA were performed following a standardized protocol. The Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were determined at 6 weeks, 3 months, 6 months, 12 months, and 2 years. Complication type, duration, management, and treatment requiring reoperation were recorded. An intention-to-treat analysis and an on-treatment analysis were conducted to address patients randomized to ORIF but converted to TEA intraoperatively. Twenty-one patients were randomized to each treatment group. Two died before follow-up and were excluded from the study. Five patients randomized to ORIF were converted to TEA intraoperatively because of extensive comminution and inability to obtain fixation stable enough to allow early range of motion. This resulted in 15 patients (3 men and 12 women) with a mean age of 77 years in the ORIF group and 25 patients (2 men and 23 women) with a mean age of 78 years in the TEA group. Baseline demographics for mechanism, classification, comorbidities, fracture type, activity level, and ipsilateral injuries were similar between the 2 groups. Operative time averaged 32 minutes less in the TEA group (P = .001). Patients who underwent TEA had significantly better MEPSs at 3 months (83 vs 65, P = .01), 6 months (86 vs 68, P = .003), 12 months (88 vs 72, P = .007), and 2 years (86 vs 73, P = .015) compared with the ORIF group. Patients who underwent TEA had significantly better DASH scores at 6 weeks (43 vs 77, P = .02) and 6 months (31 vs 50, P = .01) but not at 12 months (32 vs 47, P = .1) or 2 years (34 vs 38, P = .6). The mean flexion-extension arc was 107 degrees (range, 42 degrees -145 degrees) in the TEA group and 95 degrees (range, 30 degrees -140 degrees) in the ORIF group (P = .19). Reoperation rates for TEA (3/25 [12%]) and ORIF (4/15 [27%]) were not statistically different (P = .2). TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS. DASH scores were better in the TEA group in the short term but were not statistically different at 2 years' follow-up. TEA may result in decreased reoperation rates, considering that 25% of fractures randomized to ORIF were not amenable to internal fixation. TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients have an increased baseline DASH score and appear to accommodate to objective limitations in function with time. Displaced comminuted of the distal humerus in adults are among the most complex fractures to be managed effectively. The ulnar nerve is at high risk of impingement secondary to injury, operation, and postoperative rehabilitation in these fractures. In this study we focus on the incidence, management, and prognosis of early ulnar nerve dysfunction in the course of treating type C fractures of distal humerus.
                We examine a patient sample of 117 consecutive AO type C fractures of distal humerus, between June 1998 and October 2005. Twenty-nine patients exhibited preoperative ulnar nerve compression symptoms (incidence 24.8%) and were divided into two groups randomly, which received treatment of anterior subfascial transposition or in situ decompression of the ulnar nerve respectively, in conjunction with internal fixation with medial and lateral plates.
                The subgroup of 88 patients without preoperative ulnar nerve symptoms remained asymptomatic postoperatively (0% incidence of late ulnar nerve dysfunction). According to Bishop rating system, excellent and good results of ulnar nerve function were achieved in 13 of 15 patients (86.7%) in the transposition group, 8 of 14 patients (57.1%) in the in situ decompression group. The results difference is statistically significant (p < 0.05).
                We conclude that neurolysis and anterior subfascial transposition of vascularized ulnar nerve during open reduction and internal fixation of type C fractures of the distal humerus is beneficial in cases of early ulnat nerve dysfunction. This study compared clinical outcomes in patients with intraarticular distal humerus fractures treated using 2 different double plating methods.
                Seventeen patients were treated by perpendicular plating (group I) and 18 by parallel plating (group II) methods. Arc of flexion averaged 106 degrees +/-23 degrees in group I and 112 degrees +/-19 degrees in group II.
                Eleven patients in group I recovered full arc of flexion and 13 patients in group II achieved full arc of flexion. All patients obtained bone union, except 2 patients in group I. Nonunion in these patients developed in the supracondylar area. Complications developed in 6 patients in group I and in 8 in group II. No significant differences were found between the clinical outcomes of the 2o plating methods.
                Although more patients failed to achieve bony union in the perpendicular plating group, both parallel and orthogonal plates positioning can provide adequate stability and anatomic reconstruction of the distal humerus fractures.
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Overall, this review found there is either no or insufficient evidence from randomised or quasi-randomised controlled trials to determine whether surgery is, and which surgical interventions are, the most appropriate for the management of different types of distal humerus fractures. Well designed and reported large and multi-centre randomised controlled trials testing current interventions, such as pre-contoured and locking plating systems, are needed.