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Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897

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Original article

First-line management of distal humerus fracture by total elbow


arthroplasty in geriatric traumatology: Results in a 21-patient series
at a minimum 2 years’ follow-up
D. Lami a,∗ , M. Chivot a , A. Caubere a , A. Galland b , J.N. Argenson a
a
UMR CNRS 787/AMU, Department of Orthopedic Surgery, Institute for Locomotion, Aix-Marseille University, 270, boulevard Sainte Marguerite, BP 29,
13274 Marseille, France
b
Institut de la main et du membre supérieur, clinique Monticelli, 393, avenue du prado, 13008 Marseille, France

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Total elbow arthroplasty (TEA) is one option in distal humerus fracture in elderly osteo-
Received 29 November 2016 porotic patients.
Accepted 6 June 2017 Hypothesis: The study hypothesis was that, in patients aged 70 years or more, TEA provides functional
results and ranges of motion compatible with everyday activity, with a complications rate equal to or
Keywords: lower than with internal fixation, and no loss of autonomy or cognitive impairment.
Distal humerusfracture Material and methods: In this retrospective study, 21 patients receiving TEA for distal humerus fracture
Total elbow arthroplasty
were included. Mean follow-up was 3.2 years, with functional (Quick DASH and MEPS), cognitive (MMSE),
Osteoporotic fracture
Elderly
autonomy-related (ADL) and radiological assessment (Morrey).
Results: Mean MEPS was 84 and QuickDASH 32.4. Mean extension deficit was 22◦ , and mean flexion 125◦ .
There was no loss of autonomy or cognitive impairment. The complications rate was 9.5%. There were no
revision surgeries.
Discussion: TEA proved reliable in comminuted distal humerus fracture in elderly patients. Functional
results were comparable to those in the literature, and the complications rate was lower. Long-term
implant survival needs confirmation to validate this option as a treatment of choice in these indications
in geriatric traumatology.
Type of study: Retrospective non-comparative, single-center.
Level of evidence: 4.
© 2017 Elsevier Masson SAS. All rights reserved.

1. Introduction year from rheumatoid pathology and post-traumatic sequelae toin-


clude distal humerus fracture [10]. An increasing number of studies
Distal humerus fracture in osteoporotic elderly subjects is a sur- have reported results in geriatric distal humerus traumatology,
gical and functional challenge. The elbow joint, hinging shoulder and total elbow arthroplasty (TEA) is now a genuine treatment
and hand, is critical to autonomy in everyday activity. The reference option [11–16]. These reports encourage us to provide further evi-
treatment for distal humerus fracture is surgical reduction with dence to validate the technique, notably in terms of complications,
stable rigid internal fixation, allowing early mobilization [1–3]. Dif- functional recovery and autonomy in the elderly. The aim of the
ficulties encountered in elderly patients concern reduction, due to present study was to perform a retrospective analysis of func-
often severe comminution, and assembly stability, due to reduced tional results and complications in patients with distal humerus
bone density. Studies report high complications rates, up to 55% fracture treated in first line by a semi-constrained hinged implant,
[4], notably involving early loss of reduction, often necessitating and to assess impact on autonomy and cognitive status. The study
revision surgery [5–9]. The fragility of elderly patients requires hypothesis was that TEA provides functional recovery and ranges
well-informed caution in implementing this technique. Indications of motion (30–130◦ and free pronation-supination) compatible
for semi-constrained hinged implants have progressed in recent with everyday activity [17], without loss of autonomy (KatzAc-
tivities of Daily Living (ADL) score [18] ≥ 4), negligible impact
on cognitive status (Mini Mental State Examination (MMSE) [19]
∗ Corresponding author. > 17), and a complications rate equal to or lower than for internal
E-mail address: damienlami@hotmail.fr (D. Lami). fixation.

http://dx.doi.org/10.1016/j.otsr.2017.06.009
1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.

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892 D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897

Table 1 A3 C1 C2 C3
Demographic data.
8
Age (years)
Mean 81.3 7
Range 70–92
6
SD 5.7

5
BMI
Mean 25.61
4
Range 19.4–32
3
ASA
ASA 1 6 2
ASA 2 15
1
Gender
Male 1 0
Female 20 70-74 Yrs 75-79 Yrs 80-84 Yrs 85-89 Yrs 90-95 Yrs

ADL
Fig. 1. AO anatomic types by age group.
Mean 5.1
Range 4–6

MMSE
by age group. The two A3 fractures were in very elderly patients
Mean 25.35 with very low bone density. There were two open grade 1fractures.
Range 23–28 One patient showed humeroulnar osteoarthritis; 1 had ipsilateral
proximal humerus fracture, treated functionally; 2 had sustained
Side
distal radius fracture at the same time as the humeral fracture, both
Dominant 15
Non dominant 6 treated by antebrachial cast.

