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Management of acute distal humeral fractures in patients with rheumatoid arthritis. A case series

Bernhard Jost, Robert A Adams & Bernard F Morrey

abstract

BACKGROUND
The best surgical treatment for a patient with rheumatoid arthritis and an acute distal humeral fracture is not well established. Because of the distorted anatomy of the arthritic elbow joint and the adjacent osteoporotic bone, total elbow arthroplasty may be favored over open reduction and internal fixation in these patients. We retrospectively analyzed a series of patients with rheumatoid arthritis in whom an acute distal humeral fracture had been treated with either open reduction and internal fixation or total elbow arthroplasty; our purpose was to evaluate their outcomes and to identify any influence of age, fracture type, or the extent of the rheumatoid involvement of the elbow joint on the choice of procedure.

METHODS
Between 1982 and 2002, an acute distal humeral fracture was treated surgically in sixteen elbows in fourteen patients with rheumatoid arthritis, and the results were retrospectively reviewed at a minimum of twenty-four months postoperatively. Six elbows were treated with open reduction and internal fixation (Group 1) and ten elbows, with primary total elbow arthroplasty (Group 2). Postoperatively, the elbows were examined with standard radiographs, and the clinical outcome was assessed with the Mayo Elbow Performance Score (MEPS).

RESULTS
Six patients (six elbows) died before the time of the study, but they had been followed for more than twenty-four months and therefore were included in the series. The eight patients (ten elbows) who were still alive were examined. The mean duration of follow-up was forty-nine months in Group 1 and sixty-six months in Group 2. The MEPS averaged 93 points in Group 1 and 96 points in Group 2. Radiographically, all fractures had healed uneventfully in Group 1 and no prosthesis was loose in Group 2. We could not identify any difference between Groups 1 and 2 with respect to patient age, fracture type, or extent of the rheumatoid arthritis.

CONCLUSIONS
Distal humeral fractures in patients with rheumatoid arthritis can be treated successfully with immediate open reduction and internal fixation or with total elbow arthroplasty. Our data suggest that open reduction and internal fixation can be successful when there is mild arthritic involvement. We favor total elbow arthroplasty for patients with severe articular involvement.

LEVEL OF EVIDENCE
Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
   
citation Jost B, Adams R A, Morrey B F. Management of acute distal humeral fractures in patients with rheumatoid arthritis. A case series. J Bone Joint Surg Am 2008; 90:2197-205.
   
type journal paper/review (English)
date of publishing 10-2008
journal title J Bone Joint Surg Am (90/10)
ISSN electronic 1535-1386
pages 2197-205
PubMed 18829918
DOI 10.2106/JBJS.G.00024