Risk of Reoperation Associated with Total Elbow Arthroplasty Versus Open Reduction and Internal Fixation for Distal Humerus Fractures in Elderly Patients
Nitin Goyal, MD1, Daniel D. Bohl, MD, MPH1, Kevin L. Ong, PhD2, Edmund Lau, MS2, Gregory P. Nicholson, MD1 and Robert W. Wysocki, MD1, (1)Rush University Medical Center, Chicago, IL, (2)Exponent, Inc, Philadelphia, PA
Total elbow arthroplasty (TEA) and open reduction and internal fixation (ORIF) are valid surgical options for treating intra-articular distal humerus fractures in elderly patients. Our purpose was to compare reoperation rates following TEA and ORIF for intra-articular distal humerus fractures in elderly patients using a large, national database with potential for longer follow-up. We hypothesized that TEA would be associated with an overall lower risk for reoperation compared to ORIF.
A retrospective comparative study was conducted using the 5% Medicare Part B claims database. Patients over 65 with closed distal humerus fractures undergoing primary TEA or ORIF from 1996-2016 were included. Subsequent reoperations including ORIF, revision TEA, conversion to TEA, removal of hardware/implant, elbow release, ulnar nerve surgery, resection arthroplasty, arthrodesis, elbow arthroscopy, irrigation and debridement, and staged revision for infection were analyzed. Overall risk of reoperation was compared between TEA and ORIF groups using multivariate Cox proportional hazards modeling, controlling for age, gender, race, region, Medicare buy-in, and Charlson Comorbidity Index (CCI).
A total of 664 patients were identified, of which 142 underwent TEA and 522 underwent ORIF. Patients undergoing TEA had greater age and greater CCI compared to patients undergoing ORIF (p<0.05). TEA was associated with an overall significantly decreased risk for reoperation compared to ORIF (12.7% vs 24.5%; adjusted hazard ratio=0.57; p=0.025) (Table 1). Revision TEA occurred in 4.9% of patients (Table 2). The death rate was 65.5% in TEA group at a mean of 3.6 years and 55.7% in ORIF group at a mean of 4.9 years.
In this study, TEA was associated with a decreased risk for reoperation compared to ORIF, though half of the reoperations following ORIF included removal of the hardware. The relatively high death rate within several years of the index procedure may contribute to the low TEA revision rate even when attempting to follow patients into the medium and long-term. These results provide valuable information to inform the shared decision making process for treating intra-articular distal humerus fractures in elderly patients.
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