AO type 2.2. Surgery and postoperative care


A 2 (A3)
B 0
C 19 As our center has no emergency department, preoperative
C1 7 assessment was systematically conducted in orthopedic consul-
C2 4 tation and by the anesthesiologist and mobile geriatric team. All
C3 8 surgical procedures were performed by the same surgeon (DL),
Trauma-to-surgery time (days) 9
using the same implant (Conrad-Morrey, Zimmer/Biomet, Warsaw,
IN)[21]. Systematic prophylactic antibiotic therapy at induction
Associated lesions used a second-generation cephalosporin. Mean trauma-to-surgery
Open fracture 2 (punctiform) time was 9 days (range, 2–22 days).
Distal radius fracture 2
Patients were positioned supine, with the upper limb across the
thorax, a support on the sternum and the limb fixed by a lateral
wedge. Surgery was performed without tourniquet, under general
2. Material and methods anesthesia with analgesic axillary nerve block. The incision was
posterolateral, to shift the scar away from the bony edge of the
2.1. Study population olecranon and to optimize implant coverage. The first step was to
identify the ulnar nerve, which was completely released from the
This was a single-center single-operator retrospective non- brachial canal up to the anteromedial compartment of the forearm,
comparative study. Inclusion criteria comprised: age ≥ 70 years, and left in a medial position. Particular care was taken to spare all
living at home or autonomous with respect to everyday activi- the epitrochleo-olecranal groove tissue attached to the nerve, so
ties, Katz (ADL) score ≥ 4, MMSE > 17 and ASA (American Society as to keep a protective sheath isolating it from the future implant
of Anesthesiologists) score < 3, with distal humerus fracture man- (Fig. 2). The joint was exposed via an extended medial para-triceps
aged by TEA, and a minimum 2 years’ follow-up. Exclusion criteria approach. The olecranon was bared subperiosteally and the inci-
comprised: cognitive disorder (MMSE < 17), associated lower-limb sion was continued distally by opening the flexor carpi ulnaris. No
fracture, and ASA score ≥ 3. Preoperative AP and lateral elbow olecranal osteotomies were performed. Distal humeral bone frag-
radiographs and CT were systematic. As patients were seen in emer- ments were completely resected. No columns were fixed during
gency and osteodensitometry was not available, osteoporosis was implant positioning. The radial head was systematically spared. The
diagnosed in the light of low-energy trauma, the preponderance ulna was prepared first. The size of the humeral shaft was mea-
of menopausal women patients, and low bone density on radiogra- sured. The objective was to restore full extension intraoperatively,
phy and on Clavert’s method [20] using the corticomedullary index. and implant positioning was adjusted until this was achieved.
Fractures were classified on the AO system. All implants were cemented, using low-viscosity cement (CMW,
Twenty-six TEAs were performed for traumatologic indications Depuy) with 1-gram vancomycin, injected by pistol on either side,
between January2009and January 2014. Twenty-one patients were after fitting ulnar and humeral obturators adapted to the shaft
included in the study: 20 female and 1 male. Two patients died diameter. The resected bone fragments were used as autograft for
with less than the minimum 2 years’ follow-up; 3 more were lost the obturators and for the graft behind the anterior wing of the
to follow-up and not included in analysis. Table 1 presents patient implant. The elbow was held in complete extension during cement
characteristics. Mean age was 81.3 years (range, 70–92 years), and polymerization. At end of surgery, 3 non-absorbable woven sutures
mean follow-up 3.2 years (range: 2–7 years). Mean body-mass were passed through the olecranon and in Masson-Allen stitches
index (BMI) was 25.61 (range: 19.4–32). Mean ADL was 5.1, and in the tendon to reinsert the triceps; the elbow was positioned in
MMSE 23.35 (range: 23–28). Fig. 1 shows anatomic fracture types 90◦ flexion during reinsertion. A flexion-extension cycle checked

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Table 2
Complications.

