Abstract
Background
Treatment of distal humerus fractures (DHF) in older patients presents challenges due to high complication rates. Total elbow arthroplasty (TEA) has emerged as an alternative to open reduction and internal fixation (ORIF). This study investigates trends, outcomes, and risk factors associated with TEA and ORIF for the treatment of DHF.
Methods
Using the PearlDiver Mariner database, patients aged 55 years and older treated with either TEA or ORIF for DHF between 2010 and 2021 were identified. Trends in procedure volume, 90-day complications (postoperative bleeding, wound disruption, thromboembolic events, infection), and 12-month revision rates were analyzed. Risk factors (age, gender, diabetes, tobacco use, obesity, chronic kidney disease) were assessed using exact matching (1:4 ratio) and multivariable logistic regression.
Results
A total of 16,572 patients were reviewed, including 1825 treated with TEA and 14,747 with ORIF. TEA utilization peaked in 2014 but declined thereafter. Both TEA and ORIF showed decreased complication and revision rates over time. After exact matching (n = 8989; 1800 TEA, 7189 ORIF), TEA was associated with significantly higher 90-day postoperative bleeding (OR: 2.51, p < 0.001) and infection rates (OR: 1.83, p < 0.0001). Multivariable logistic regression showed that tobacco use increased wound disruption (OR: 1.71, p = 0.002), while chronic kidney disease was a predictor of infection (OR: 1.62, p < 0.001).
Conclusion
TEA utilization for DHF has declined, possibly due to its association with a 2.5-fold higher risk of postoperative bleeding and 1.8-fold higher risk of infection compared to ORIF. Further assessment of treatment trends and their impact on clinical practice is needed.
Keywords: Elbow joint, Arthroplasty, Fracture fixation, Humeral fractures, Aged
1. Background
Distal humerus fractures (DHF) account for approximately 2 % of total fractures in adults, and can be challenging to treat due to comminution and intra-articular extension.1,2 The incidence of DHF follows a bimodal distribution, typically occurring early in young, healthy patients with high-energy trauma, and later in life with geriatric patients as a result of lower-energy injuries, such as falls.2,3 As the U.S. population ages, the incidence of geriatric DHF is steadily rising, highlighting the need to optimize treatment strategies.1,4,5
Surgical osteosynthesis remains the treatment of choice for most DHF. However, recent literature has highlighted controversy surrounding this standard intervention. Plate osteosynthesis (open reduction and internal fixation, ORIF) is conventionally preferred in younger patients with favorable bone density as it preserves the anatomical integrity of the joint and avoids the potential complications associated with arthroplasty.6 Advancements in locking plate technology, improved fixation constructs, and a better understanding of ORIF biomechanics have further refined surgical fixation techniques, enhancing construct stability and reducing failure rates.7 O'Driscoll et al. emphasized that parallel plating in the sagittal plane provides greater biomechanical stability than traditional 90°/90° constructs, while interdigitating screws enhance fixation strength in distal fragments, particularly in cases of severe comminution.8
In contrast, total elbow arthroplasty (TEA) has been suggested for the surgical treatment of complex comminuted DHF in elderly, low-demand patients with poor bone quality, extensive articular comminution, and/or prior end stage osteoarthritis/rheumatoid arthritis.9,10 Continued improvements in implant design, polyethylene wear resistance, and cement fixation techniques have aimed to reduce implant loosening and long-term mechanical failure, potentially expanding the role of TEA in treating complex fractures.11 Advantages of TEA over ORIF include potentially faster rehabilitation with earlier motion and improved short-term outcomes.9 However, TEA entails a lifelong burden of weight-bearing restrictions, a potential need for revision arthroplasty, and its own set of complications, including loss of bone stock, implant loosening, instability, deep infection, and periprosthetic fracture.10
Conversely, ORIF is also not without its drawbacks. Potential complications associated with ORIF include fixation failure, persistent pain and/or stiffness, heterotopic ossification, ulnar neuropathy, nonunion, malunion, and posttraumatic arthritis.12 Therefore, with the predicted boom of an aging population and advancements in implant technology and surgical expertise, an argument has emerged for a widened scope of usage for TEA in treating DHF.13
Despite increasing literature on the role of TEA in DHF management, its adoption trends and comparative outcomes with ORIF remain undefined at a national level. Understanding learning curves, adoption rates, utilization trends, and complication data is critical to appreciating practice patterns in DHF management. This study leverages a large-scale U.S. database to analyze 10-year trends, complication rates, and practice patterns in geriatric DHF management. We hypothesized that the utilization of TEA has increased over time in response to evolving evidence supporting its role in treating DHF.
