Treatment of the Complex Intraarticular Fracture of the Distal Humerus with the Latitude Elbow Prosthesis

Objective Therapy of comminuted intraarticular distal humerus fractures in elderly patients with primary total elbow arthroplasty to achieve stable and painless function. Use of "third-generation" elbow prosthesis with the following options: -linked total elbow arthroplasty, -unlinked total elbow arthroplasty, -either with or without radial head replacement, -hemiarthroplasty. Indications Comminuted intraarticular distal humerus fractures with poor bone quality, in which stable osteosynthesis is impossible. Failure of internal fixation without the technical possibility of revision osteosynthesis. Posttraumatic osteoarthritis or rheumatoid arthritis. Contraindications Open fractures (Gustilo-Anderson type II or III) or contaminated wounds should not initially be treated with total elbow arthroplasty. Prosthetic replacement may be considered after consolidation of the soft tissue. Low compliance, high functional demands. Paralysis of the biceps muscle. Surgical Technique Supine positioning of the patient. Surgical approach after Bryan-Morrey. Anterior transposition of the ulnar nerve. Preparation of the insertion of the triceps at the distal humerus, capsule and proximal ulna. Reflection of the triceps in continuity with the ulnar periosteum and the forearm fascia. Attempt at reconstruction of the epicondyles to achieve ligamentary stability and to implant an unlinked prosthesis. If this is technically not possible, the prosthesis is linked at the end of the operation. Removal of the distal humerus fragments. Determination of the prosthesis size. Detection of the extension-flexion axis. Opening of the humeral intramedullary canal. Determination of the offset. Preparation of the humeral prosthesis repository. Placement of the trial prosthesis. Potential implantation of a hemiprosthesis, if radial head, proximal ulna and ligaments are unaffected. Otherwise preparation of the ulnar prosthesis repository. If the radial head is unaffected, it can be preserved. Otherwise it has to be resected and preferably replaced. Placement of the ulnar and radial trial prosthesis. After correct trial reposition cementing of all definitive prosthesis components with attachment of a cortical bone graft behind the ventral flange of the humeral component. If there is no sufficient stability at the end of the operation, the prosthesis must be linked by insertion of the ulnar cap. Postoperative Management Postoperative anterior upper-arm splint in full extension. Active motion. No active extension for 6 weeks. Avoidance of single-event weight lifting > 5 kg, no repetitive weight lifting > 1 kg, and no forced elbow movements, e.g., racquet sports. Results 15 Latitude elbow prostheses were implanted in 2007 and 2008 at the Department of Trauma Surgery of the University Hospital Mainz, Germany, due to the following indications:fractures (n = 7), pseudarthrosis (n = 4), posttraumatic osteoarthritis (n = 3), and rheumatoid arthritis (n = 1). Six hemiprostheses, two unlinked and seven linked prostheses were implanted. The mean age of patients was 67 years (31-88 years). For the treatment of acute fractures, the indication was made only in elderly patients. The mean age was 77 years (66-88 years). Eleven of these 15 patients were reexamined after 13.5 months (6-23 months). The mean extension deficit was 15 degrees (0-30 degrees), the mean flexion 119 degrees (95-140 degrees). The mean pronation was 78 degrees (60-90 degrees), the mean supination 79 degrees (50-90 degrees). According to the Mayo Elbow Performance Score, three patients achieved an excellent, seven a good, and one a fair result. The mean Mayo Score was 89.2 (74-100). The mean DASH (Disabilities of the Arm, Shoulder and Hand) Score was 8.4 (0-28).