Can Total Elbow Arthroplasty Effectively Treat Post-traumatic Sequelae After Proximal Ulna or Radius Fracture and Fracture-Dislocations?

Abstract

In the United States, more than 50% of total elbow arthroplasties (TEA) are performed for acute trauma or post-traumatic sequelae. Outcomes of TEA performed for distal humerus fracture or nonunion have been well-documented; however less is known regarding outcomes of TEA for sequelae of complex proximal ulna or radius fractures. This study aimed to (1) identify operative considerations and outcomes and (2) determine TEA survivorship when performed for post-traumatic sequalae after proximal ulna or radius fracture or fracture-dislocation. Patients who underwent TEA for sequelae of proximal ulna or radius fractures between 1990 and 2024 at a single institution were identified using a Total Joint Registry. Forty elbows (mean age 59±10 years, 58% female) with a mean follow-up of 9±6 years were included. Post-traumatic arthritis after transolecranon fracture [n=13], Monteggia-variant [n=9], transulnar basal coronoid fracture [n=8], radial head fracture [n=2] accounted for 80% of cases. Complex elbow instability (terrible triad [n=5], varus posteromedial rotatory instability [n=3]) comprised the remaining 20%. The mean number of prior operations was 3±2, and 75% of elbows had a history of radial head resection (n=18) or a poorly tracking radiocapitellar joint (n=12). 40% had preoperative ulnar nerve symptoms. Implant survival free of revision or resection was estimated using the Kaplan-Meier method. When successful, TEA provided adequate pain relief and good functional restoration. However, the overall revision rate was 28%. Operative times were long (158±74 minutes) and difficulty with ulnar preparation was common (35%). Prior hardware was retained in 23% of elbows, and 10% required ulnar component modification. The ulnar nerve had not been previously decompressed or transposed in 63% of elbows; most were then decompressed (n=5) or transposed (n=17) at the time of TEA. The most common postoperative complications were neurologic complications (20%), aseptic loosening (18%), and deep infection (13%). Ulnar sided aseptic loosening (n=4) and infection (n=4) accounted for 72% of revisions. At 10 years, implant survival free from revision or resection for infection, mechanical failure or radiographic loosening, and for any reason were 88%, 83%, and 73%, respectively. TEA for salvage of post-traumatic sequelae after proximal ulna or radius fracture or fracture-dislocation demonstrated 73% survival free of revision at 10 years, comparable to TEA for distal humerus fracture sequelae. Surgeons performing this procedure should be prepared for potential technical difficulties in the setting of prior surgery, retained hardware, malunion/nonunion, preexisting ulnar neuropathy, or radial head absence.