2. Materials and methods
2.1. Data source and study population
A United States national insurance database, PearlDiver, was queried to establish trends and utilization data for DHF. The PearlDiver database is a commercially available insurance dataset containing private and public insurance data on 250 million people across the United States. Patients can be selected and filtered based on Current Procedural Terminology (CPT), International Classification of Diseases, 9th and 10th revision, and Clinical Modification (ICD-9-CM, ICD-10-CM) diagnostic and procedural coding. All data in the PearlDiver database are fully de-identified and compliant with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which protects patient confidentiality. As this study involved retrospective analysis of a de-identified database, it was deemed exempt from Institutional Review Board (IRB) approval in accordance with federal regulations (45 CFR 46.104), which state that research involving publicly available, de-identified data does not meet the definition of human subjects research.
Using ICD-9 and ICD-10 diagnosis codes, the M161 dataset within PearlDiver was queried to identify all patients aged 55 and older with DHF from 2010 to the first quarter of 2021. This lower age threshold was chosen to ensure that no patients slightly younger than 60 years—where TEA is more commonly recommended—were inadvertently excluded, allowing for a more comprehensive analysis of treatment patterns. Prior literature, including Chadwick et al., has used 60 years as a guideline for TEA candidacy14; however, we extended inclusion to 55 years to capture a broader population potentially considered for either TEA or ORIF.
Inclusion in the study required treatment of the fracture within 2 weeks of injury, and all patients required a minimum of 12 months of postoperative follow-up with continued database enrollment. Exclusion criteria included pediatric patients, adults younger than 55 years old, non-articular fractures of the distal humerus, and prior or current diagnosis of cancer. Additionally, patients with a previous DHF, either ipsilateral or contralateral, were excluded to ensure a cohort of patients with primary, first-time injuries. This was done to minimize potential confounding from prior surgical interventions, altered bone quality, or prior treatment choices that could influence outcomes.
Patients were then divided into TEA or ORIF cohorts based on initial treatment modality, identified through ICD-9/10 procedure and CPT codes. The specific codes used for cohort identification are detailed in Table 1.
Table 1.
ICD-9-PCS, ICD-10-PCS, and CPT procedure codes used to identify TEA and ORIF procedures in the PearlDiver national insurance database.
| Procedure Type | ICD PCS Procedure Codes Used | CPT Procedure Code(s) Used |
|---|---|---|
| TEA |
ICD-9-P-8184, | CPT-24363 |
| ICD-10-P-0RGM0ZZ, | ||
| ICD-10-P-0RGL04Z, | ||
| ICD-10-P-0RGL07Z, | ||
| ICD-10-P-0RGL0JZ, | ||
| ICD-10-P-0RGL0KZ, | ||
| ICD-10-P-0RGL0ZZ, | ||
| ICD-10-P-0RGM04Z, | ||
| ICD-10-P-0RGM05Z, | ||
| ICD-10-P-0RGM07Z, | ||
| ICD-10-P-0RGM0JZ, | ||
| ICD-10-P-0RGM0KZ, | ||
| ICD-10-P-0RHL33Z, | ||
| ICD-10-P-0RHM33Z, | ||
| ICD-10-P-0RPL03Z, | ||
| ICD-10-P-0XHB33Z, | ||
| ICD-10-P-0XHB43Z, | ||
| ICD-10-P-0XHC33Z | ||
| ORIF | ICD-9-P-7931, | CPT-24545, |
| ICD-10-P-0RGM04Z, | CPT-24546, | |
| ICD-10-P-0RGL04Z, | CPT-24575, | |
| ICD-10-P-0RHM04Z, | CPT-24579, | |
| ICD-10-P-0RHL04Z, | CPT-24586 | |
| ICD-10-P-0RSM04Z, | ||
| ICD-10-P-0RSL04Z |
2.2. Patient characteristics and outcomes
Demographic data (e.g., age, gender), comorbidities (e.g., diabetes, obesity, tobacco use, chronic kidney disease), and known risk factors for complications following each treatment modality were collected.15, 16, 17 Early complications within 90 days (e.g., postoperative bleeding, wound disruption, thromboembolic events, infection) and 12-month revision rates were also gathered. Complication categories were defined using ICD-9/10 diagnosis codes: bleeding (postoperative hemorrhage, hematoma, device-related bleeding), wound disruption (dehiscence, delayed healing), infections (surgical site, periprosthetic joint, osteomyelitis), and thromboembolic events (DVT, PE). Revisions were identified via CPT and ICD-9/10 procedural codes for repeat ORIF, TEA, hardware removal, and revision arthroplasty.