Time to onset Flexion Extension

Skin ulceration (ipsilateral shoulder J8 90 60


dislocation)
Severe stiffness (peritonitis) J10 95 85

2 mm radiolucency at the interface, and cement going beyond the


tip of the implantor < 2 mm radiolucency and no cement beyond
the implant stem; and type 3, insufficient cementation with > 2 mm
radiolucency and no cement beyond the implant stem.
Implant fixation was assessed on X-ray ahead of each follow-
up consultation, and scored 0 to 4, again following Morrey [23]:
type 0,< 1 mm radiolucency involving < 50% of the interface; type
1, 1 mm radiolucency involving < 50%; type 2, > 1 mm radiolucency
involving > 50%; type 3, > 2 mm radiolucency involving the entire
interface; and type 4, massive bone lysis.
Polyethylene bushing wear at the hinge was classified on X-ray
at last follow-up, following Lee and Morrey [24]:

• type 1: normal bushings, with < 3.5◦ ulnohumeral angle in the


coronal plane;
• type 2: partial wear, with 3.5–5◦ bushing angulation;
• type 3:complete bushing wear, with > 5◦ angulation.

All radiographs were examined for signs of anterior cortical graft


integration.

3. Results
Fig. 2. The perineural tissue is conserved to respect the ulnar nerve against the
implant. Mean follow-up for the 21 elbows was 3.2 years (range:
2–7.4 years). Mean operating time was 95 minutes (range,
any suture loosening, which did not in fact occur. The flexor carpi 70–120 min). Fifteen of the humeral implants were size 4, 5 size
ulnaris fascia was sutured. There was no postoperative immobiliza- 6, and 1 size 8; 14 were “extra-small”, 5 “small”, and 2 “regular”.
tion, apart from a simple scarf to minimize pain, and immediate Eighteen of the ulnar implants were of normal length, and “3 long”.
mobilization was authorized. Rehabilitation was initiated on day 2,
without limitation on motion, and without force, associated to ergo 3.1. Complications
therapy. Mobilization was according to pain.
One patient died of acute coronary syndrome at 3 years, with
2.3. Clinical assessment no complications related to the TEA observed at last follow-up
(Table 2).
Patients were followed up in consultation at 1, 3 and 6 months, There were 2 principal complications (9.5%): 1 case of severe
1 year and then annually. Ranges of motion were recorded. Elbow stiffness, and 1 of skin necrosis at the tip of the olecranon. The
extension, flexion and pronation-supination were assessed using a patient with stiffness had suffered peritonitis at day 18, necessitat-
circular goniometer. Functional recovery was assessed on Quick- ing 32 days’ admission to the visceral surgery department which,
DASH and Mayo Elbow Performance scores [22], autonomy on combined with the resulting asthenia, involved extreme immobil-
ADL [18], and cognitive status on MMSE [19]. Satisfaction was ity and hence stiffness; the patient and family declined revision
self-assessed on a simple 4-level scale: very satisfied, satisfied, surgery to release the prosthetic joint, and rehabilitation failed
moderately satisfied, and dissatisfied. Intraoperative complications to restore a functional range of motion. The case of skin necro-
were recorded in the surgical report and general complications in sis followed an in-hospital fall with skin abrasion at the olecranon
the hospital file. Skin healing was recorded at the first postoperative and shoulder dislocation, which was irreducible due to associated
consultation. Subjective clinical assessment of force in extension glenoid fracture, for which the patient declined further surgery; the
screened for complications related to triceps release/reinsertion. constant pressure of the limb on the olecranon caused ulceration of
Neurologic disorder in the ulnar territory was screened for by the abrasion (Fig. 3), without exposing the implant. Iterative dress-
analyzing interosseous muscle function and any self-reported ing and preventing pressure on the tip of the olecranon allowed
paresthesia. satisfactory healing without further intervention. For these two
patients, functional outcome was poor and showed no improve-
2.4. Radiologic assessment ment during follow-up.
There were no cases of infection or of revision surgery.
Immediate postoperative AP and lateral elbow views screened
for leakage, implant malpositioning or protrusion. Ulnar and 3.2. Clinical results
humeral cementation was checked on immediate postoperative
X-rays, and classified in 3 types, following Morrey [23]: type 1, Mean hospital stay was 4.3 days (range, 2–32days). Seven
adequate cementation with < 1 mm radiolucency at the cement- patients were referred to a rehabilitation center, due to their social
bone interface and cement going beyond the implant stem; type 2, isolation, and 14 were discharged home. There were no cases

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894 D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897

Fig. 4. 1-year radiograph: > 2 mm cement/bone radiolucency.


