DELAYED TOTAL ELBOW ARTHROPLASTY FOR MANAGEMENT OF FAILED FIXATION, NONUNION, AND POST-TRAUMATIC ARTHRITIS OF DISTAL HUMERUS FRACTURES: DO OUTCOMES COMPARE TO ACUTE TOTAL ELBOW ARTHROPLASTY?

While advances in anti-rheumatic medications have decreased the need for total elbow arthroplasty (TEA) in patients with rheumatoid arthritis, TEA rates after trauma have nearly doubled over the last decade. Primary TEA for acute management of severely comminuted distal humerus fractures has shown favourable outcomes in low-demand elderly patients; however, less is known about the safety and efficacy of delayed TEA following failed fixation or nonoperative management. This systematic review aimed to: (1) assess clinical and functional outcomes following delayed TEA for failed fixation, non-union, or posttraumatic arthritis after distal humerus fracture and; (2) compare outcomes with those following TEA performed acutely. MEDLINE, EMBASE, and Cochrane CENTRAL Register of Controlled Trials databases were queried for articles reporting complications, reoperations, or functional outcomes of delayed TEA for management of failed operative fixation, non-union, or posttraumatic arthritis after distal humerus fracture. Studies published between January 2000 to September 2024 were included. Demographic and clinical data were collected, descriptive statistics were summarized, and meta-analysis was performed to compare outcomes to those following acute TEA. Sixteen studies were included, encompassing 380 patients (mean age 63.5 years, 77.1% female) receiving delayed TEA with average follow-up ranging from 11.1–73.0 months. Among reporting studies, delayed TEA was most commonly indicated for failed operative fixation (47.9%), followed by non-union (32.0%) and posttraumatic arthritis (20.1%). Nine studies additionally assessed 251 patients (mean age 73.8 years, 74.8% female) with distal humerus fracture treated with acute TEA for comparative purposes. Pooled analyses noted significant differences in fracture classification (p = 0.003)and surgical approach (p = 0.002) between cohorts. Specifically, patients undergoing delayed TEA demonstrated lower rates of AO type C fracture (68.1% vs. 83.4%) and greater utilization of the triceps sparing approach (53.8% vs. 37.0%). Complications were more common following delayed TEA (46.3% vs. 29.1%, p < 0.001) secondary to increased incidence of nonoperative ulnar neuropathy (6.3% vs. 2.4%, p = 0.027) and aseptic loosening (10.0% vs. 2.4%, p < 0.001), although heterotopic ossification developed more often after acute TEA (3.2% vs. 8.4%, p = 0.003). Reoperation rates were higher after delayed TEA (23.2% vs. 13.9%, p = 0.006). Meta-analyses determined delayed TEA patients achieved similar elbow flexion (mean difference [MD] −2.40°, 95% confidence interval [CI] −9.11° – 4.31°), extension (MD 1.08°, 95% CI −2.30° − 4.46°), pronation (MD 0.00°, 95% CI −1.07° − 1.06°), and supination (MD −0.04°, 95% CI −0.97° − 0.89°) relative to acute TEA patients at final follow-up. Nevertheless, Mayo Elbow Performance Scores were lower after delayed TEA (MD −9.69, 95% CI −18.79 – −0.59). This review demonstrated that patients generally do well following delayed TEA for management of failed fixation, non-union, or posttraumatic arthritis after distal humerus fracture at mid-term follow-up. However, complication and reoperation rates were higher and functional outcomes were slightly inferior relative to patients with distal humerus fracture treated acutely with TEA. These findings warrant the consideration of surgeons and patients alike to inform surgical decision-making and accurately manage expectations for those with traumatic distal humerus pathology.