2.3. Utilization and outcome analysis
The year-over-year utilization rates of TEA and ORIF were tracked from 2010 to the first quarter of 2021, inclusive. Comparative complication rates between the two treatments were visualized over time. Exact cohort matching (1:4 ratio) was applied to control for established risk factors and potential confounders, ensuring comparable groups between TEA and ORIF. Secondary outcomes included complication rates over the study period, analyzed through year-over-year trends.
2.4. Statistical analysis
Statistical analysis was performed using R software (version 4.1.0; The R Foundation for Statistical Computing) integrated into PearlDiver. Chi-square analysis was performed to compare complication and revision rates between TEA and ORIF cohorts. Multivariable logistic regression was used to compute odds ratios (ORs) for key covariates (e.g., age, gender, diabetes, obesity, tobacco use, chronic kidney disease) identified through univariable regression.
Given the large sample size of the national database, which increases the statistical power and the likelihood of detecting small differences as statistically significant, the threshold for statistical significance was set at p < 0.01. This was done to reduce the risk of false positives (Type I error) and to ensure that the reported findings are clinically meaningful and not merely artifacts of the large dataset.
3. Results
3.1. Trends in management
After initial data review, 16,572 patients met the inclusion criteria for the study between 2010 and 2021, with 1825 in the TEA group and 14,747 in the ORIF group. The overall mean patient age was 69.0 years (SD: 7.3), with female patients comprising 78.4 % of the cohort. The mean age was 71.0 (SD: 6.7) in the TEA group and 68.7 (SD: 7.3) in the ORIF group. Both groups had a majority of female patients, though the TEA cohort had a significantly higher percentage (85.2 % vs 77.6 %, p < 0.001). Over the study period, the mean age of all patients increased, with a corresponding upward trend in the prevalence of all tracked comorbidities.
The yearly ratio of TEA:ORIF reached a peak in 2014 at 0.150 but trended downwards over time, with the lowest ratio of 0.093 observed in 2019 [Fig. 1]. Prior to patient matching, overall trends in complication rates were analyzed, demonstrating a decline over the 10-year period for both TEA and ORIF [Fig. 2]. The complications analyzed included postoperative bleeding (90 days), wound disruption (90 days), thromboembolism (90 days), infection (90 days), and revision procedures performed (12 months). Similarly, yearly revision rates decreased following ORIF, while they remained stable for TEA, though significant variation was observed within the database [Fig. 3].
Fig. 1.
Annual trends in TEA and ORIF procedure volumes from 2010 to 2020. The TEA:ORIF ratio line highlights shifts in surgical preference over time. TEA procedures have experienced yearly declines in the total number of procedures after a peak in 2014.
Fig. 2.
Annual trends in 90-day complication rates following TEA and ORIF. This figure presents the year-over-year incidence of postoperative complications, including bleeding, wound disruption, thromboembolism, and infection, comparing TEA and ORIF cohorts from 2010 to 2020. Complication rates were consistently higher in the TEA cohort across the study period. Downward trends were observed for both TEA (R2 = 0.538) and ORIF (R2 = 0.932).
Fig. 3.
Annual trends in 12-month revision rates following TEA and ORIF. This figure illustrates the year-over-year revision rates within one year of the initial procedure, comparing long-term failure rates between TEA and ORIF cohorts from 2010 to 2020. ORIF demonstrated a strong downward trend in revision rates over time (R2 = 0.797). In contrast, TEA showed minimal change, with no meaningful trend in revision rate reduction over the same period (R2 = 0.004).
3.2. Complications and revision
After employing a 1:4 exact matching method, a total of 8989 patients (1800 for TEA, 7189 for ORIF) were identified. Exact matching produced similar groups matched for risk factors and was found to mirror that of the larger unmatched population [Table 2].
Table 2.
Demographic and comorbidity characteristics of the matched cohort following 1:4 exact matching. This table summarizes baseline characteristics of all included patients (n = 8989), stratified by treatment group (TEA: n = 1800; ORIF: n = 7189). Demographics include age distribution and gender, while comorbidities include known risk factors such as tobacco use, chronic kidney disease, diabetes, and obesity.
