Approaches to distal humerus fractures and nonunions

Advanced Fixation Techniques and Replacement Surgery Solve a Challenging Problem

Most orthopedic surgeons are challenged by a complex distal humerus fracture or an established distal humerus nonunion. Obtaining optimal functional outcomes for these patients has traditionally been difficult for multiple reasons, chief among them that comminution and bone deficiency complicate reconstructive surgery in an anatomic area with intricate geometry and a high propensity to stiffness and poor function.

Severe bone destruction

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"Many patients are left with either a stiff, dysfunctional elbow or a nonunion with gross instability," explains Joaquin Sanchez-Sotelo, M.D., Ph.D., an orthopedic surgeon specializing in elbow surgery at Mayo Clinic in Rochester, Minn. "Fortunately, our elbow group at Mayo Clinic has developed improved fixation techniques and has also been a pioneer in the field of replacement surgery for the salvage of selected fractures and nonunions. These two advances have changed the way distal humerus fractures and nonunions are treated all over the world."

An Improved Principle-Based Fixation Strategy

Orthopedic surgeon Shawn W. O'Driscoll, M.D., Ph.D., developed the principle-based parallel-plating internal fixation technique for both fractures and nonunions. Dr. Sanchez-Sotelo helped popularize the technique and independently reviewed the results obtained. "Dr. O'Driscoll's technique provides surprisingly robust fixation even in complex fractures considered unfixable in the past," explains Dr. Sanchez-Sotelo. "Traditional fixation techniques used in the past failed to provide sufficient stability. Our technique satisfies two major principles: maximal fixation in the distal fragments and true compression at the supracondylar level."

X-ray of improved parallel-plating technique

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Parallel-plating technique illustration

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The details of the principle-based internal fixation technique and the results obtained were published in the American edition of the Journal of Bone and Joint Surgery. In a selected group of complex fractures, results show that no patients experienced hardware failure or fracture re-displacement despite an aggressive physical therapy protocol.

Replacement as a Salvage Option

Mayo Clinic's Bernard F. Morrey, M.D., pioneered the use of replacement arthroplasty for the salvage of selected fractures and nonunions. "Early in my career, the orthopedic community showed reluctance to perform arthroplasty for these conditions. A linked arthroplasty design and a surgical technique that does not violate the triceps provide a low-morbidity and relatively easy procedure for patients with no other alternatives," explains Dr. Morrey.

"We just published the long-term results of elbow arthroplasty in distal humerus nonunions, with impressive clinical results and good durability. Some patients returned 20 years after surgery with well-functioning implants," Dr. Sanchez-Sotelo adds.

X-ray of elbow arthroplasty

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Elbow arthroplasty outcomes

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The study mentioned above, also recently published in the American edition of the Journal of Bone and Joint Surgery, included close to 100 elbow arthroplasties in patients with distal humerus nonunions who were followed for a mean of 6.5 years. Subjective satisfaction and implant survival at 5 years were both higher than 80 percent.

Innovation Well Served By Team Approach

The close collaboration of three elbow surgeons at Mayo Clinic has resulted in the development of two innovative orthopedic treatment alternatives that simply did not exist in the past. Patients all over the world now benefit from improved fixation techniques and replacement surgery.

Mayo Clinic and Dr. O'Driscoll receive royalties related to development of some of the technologies mentioned in this article.