Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for Intra-articular Distal Humerus Fractures in Patients 65 Years or Older: A Meta-analysis

BACKGROUND: Distal humerus fractures (DHF) in the elderly pose a challenge due to osteoporotic bone, comminution, and potential for poor functional recovery. Surgical management typically involves open reduction and internal fixation (ORIF) or total elbow arthroplasty (TEA). However, inconsistent findings across studies have led to uncertainty regarding which intervention optimizes outcomes, underscoring the need for a rigorous meta-analysis to guide clinical decision making. METHODS: A systematic literature search was conducted across PubMed, Scopus, Cochrane Library, and Google Scholar for studies published up to October 28, 2025. Randomized controlled trials and comparative studies evaluating ORIF vs. TEA in patients older than 65 years with DHF were included. Seven studies (1,347 patients aged ≥65 years) met inclusion criteria. Key outcome measures included the DASH score, flexion-extension arc, hospital stay, surgical time, complication rate, infection rate, revision surgery rate, and Mayo Elbow Performance Score. RESULTS: Pooled analysis demonstrated that TEA was associated with a statistically significant improvement in elbow flexion-extension range of motion compared with ORIF (mean difference: -9°, 95% confidence interval, -14.72 to -3.28; P = 0.002). No statistically significant differences were observed between TEA and ORIF about surgical time, hospital length of stay, Mayo Elbow Performance Score, overall complication rates, infection rates, or revision surgery rates (all P > 0.05). CONCLUSION: In elderly patients with intra-articular DHF, TEA provides a modest but statistically significant improvement in elbow range of motion compared with ORIF, although this difference is below commonly reported thresholds for minimal clinically important difference. These findings support an individualized treatment approach, favoring ORIF when durable fixation is achievable, while reserving TEA for carefully selected low-demand or frail patients with fracture patterns unlikely to permit stable reconstruction. Long-term implications of implant-related failure should be considered in surgical decision making. LEVEL OF EVIDENCE: Meta-analysis, Level II.