Fig. 3. Skin necrosis due to irreducible shoulder dislocation following an in-hospital
fall.

Table 3
Average functionnal results.

Mean Range 6 months 1 year Last follow-up

Q-DASH 36.2 24.5 32.4


15.2–74.4
MEPS 82 84 87
50–99
Pian 41 42.2 43.2
15–45 30–45 30–45
Mobility 14.2 14.7 15
5–20 5–20 5–20
Stability 9.7 9.7 9.7
5–10 5–10 5–10
Function 17.1 17.4 19.1
0–25 0–25 0–25
Flexion 125
118 125 95–130
Extension 22
−25 −22 5–75

of suture detachment at the triceps: active extension was con-


served. Mean flexion was 126◦ , and mean extension defect 22◦ ;
pronation-supination was full in 19 cases and impaired by 50% in Fig. 5. Postoperative radiograph: anterior implant corticalization, a criterion of sta-
both directions in 1. Mean QuickDASH was 32 (rang: 15.2–72.4; SD: bility.
14.8) at last follow-up. Mean MEPS was 84 (range: 50–99;SD: 12.6),
with pain, mobility, stability and function subscores of respectively radiological results. Most patients showed anterior cortical graft
43.2 (30–45), 15 (5–20), 9.7 (5–10) and 19.1 (0–25), and 16 excel- integration by 3 to 6 months (Fig. 5). Four showed periprosthetic
lent, 3 good and 2 poor outcomes. Functional results are shown in ossification, without pain or functional impact; there were no cases
Table 3. All patients were able to return home. Mean ADL score at of heterotopic ossification. Four patients showed signs of loosen-
last follow-up was 4.3 (range: 4–6), with the “dressing” subscore ing on the humeral side, without functional impact; there were no
deteriorating in most cases. There was no cognitive impairment, cases of loosening on the ulnar side. There was no bushing wear at
with a mean MMSE of 23.61 (range: 19–28) at last follow-up. Fifteen last follow-up.
patients were very satisfied, 4 satisfied and 2 dissatisfied.
4. Discussion
3.3. Radiologic results
We particularly wished to study the management of osteo-
There were no immediate postoperative abnormalities. One porotic distal humerus fracture due to its increasing prevalence
patient had type-1 humeral cementation. At 1 year, 1 patient [2,3,21]. Open internal fixation is the reference treatment and gives
showed type-3 loosening, without clinical or functional impact at very good functional results, but with a worrying rate of compli-
2 years (Fig. 4); this patient later sustained a femoral shaft frac- cations [5–9]. Arthroplasty has therefore been considered as an
ture, managed by intramedullary nailing; the loosening may have alternative for several years, and seems to give encouraging results
been related to resumption of walking with crutches. Table 4 shows [11–16]. The present study sought to analyze functional results in

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Table 4
Radiologic results.

Follow-up Cementation quality Fixation quality Polyethylene Anterior


wear corticalisation

Humeral Ulnar Humeral Ulnar

Immediate postoperative Type 1: 20 Type 1: 21 NE NE NE 0


Type 2: 1 Type 2: 0
Type 3: 0 Type 3: 0
6 months NA NA Type 0: 20 Type 0: 21 Type 1: 21 16
Type 1: 1
12 months NA NA Type 0: 18 Type 0: 21 Type 1: 21 18
Type 1: 2
Type 2: 1
Last follow-up NA NA Type 0: 17 Type 0: 21 Type 1: 21 18
Type 1: 2
Type 2: 1
Type 3: 1

NA: not assessed.