| All Patients (n = 8989) | TEA (n = 1800) | ORIF (n = 7189) | |
|---|---|---|---|
| DEMOGRAPHICS | |||
| Female Gender | 7670 (85.33 %) | 1535 (85.28 %) | 6135 (85.3 %) |
| Age 55-59 | 720 (8.01 %) | 144 (8.00 %) | 576 (8.01 %) |
| Age 60-64 | 1064 (11.84 %) | 213 (11.83 %) | 851 (11.84 %) |
| Age 65-69 | 1263 (14.05 %) | 253 (14.06 %) | 1010 (14.05 %) |
| Age 70-74 | 2835 (31.53 %) | 567 (31.50 %) | 2268 (31.56 %) |
| Age 75-79 | 2614 (29.06 %) | 524 (29.11 %) | 2090 (29.08 %) |
| Age 80+ | 493 (5.48 %) | 99 (5.50 %) | 394 (5.48 %) |
| COMORBIDITIES | |||
| Tobacco | 1365 (15.18 %) | 274 (15.22 %) | 1091 (15.17 %) |
| Chronic kidney disease | 1377 (15.32 %) | 277 (15.39 %) | 1100 (15.30 %) |
| Diabetes | 3713 (41.30 %) | 743 (41.28 %) | 2970 (41.32 %) |
| Obesity | 1294 (14.39 %) | 260 (14.44 %) | 1034 (14.38 %) |
Postoperative bleeding within 90 days showed a significant difference between TEA and ORIF (OR: 2.51 [1.50–4.21], p < 0.001) based on chi-square analysis. Infection within 90 days postoperatively also was significantly different between TEA and ORIF (OR: 1.83 [1.42–2.39], p < 0.0001). There were no significant differences found between TEA and ORIF for wound disruption within 90 days, thromboembolism within 90 days, or revision surgery within 12 months [Table 3].
Table 3.
Chi-square analysis comparing 90-day postoperative complications and 12-month revision rates between TEA and ORIF cohorts. Complications assessed include postoperative bleeding, wound disruption, thromboembolism, and infection, with statistical significance determined using chi-square testing (p < 0.01 considered significant and bolded for emphasis).
| All Patients (n = 8989) | TEA (n = 1800) | ORIF (n = 7189) | p value | OR (95 % CI) | |
|---|---|---|---|---|---|
| Postoperative Bleeding (90d) | 60 (0.67 %) | 23 (1.28 %) | 37 (0.51 %) | <0.001 | 2.51 (1.50 to 4.21) |
| Wound Disruption (90d) | 153 (1.70 %) | 41 (2.28 %) | 112 (1.56 %) | 0.03 | 1.46 (1.03–2.08) |
| Thromboembolism (90d) | 133 (1.48 %) | 23 (1.28 %) | 110 (1.53 %) | 0.43 | 0.84 (0.53–1.31) |
| Infection (90d) | 254 (2.83 %) | 80 (4.44 %) | 174 (2.42 %) | <0.0001 | 1.83 (1.42 to 2.39) |
| Revision (12mo) | 393 (4.37 %) | 62 (3.44 %) | 331 (4.60 %) | 0.03 | 0.75 (0.57–0.98) |
Multivariable logistic regression demonstrated significant associations between tobacco use and an increased risk of wound disruption (OR: 1.71 [1.22–2.39], p = 0.002). Infection risk was significantly higher in older patients (OR: 0.97 [0.95–0.98], p < 0.001) and those with chronic kidney disease (OR: 1.62 [1.26–2.08], p < 0.001). For revision surgery, age was the only significant predictor (OR: 0.98 [0.96–0.99], p = 0.002) [Table 4].
Table 4.
Multivariable logistic regression analysis assessing independent predictors of postoperative complications and revision in TEA patients. Significant predictors were identified through univariable regression, with variables meeting a threshold of p < 0.01 included in the final multivariable model.
| p value | OR (95 % CI) | |
|---|---|---|
| Wound Disruption | ||
| Age | 0.038 | 0.98 (0.95–0.99) |
| Tobacco | 0.002 | 1.71 (1.22–2.39) |
| Infection | ||
| Age | <0.001 | 0.97 (0.95–0.98) |
| Tobacco | 0.250 | 1.16 (0.90–1.49) |
| Chronic kidney disease | <0.001 | 1.62 (1.26–2.08) |
| Obesity | 0.079 | 1.26 (0.97–1.62) |
| Gender (male) | 0.570 | 1.10 (0.79–1.52) |
| Revision | ||
| Age | 0.002 | 0.98 (0.96–0.99) |
| Obesity | 0.013 | 1.31 (1.06–1.62) |
4. Discussion
In brief, this was a retrospective observational study using a national administrative database to evaluate trends and outcomes of TEA and ORIF for DHF in older adults.
