Die Gelenkfraktur des alten Menschen: to fix or to replace? – Distaler Humerus

 

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Zusammenfassung

Frakturen des distalen Humerus sind selten und werden i. d. R. operativ therapiert. Primäres Ziel und aktueller Goldstandard ist die offene Reposition und Osteosynthese, um eine langfristige, schmerzfreie und uneingeschränkt belastbare Gelenkrekonstruktion zu erreichen. Ausschlaggebend für den Erfolg der gelenkerhaltenden Therapie sind die primäre Stabilität der Osteosynthese und die Sicherung der Fragmentretention. Obwohl aktuelle Studien durch neue Implantattechnologien auch bei komplexen Frakturen und Osteoporose eine Rekonstruktion und gute Ergebnisse nachweisen konnten, bleiben die Komplikationsraten hoch. Nach Erstpublikation der Endoprothesenversorgung am distalen Humerus durch Cobb und Morrey ist in den vergangenen Jahren die Frakturversorgung mit einer Ellenbogenprothese zunehmend in den Fokus gerückt. Dies gilt insbesondere für Patienten mit niedrigen funktionellen Ansprüchen und vorbestehenden Gelenkpathologien wie Arthrose oder rheumatoider Arthritis. Die Ergebnisse im kurzfristigen Nachuntersuchungsintervall sind vielversprechend, Studien mit relevanten Patientenzahlen im mittel- bis langfristigen Verlauf fehlen allerdings fast vollständig. Wesentliche Nachteile der endoprothetischen Versorgung am distalen Humerus sind die strikt einzuhaltende lebenslange Belastungsrestriktion sowie steigende Komplikationsfrequenzen im Langzeitverlauf. Die optimale Therapie der distalen Humerusfraktur im Alter ist anhand der aktuellen Evidenz nicht eindeutig zu definieren. Im kurzfristigen Verlauf sind die Ergebnisse nach Osteosynthese und Prothese nahezu identisch. Die Expertise des Operateurs in Kombination mit einer offenen Patientenaufklärung sollte unter Beachtung der Kontraindikationen die Therapie bestimmen.

Abstract

Distal humeral fractures in adults are rare. They are routinely treated by open reduction and internal fixation in an attempt to retain a painless, stable and functional joint. However, even with advances in plate technology, the results of fixation still depend on screw purchase and bone quality. Even if functional results appear to be favourable, complication rates remain quite high. This is particularly true in elderly patients, in whom multifragmentary intraarticular fractures are mostly associated with diminished bone quality. Recent results support the use of primary total elbow arthroplasty in patients with highly comminuted distal humeral fractures. This applies particularly to the elderly with low physical demands, or patients with marked joint destruction from significant preexisting inflammatory joint disease. Although short term results seem to be promising, the intermediate and long term data are still inadequate. There is indeed evidence for a dramatic increase in complications and revision rates over time. Lifelong weight restriction is a major drawback in total elbow arthroplasty. It is unclear whether the primary treatment of distal humeral fractures in the elderly should be open reduction and internal fixation or total elbow arthroplasty. The operation should be selected for the individual patient on the basis of the surgeonʼs experience and judgment as well possible contraindications. The surgeon should discuss the question openly with the patient.

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