distal humerus fracture treated in first line by total elbow arthro- to validate the medico-economic aspect [35] and long-term results
plasty, and to determine immediate and short-term complications [30]. Obert also reported that complications were fewer with elbow
and impact on autonomy and cognitive status. arthroplasty, but liable to be more difficult to manage [36]. Ducrot
Functional results were altogether satisfactory, with a mean et al. reported 2 cases of ulnar neuropathy in their series [13], which
QuickDASH of 32, MEPS of 87, extension loss of 22◦ and flexion they thought might be due to medial bone fragments.
of 125◦ . Our hypothesis was confirmed. All patients were able to Internal fixation remains the reference treatment, and elbow
return home, with mean ADL score > 4, due to an average 1-point arthroplasty needs to demonstrate functional results that are at
loss mainly concerning the “dressing” item. There was no major least equivalent if it is to be used in this indication. It is probably
cognitive impairment, with mean MMSE of 23.61 at last follow-up; wise to be cautious, and reserve TEA for type B and C fracture in
the patient who deteriorated the most had a hospital stay of more over-70 year-old subjects, especially as follow-up is lacking in the
than 1 month. The complications rate was 9.5%, notably associated various reports of elbow arthroplasty in traumatology. In type-A
with concomitant acute pathologies necessitating immobilization fracture, internal fixation, thanks to the rigidity of locked assem-
and severe asthenia during the first postoperative month. Early bly, is stable despite osteoporosis [2]. However, type A is not the
mobilization seems to be vital. One patient showed true radiologic most frequent form of fracture in this age group and, although
signs of humeral loosening, without functional impact. There were extra-articular, can be highly comminuted in the metaphysis, and
no cases of infection or heterotopic ossification. There were no revi- particularly unstable [6–8]. Non-operative management has its
sion surgeries. Mean BMI, elevation of which is usually a factor of place in treatment strategy, especially when patients do not meet
poor prognosis, was 25.61 (range: 19.4–32). One patient was dis- the criteria for surgery or have excessive comorbidity [37]; sec-
satisfied and another only moderately satisfied, and had BMIs of ondary implantation remains possible in case of failure, if pain or
respectively 20.6 and 19.4; thus, obesity was not implicated, but functional impact is unacceptable for the patient or family [38].
rather the complications described above. Only 1 patient was obese Extrapolating results for other joints, such as the hip [39], to the
(BMI > 30), with a BMI of 32; he was 70 years old at time of surgery, humerus, it would seem that revision is more complex after failed
and was followed up for 4 years, with MEPS 85, QuickDASH 24.45, internal fixation than in a non-operated elbow. McKee [32], in
“very satisfied”, ADL 5, MMSE 23, extension/flexion −20/125◦ and a prospective study, found equivalent ranges of motion between
unrestricted pronation-supination. Obesity was thus not a factor for elbow arthroplasty (−26◦ /133◦ ) and internal fixation (−28◦ /123◦ ).
poor functional outcome. Neurologic complications are frequently Leigey reported a mean range of motion of about 105◦ in elderly
reported, but did not occur in the present series, perhaps thanks to patients with medial and lateral double plate internal fixation [3].
the conserved perineural tissue sheath, although this could not be Even so, some comparative studies reported better functional
confirmed by comparison against a control group. results with total elbow arthroplasty [40]. Frankle [29] reported
The present results confirm those already published in this indi- a mean −30◦ extension deficit with internal fixation versus −15◦
cation; sample size was small, but the findings were similar to those with elbow arthroplasty. McKee andMansat et al. reported similar
of most previous studies. Table 5 presents published results on the findings [12,21].
subject [4,6,11–14,24–34], which we averaged and compared to our The present results show similar mean values for extension,
own. The present sample size was comparable to those of other flexion and pronation-supination, and contribute an extra series
studies. The implant used was that most frequently found in the with a respectable sample size, confirming the reliability of these
literature. The mean age was 6 years greater than the average, and implants in terms of functional recovery in this indication. Another
follow-up 6 months shorter. Functional outcome and complications strong point was the inclusion of autonomy and cognitive scores,
were as in the other reports [28]. which are part of standard assessment in geriatrics. A major
The complications rate was 9.5%, lower than in comparative limitation was the short follow-up, especially regarding late com-
studies, which favored elbow arthroplasty over internal fixation. plications and implant survival.
McKee reported a 27% rate with internal fixation, in contrast to 12% Implant survival is, indeed, a legitimate question, which few
with elbow arthroplasty [29]. Elweinn, studying type-C fracture in studies have answered in traumatology. Plaschkeshowed implant
over-60 year-olds, likewise found a major complications rate of 55% survival to be shorter in distal humerus fracture than in other
with internal fixation, versus 13% with elbow arthroplasty, the main indications, but with overall 10-year survival of 81%, taking all indi-
cause of failure being loss of reduction due to disassembly of the cations for TEAtogether [41]. The life expectancy and activity level
internal fixation [4]. Githens’ meta-analysis found a higher overall of our patients may make this survival rate worrying.
complications rate with internal fixation, although the difference The study hypothesis was that functional results are satisfactory
was not significant [1], and stressed the need for further studies and the complications rate is low, without cognitive deterioration