Recent literature on the indications and outcomes for TEA has been positive, leading to a presumed increase in interest and expectations for TEA utilization. While the overall number of patients undergoing ORIF remains higher than that of patients undergoing TEA, one study in Germany and another from six registries from Australia, the Netherlands, New Zealand, Norway, the United Kingdom, and Sweden reported an increase in TEA use, especially for acute trauma.18,19 Conversely, our study demonstrates a downward trend over a 10-year period in both the yearly ratio of TEA:ORIF and the total number of yearly TEA procedures, indicating that U.S. surgeons have not followed similar global trends during this period.
Several factors may contribute to the differences in TEA utilization across countries. Differences in surgeon training and guidelines appear to be influential. In the U.S., trauma surgeons—who typically manage DHF—may favor ORIF due to limited TEA exposure, whereas countries like the UK have centralized elbow arthroplasty in high-volume centers, enhancing surgeon proficiency and confidence.20 Healthcare economics further influence treatment patterns. In the U.S. fee-for-service model, financial considerations may favor ORIF and disincentivize TEA utilization.21 Publicly funded systems abroad may better absorb these costs when outcomes justify the procedure, contributing to greater adoption.22
Poff et al. similarly highlighted the decreasing utilization of TEA as early as 2011,23 but no study to date has directly compared the utilization rates of TEA or the ratio of TEA to ORIF at a national level. This trend may reflect increasing awareness and a caution regarding the higher complication rates for TEA as seen in current literature. Interestingly, our study also noted a decline in the rates of complications from 2010 to Q1 2021, suggesting potential improvements in perioperative care and implant technology.
One previously well reported reason for the lack of wide adoption of TEA for DHF is that use of TEA may be associated with more immediate complications than ORIF. While in our study, both complication and revision rates for TEA and ORIF trended downwards over time, 90-day complication rates were still elevated overall for TEA. Multiple studies have noted that primary total elbow replacement for treatment of complex DHF, particularly in elderly patients, can lead to satisfactory short-term outcomes, but also warned of the high complication rates after TEA.9,10,24 Another contributing factor to the cautious approach towards TEA may be recent improvements in ORIF techniques.25 Historically, poor outcomes after ORIF of the distal humerus resulted from older, non-locking, non-anatomically contoured plates, along with more limited overall understanding of the fixation principles in these challenging fractures.9,26 Modern techniques and implant designs, such as locking plates and other advanced elbow fixation technologies, have since addressed many of the previous constraints regarding fixation efficacy and durability. These improvements have likely contributed to a decrease in complication rates associated with ORIF and may influence surgeons to favor ORIF over TEA in suitable cases.
Overall, TEA is associated with lower revision rates and greater longevity over ORIF, although this was not the focus of the current study. In a randomized-controlled study by Dehghan et al., only 1 of 25 TEA patients required revision arthroplasty within a minimum follow-up period of 2 years postoperatively. Notably, over 50 % of the patients in this study were deceased prior to the final follow-up, which underscores the rationale behind our study's focus on the 1-year mark following surgery.27 Several studies, including one by Goyal et al., indicate that DHF may be an indicator of patient frailty, leading to higher mortality rates. This factor could confound the evaluation of long-term complication rates, potentially contributing to the observed lower revision rates in short-term follow-ups.28 A systematic review by Seok et al. found that reoperation rates have been inconsistent in studies, and this may suggest that for even longer-term periods, the advantage of TEA over ORIF becomes negligible when compared based on the risk of requiring revision surgery.29
Understanding the risk factors associated with treatment outcomes and complications is critical to informed patient discussion and treatment selection. Tobacco is a well-documented risk factor for wound disruption following total joint arthroplasty,30,31 and this study mirrors those findings for TEA. While previous studies have elucidated several risk factors associated with infection, non-union and other complications in ORIF and within the arthroplasty literature itself, no studies to date have specifically investigated the relationship between chronic kidney disease and infection in TEA.
Previous studies in knee and hip arthroplasty have highlighted the impact of chronic kidney disease on postoperative outcomes, including a 2020 meta-analysis that identified dialysis-dependent patients as particularly at risk for complications and mortality.32 Similarly, Polachek et al. and Baker et al. both found diabetic kidney disease to be associated with increased complications rates following fracture surgery for ankle and proximal humerus respectively. In the ankle there was a fivefold increase in complications overall, while for the proximal humerus, non-union (OR: 1.48, p < 0.001) and post-op infection (OR: 1.26, p < 0.001) illustrated the negative effect of kidney disease on orthopaedic outcomes.33,34 These findings underscore that chronic kidney disease is a systemic risk factor for surgical complications across multiple anatomic sites, necessitating further investigation in TEA. Our study builds on this existing literature by specifically examining chronic kidney disease as a risk factor in upper extremity arthroplasty.
