Hemiarthroplasty vs. open reduction and internal fixation for comminuted distal humerus fractures in patients under 65 years: a systematic review

TL;DR

This study compares two surgical treatments for complex elbow fractures in patients under 65 and finds that one method leads to better outcomes.

Contribution

The study provides a systematic comparison of ORIF and HA for distal humerus fractures in younger patients.

Findings

ORIF showed better functional outcomes and fewer complications compared to HA.

HA had higher rates of stiffness, hardware discomfort, and revision surgeries.

HA may be suitable for highly comminuted fractures that cannot be repaired with ORIF.

Abstract

Comminuted articular fractures of the distal humerus present a significant surgical challenge due to their complexity. Complications are common, and achieving optimal functional outcomes is crucial, particularly in young, active patients. This study aims to compare the outcomes of open reduction and internal fixation (ORIF) with those of hemiarthroplasty (HA) in patients under 65 years old.

This study is a systematic review and comparative analysis of patients under 65 years of age with comminuted articular fractures of the distal humerus, identified from the existing literature. A comprehensive search of PubMed, Cochrane, and Embase databases was conducted using predefined keywords. Only studies providing detailed individual patient data, including preoperative diagnosis and clinical outcomes after either ORIF or HA, were included. Patients were allocated into 2 groups (ORIF and HA) based on the reported surgical procedure. The primary outcomes assessed were functional results (range of motion, pain (visual analog scale); Disabilities of the Arm, Shoulder, and Hand; and Mayo Elbow Performance scores) and complication rates. The risk of bias and methodological quality of included studies were assessed using the Newcastle-Ottawa Scale.

With an average follow-up of 66 ± 34 months, the 2 groups were comparable in terms of sex, age, follow-up duration, and fracture type according to the Arbeitsgemeinschaft für Osteosynthesefragen classification. The ORIF group included 74 patients (56.8% female, mean age 52 years), and the HA group included 68 patients (70.6% female, mean age 57 years). No significant differences were found between the groups for visual analog scale; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder, and Hand score; flexion; pronation; and supination. The HA group showed a significantly greater loss of extension (22° vs. 14°, P = .013) and a lower flexion-extension arc (97° vs. 109°, P = .024). Complications were more frequent in the HA group (54.4% vs. 22.7%, P = .002), including stiffness, olecranon hardware discomfort, and clinical instability. The overall revision rate was higher in the HA group (23.5% vs. 8.1%, P = .02), mainly due to olecranon hardware revisions (45.4% vs. 0%, P < .001). Heterotopic ossifications were also more frequent in the HA group (45.8% vs. 20%, P = .027).

For comminuted distal humerus fractures in young patients, ORIF appears to be the preferred surgical option, offering superior functional outcomes and a lower incidence of complications and heterotopic ossification. HA can be used in highly comminuted fractures that cannot be reconstructed with a solid ligament suture or column osteosynthesis and without olecranon osteotomy.

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