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Table 5
Previously published results in the literature.
Patients/Elbows Gender Implant type Mean age Mean Mean exten- Mean Supina- Mean MEPS Infection Radiolucency Fracture Neural Revision
(years) follow-up sion/flexion tion/pronation lesions
(years) (degrees) (degrees)
Gallucci et al. (2016) 23/23 21F-2M Coonrad-Morrey 79 3.1 17–123 N/D 83 0 4 1 3 3a
semi-constrained hinged
Prasad et al. (2016) 19/19 12F-7M Coonrad-Morrey 68 13.2 34–118 N/D 90 1 6 0 2 2b
semi-constrained hinged
Pogliacomi et al. (2016) 20/20 19F-1M Latitude/Tornier 74.1 5 N/D > 100 N/D 88.7 1 4 0 0 0

D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897
Coonrad-morrey/Zimmer
Ellwein et al. (2015) 29/29 21F-8M Latitude/Tornier 70 1.8 13–123 87–89 94 1 0 0 3 0c
Giannicola et al. (2014) 24/24 Prospective 15F-9M Discovery Elbow system Djo 78 2.9 15–138 84–83 99.5 0 2 0 0 0d
surgical
Mansat et al. (2013) 70/78 N/D 18 Fractures Coonrad-Morrey 70 3.5 30–126 70/67 78 1 1+1 0 0 1e
semi-constrained hinged deterotopic
ossification
Ducrot et al. (2013) 15/15 18F-2M Coonrad-Morrey 80 3.6 33–130 N/D 83 0 6 0 2 0
semi-constrained hinged
Chalidis et al. (2009) 11/11 9F-2M Coonrad-Morrey 80 2.8 17–125 70–60 90 0 0 1 0 1
semi-constrained hinged
Charissoux et al. (2008) 36/44 N/D Coonrad-Morrey 81 2 27–124 94–91 84 N/D N/D N/D N/D 2
semi-constrained hinged
McKee et al. (2008) 25/25 19F-1M Coonrad-Morrey 77 2 26–133 N/D 86 4 1 0 3 1
semi-constrained hinged
Prasad et Dent (2008) 32/32 25F-7M Coonrad-Morrey 78 4.6 26–118 80–70 85 2 6 0 2 2
semi-constrained hinged
Lee et al. (2006) 7/7 5F-2M Coonrad-Morrey 72.9 2 41.4–130 72.9–75.7 94.3 0 0 0 0 0
semi-constrained hinged
Kamineni et Morrey (2004) 48/49 31F-12M Coonrad-Morrey 69 7 24–131 N/D 93 1 3 3 3 5
semi-constrained hinged
Frankle et al. (2003) 12/12 12F Coonrad-Morrey 72 3.8 15–125 N/D 95 1 1 0 2 0
semi-constrained hinged
Gambirasio et al. (2002) 10/10 10F Coonrad-Morrey 84.6 1.5 23.5–125.5 74.5–79 94 0 2 0 0 0
semi-constrained hinged
Garcia et al. (2002) 19/19 12F/4M Coonrad-Morrey 73 3 24–125 90–70 93 1 1 0 0 0
semi-constrained hinged
Ray et al. (2000) 7/7 7F Coonrad-Morrey 81.7 3.8 25–130 N/D 92 1 2 0 0 0
semi-constrained hinged
Cobb et Morrey (1997) 20/21 15F-5M Coonrad-Morrey 72 3.3 25–130 73–74 N/D 1 3 1 1 1
semi-constrained hinged
Means 20.8 15.9F-3.8M 75.2 3.8 24.4–124.8 78.7–74.3 89.3 0.8 2.5 0.3 1.2 1
Present series (2017) 21 20F-1M Coonrad-Morrey 81.3 3.2 22–125 N/D 85.4 0 4 0 0 0f
semi-constrained hinged
N/D: No data; OA: osteoarthritis.
a
Two Revisioons for wear 1 technical error
b
Minimum follow-up 10 years; 36 patients initially; revision-free survival at last follow-up 89.5%.
c
Twenty-one Internal fixations 9 Implants.
d
Ten fractures.
e
Forty-five inflammatory OA 3 Traumas: 18 fractures, 10 non-unions, 5 OA.
f
One skin necrosis + 1 peritonitis.
D. Lami et al. / Orthopaedics & Traumatology: Surgery & Research 103 (2017) 891–897 897

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