The current study has several important limitations, many of which are characteristic of large, retrospective database studies. First, while our findings highlight associations, they do not establish causation. Database studies are well-suited for detecting trends and offering population-level insights, but they lack clinical detail. Second, database studies rely on the integrity and quality of the data put into the database, and as such there is a potential for human error in coding and billing. Third, it is possible that TEA was preferentially selected for frailer patients or those with more complex fracture patterns, introducing residual confounding despite exact matching. Additionally, the PearlDiver database does not capture detailed factors such as surgeon experience, hospital type, or implant brand, all of which are known to influence surgical outcomes. While these variables could impact individual patient results, our study was designed to evaluate broad utilization patterns and population-level outcomes rather than specific predictors of revision or surgical failure.
Our analysis also includes all DHF as a single cohort without stratification by fracture pattern (e.g., extra-articular, intra-articular, or complex articular). While fracture patterns may influence treatment choice, our study assumes that their relative proportions remain stable over time. Although this assumption may not be entirely accurate, any resulting effect is likely minimal given the large sample size. Unfortunately, while controlling for fracture patterns would have enabled improved granularity, such data was not available to perform adequate subtype analysis. Given that our primary focus is on trend and utilization data rather than treatment-specific outcomes, we believe this approach remains valid. However, future studies with more detailed fracture classifications may be necessary to further refine these findings.
5. Conclusion
The utilization of TEA for DHF declined from 2010 to the first quarter of 2021, while ORIF remained the more frequently selected procedure. Although overall complication rates decreased for both TEA and ORIF over time, TEA continued to be associated with higher 90-day complication rates but lower 1-year revision rates. These findings suggest that TEA may remain a viable option in carefully selected patients but should be approached with caution in high-risk populations, such as those with significant comorbidities (e.g., chronic kidney disease, tobacco use). Consideration of fracture pattern, patient activity level, and perioperative risk factors is essential in optimizing treatment selection. However, the lack of granular patient and procedural data in this database limits the ability to account for key surgical factors, such as fracture complexity, surgeon experience, or implant choice, which may influence outcomes. Additional prospective studies, including randomized controlled trials, are needed to further define the optimal patient selection criteria for TEA and determine whether its role in DHF management should evolve.
Patient consent
This study utilized a de-identified database, and thus patient consent was not required.
Patient consent
As this study utilized de-identified data from the PearlDiver Mariner Database, individual patient consent was not required. Our Institutional Review Board confirmed that the use of anonymized, retrospective data in this study exempts it from the need for direct patient consent.
Ethics approval and consent to participate
This retrospective research study utilized the PearlDiver Mariner Database, a national private payer insurance database containing indexed and de-identified data. The database includes procedural volumes and patient demographics for individuals with International Classification of Diseases, 9th Revision (ICD-9) and 10th Revision (ICD-10) diagnoses, as well as Current Procedural Terminology (CPT) codes. The Institutional Review Board deemed this study exempt from requiring participants’ consent for participation and publication of the results.
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Ethical clearance
This study was determined to be IRB exempt.
Authors’ statements
The authors have no additional statements. We acknowledge this is the result of our own work and analysis.
Credit author statment
DJ: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization, Project administration. SK: Investigation, Data curation, Writing – original draft, Writing – review & editing. DZ: Investigation, Data curation, Writing – original draft, Writing – review & editing. SS: Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization. DH: Investigation, Data curation, Writing – original draft, Writing – review & editing. JS: Conceptualization, Methodology, Validation, Writing – original draft, Writing – review & editing, Supervision, Project administration
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jason A. Strelzow reports a relationship with Stryker Orthopaedics that includes: consulting or advisory. Jason A. Strelzow reports a relationship with Acumed LLC that includes: consulting or advisory. Jason A. Strelzow reports a relationship with OrthoXel that includes: consulting or advisory. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgment
None.
References
- 1.Robinson C.M., Hill R.M., Jacobs N., Dall G., Court-Brown C.M. Adult distal humeral metaphyseal fractures: epidemiology and results of treatment. J Orthop Trauma. 2003;17:38–47. doi: 10.1097/00005131-200301000-00006. [DOI] [PubMed] [Google Scholar]
- 2.Galano G.J., Ahmad C.S., Levine W.N. Current treatment strategies for bicolumnar distal humerus fractures. J Am Acad Orthop Surg. 2010;18:20–30. doi: 10.5435/00124635-201001000-00004. [DOI] [PubMed] [Google Scholar]
- 3.Nauth A., McKee M.D., Ristevski B., Hall J., Schemitsch E.H. Distal humeral fractures in adults. J Bone Joint Surg Am. 2011;93:686–700. doi: 10.2106/JBJS.J.00845. [DOI] [PubMed] [Google Scholar]
- 4.Srinivasan K., Agarwal M., Matthews S.J., Giannoudis P.V. Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice? Clin Orthop Relat Res. 2005;434:222–230. doi: 10.1097/01.blo.0000154010.43568.5b. [DOI] [PubMed] [Google Scholar]
- 5.Desloges W., Faber K.J., King G.J., Athwal G.S. Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients. J Shoulder Elb Surg. 2015;24:1187–1196. doi: 10.1016/j.jse.2015.05.032. [DOI] [PubMed] [Google Scholar]
- 6.John H., Rosso R., Neff U., Bodoky A., Regazzoni P., Harder F. Operative treatment of distal humerus fractures in the elderly. J Bone Joint Surg Br. 1994;76:793–796. [PubMed] [Google Scholar]
- 7.Kong L., Wang Y., Lu Q., Han Y., Wang F. Biomechanical properties of a novel fixation system for intra-articular distal humerus fractures: a finite element analysis. J Orthop Surg Res. 2021;16(1):674. doi: 10.1186/s13018-021-02836-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.O'Driscoll S.W. Optimizing stability in distal humeral fracture fixation. J Shoulder Elb Surg. 2005;14(1 Suppl S):186S–194S. doi: 10.1016/j.jse.2004.09.033. [DOI] [PubMed] [Google Scholar]
- 9.McKee M.D., Veillette C.J., Hall J.A., et al. A multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elb Surg. 2009;18:3–12. doi: 10.1016/j.jse.2008.06.005. [DOI] [PubMed] [Google Scholar]
- 10.Githens M., Yao J., Sox A.H., Bishop J. Open reduction and internal fixation versus total elbow arthroplasty for the treatment of geriatric distal humerus fractures: a systematic review and meta-analysis. J Orthop Trauma. 2014;28:481–488. doi: 10.1097/BOT.0000000000000050. [DOI] [PubMed] [Google Scholar]
- 11.Nelson B.K., Nazzal E.M., Moody D., Jakucki M., Kaufmann R.A. Polyethylene wear testing of a nonmechanically linked total elbow replacement. J Shoulder Elb Surg. 2024;S1058–2746(24) doi: 10.1016/j.jse.2024.07.015. 00604-9. [DOI] [PubMed] [Google Scholar]
- 12.Baik J.S., Lee S.H., Kang H.T., Song T.H., Kim J.W. Comparison of open reduction and internal fixation with total elbow arthroplasty for intra-articular distal humeral fractures in older age: a retrospective study. Clin Shoulder Elb. 2020;23:94–99. doi: 10.5397/cise.2020.00052. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Harmer L.S., Sanchez-Sotelo J. Total elbow arthroplasty for distal humerus fractures. Hand Clin. 2015;31:605–614. doi: 10.1016/j.hcl.2015.06.008. [DOI] [PubMed] [Google Scholar]
- 14.Chadwick N.S., Weaver J.S., Shechtel J.L., Hall G.L., Shultz C.L., Taljanovic M.S. Update on elbow arthroplasties with emphasis on imaging. Pol J Radiol. 2024;89:e249–e266. doi: 10.5114/pjr/186592. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ku K.H., Baek J.H., Kim M.S. Risk factors for non-union after open reduction and internal fixation in patients with distal humerus fractures. J Clin Med. 2022;11:2679. doi: 10.3390/jcm11102679. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Patterson D.C., Shin J.I., Andelman S.M., Olujimi V., Parsons B.O. Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program database. JSES Open Access. 2017;1:19–24. doi: 10.1016/j.jses.2017.03.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Lovy A.J., Keswani A., Koehler S.M., Kim J., Hausman M. Short-term complications of distal humerus fractures in elderly patients: open reduction internal fixation versus total elbow arthroplasty. Geriatr Orthop Surg Rehabil. 2016;7:39–44. doi: 10.1177/2151458516630030. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Klug A., Gramlich Y., Buckup J., Schweigkofler U., Hoffmann R., Schmidt-Horlohé K. Trends in total elbow arthroplasty: a nationwide analysis in Germany from 2005 to 2014. Int Orthop. 2018;42:883–889. doi: 10.1007/s00264-018-3818-x. [DOI] [PubMed] [Google Scholar]
- 19.Macken A.A., Prkic A., Kodde I.F., Lans J., Chen N.C., Eygendaal D. Global trends in indications for total elbow arthroplasty: a systematic review of national registries. EFORT Open Rev. 2020;5:215–220. doi: 10.1302/2058-5241.5.190036. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Hamoodi Z., Sayers A., Whitehouse M.R., et al. Total elbow replacement in england: a protocol for analysis of national joint registry and hospital episode statistics data. J Orthop Surg Res. 2024;19:526. doi: 10.1186/s13018-024-04903-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Macken A.A., Prkic A., Kodde I.F., Lans J., Chen N.C., Eygendaal D. Global trends in indications for total elbow arthroplasty: a systematic review of national registries. EFORT Open Rev. 2020;5(4):215–220. doi: 10.1302/2058-5241.5.190036. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Nayar S.K., Marrache M., Greenberg M., et al. Is primary total elbow arthroplasty appropriately compensated compared to other major total joint arthroplasty? Semin Arthroplasty. 2021;31:112–116. doi: 10.1053/j.sart.2020.11.001. [DOI] [Google Scholar]
- 23.Poff C.B., Kothandaraman V., Kunkle B.F., Friedman R.J., Eichinger J.K. Trends in total elbow arthroplasty utilization in the United States from 2002-2017. Semin Arthroplasty. 2021;31:389–394. doi: 10.1053/j.sart.2020.12.005. [DOI] [Google Scholar]
- 24.Kim D.H., Kim B.S., Baek C.S., Cho C.H. Primary total elbow replacement for treatment of complex distal humerus fracture: outcomes of short-term follow-up. Clin Shoulder Elb. 2020;23:20–26. doi: 10.5397/cise.2020.00045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Schuster I., Korner J., Arzdorf M., Schwieger K., Diederichs G., Linke B. Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma. 2008;22:113–120. doi: 10.1097/BOT.0b013e3181632cf8. [DOI] [PubMed] [Google Scholar]
- 26.Korner J., Lill H., Müller L.P., Rommens P.M., Schneider E., Linke B. The LCP-concept in the operative treatment of distal humerus fractures—biological, biomechanical and surgical aspects. Injury. 2003;34:B20–B30. doi: 10.1016/j.injury.2003.09.022. [DOI] [PubMed] [Google Scholar]
- 27.Dehghan N., Furey M., Schemitsch L., et al. Long-term outcomes of total elbow arthroplasty for distal humeral fracture: results from a prior randomized clinical trial. J Shoulder Elb Surg. 2019;28:2198–2204. doi: 10.1016/j.jse.2019.06.004. [DOI] [PubMed] [Google Scholar]
- 28.Goyal N., Bohl D.D., Ong K.L., Lau E., Nicholson G.P., Wysocki R.W. Reoperation risk after total elbow arthroplasty versus open reduction internal fixation for distal humerus fractures in elderly patients. J Orthop Trauma. 2020;34:503–509. doi: 10.1097/BOT.0000000000001767. [DOI] [PubMed] [Google Scholar]
- 29.Seok H.G., Park J.J., Park S.G. Comparison of the complications, reoperations, and clinical outcomes between open reduction and internal fixation and total elbow arthroplasty for distal humeral fractures in the elderly: a systematic review and meta-analysis. J Clin Med. 2022;11:5775. doi: 10.3390/jcm11195775. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Bedard N.A., DeMik D.E., Owens J.M. Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures. J Arthroplast. 2019;34:385–396. doi: 10.1016/j.arth.2018.09.089. [DOI] [PubMed] [Google Scholar]
- 31.Zhu J., Si M., Huang Z. Effect of tobacco usage on surgical site wound problems after primary total hip and total knee arthroplasty: a meta-analysis. Int Wound J. 2024;21 doi: 10.1111/iwj.14375. [DOI] [PMC free article] [PubMed] [Google Scholar] [Retracted]
- 32.Kim C.W., Kim H.J., Lee C.R., Wang L., Rhee S.J. Effect of chronic kidney disease on outcomes of total joint arthroplasty: a meta-analysis. Knee Surg Relat Res. 2020;32:12. doi: 10.1186/s43019-020-0029-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Polachek W.S., Baker H.P., Dahm J.S., Strelzow J.A., Hynes K.K. Diabetic kidney disease is associated with increased complications following operative management of ankle fractures. Foot Ankle Orthop. 2022;7(3) doi: 10.1177/24730114221112106. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Baker J., Manirajan A., Lewis J., Seidel H., Strelzow J. Assessing the risk of postoperative complications for proximal humeral fractures treated by open reduction and internal fixation in patients with diabetes and chronic kidney disease. J Am Acad Orthop Surg Glob Res Rev. 2023;7(5) doi: 10.5435/JAAOSGlobal-D-23-00043. [DOI] [PMC free article] [PubMed] [Google Scholar]