• Shoulder/Elbow Surgery

This thesis investigates the treatment options for comminuted intraarticular distal humeral fractures in middle-aged and elderly patients by examining the functional outcomes, complications, and reoperation rates following Elbow Hemiarthroplasty (EHA) and Open Reduction Internal Fixation (ORIF). Additionally, it aims to introduce a simple and clinically applicable classification system to identify fractures that may require treatment with Elbow Hemiarthroplasty (EHA) or Total Elbow Arthroplasty (TEA). The thesis consists of 4 studies:
Study I: Good outcome after elbow hemiarthroplasty in active patients with an acute intra-articular distal humeral fracture.
This retrospective study reported the clinical outcomes and complications following EHA for acute distal humeral fractures AO/OTA type 13-C2 and -C3. Over a 6-year period, 24 consecutive active patients were treated with EHA for distal humeral fracture. The mean age was 65 years, with a median follow-up time of 20 months. The median Oxford Elbow Score (OES) was 40, indicating “good to excellent results” in 21 patients, “fair” in 2 patients, and “poor” in 1 patient. The median Mayo Elbow Performance Score (MEPS) was 85 points, with “good to excellent” outcomes in 19 patients, “fair” in 4 patients, and “poor” in 1 patient. The median flexion-extension and supination-pronation arcs were 110 and 160 degrees, respectively. Complications were recorded in 7 patients, and 3 of them underwent reoperation. We concluded that EHA provides a good and reliable treatment option for acute intraarticular distal humeral fracture unsuitable for open reduction and internal fixation.
Study II: Good functional outcomes after open reduction and internal fixation for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in patients aged over 45 years.
The purpose of this retrospective study was to report the functional outcomes and complications after ORIF for AO/OTA type 13-C2 and -C3 acute distal humeral fractures. During a 6-year period, 23 consecutive patients aged over 45 years were treated with double plating for AO/OTA type 13-C2 or -C3 fractures. The mean age was 62 years, with a median follow-up time was 54 Months. The median OES was 42. According to OES, 20 patients achieved good to excellent outcomes, and 3 achieved fair outcomes. The median MEPS was 85. According to MEPS, 18 patients achieved good to excellent outcomes, and 5 achieved fair outcomes. The median flexion-extension and supination-pronation arcs were 120 and 160 degrees, respectively. Eight complications were recorded in 7 patients, with 4 requiring reoperation due to pseudarthrosis or elbow stiffness. We concluded that ORIF is a reliable treatment option for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in middle-aged and elderly patients despite complications. Good to excellent results can be achieved in most patients.
Study III: Elbow hemiarthroplasty versus open reduction and internal fixation for AO/OTA
type 13 C2 and C3 fractures of distal humerus in patients aged 50 years or above: a randomized controlled trial. (Protocol)
Distal humeral fractures AO/OTA type 13-C2 and -C3 pose a surgical challenge despite the evolution of surgical implants and techniques. ORIF is often preferred as the first choice of treatment, but outcomes can vary and may sometimes be disappointing. TEA has been widely used for fractures that are not amenable to ORIF in elderly patients, but the mechanical complications remain a challenge. EHA provides an alternative that might avoid some of the known mechanical complications of TEA. This is the protocol for an investigator-initiated, non-blinded, randomized controlled trial comparing the outcomes of EHA with ORIF in patients aged 50 years or older. Patients will be evaluated postoperatively and at 3 months, 1 year, 2 years, 5 years, and 10 years. The trial is still ongoing, with 40 out of 44 patients enrolled. We plan to publish the results of this study at the 2-year follow-up.
Study IV: The Copenhagen Classification System for Distal Humeral Fractures is useful to identify patients who may require treatment with hemi- or total elbow arthroplasty.
The purpose of this study was to introduce a simple and clinically applicable classification system – The Copenhagen Classification for Distal Humeral Fractures (CCDHF) and to compare the inter- and intra-observer agreement for this classification with the AO/OTA, and the Sheffield classification systems. Five experienced elbow surgeons assessed a series of 105 sets of X-rays of distal humeral fractures on 2 occasions with at least 10 weeks interval. All X-rays were classified according to AO/OTA, Sheffield, and the CCDHF systems. The CCDHF system was collaboratively developed by a panel of five consultant elbow surgeons. Based on consensus, the surgeons identified specific fracture characteristics where EHA or TEA might be needed. We found that the mean inter-observer agreement was fair for AO/OTA and moderate for Sheffield and the CCDHF. The mean intra-observer agreement was moderate for AO/OTA and substantial for Sheffield and the CCDHF. We concluded that the CCDHF demonstrated validity and clinical applicability and can assist surgeons in identifying fractures that may require treatment with hemi- or total elbow arthroplasty.
General conclusion
Elbow hemiarthroplasty (EHA) and Open Reduction and Internal Fixation (ORIF) are reliable options for treating acute distal humeral fractures AO/OTA type 13-C2 and -C3 in middle-aged and elderly patients. Good to excellent results can be obtained in most patients despite the presence of complications. Since no major differences were detected between these 2 treatment options, we should wait for the result of our ongoing trial before making any general recommendations. The Copenhagen Classification System for Distal Humeral Fractures (CCDHF) has shown validity and clinical applicability in classifying distal humeral fractures. The CCDHF can assist surgeons in identifying fractures that may necessitate treatment with hemi- or total elbow arthroplasty.

Study I
Ali Al-Hamdani, Jeppe V Rasmussen, Anne Kathrine B Sørensen, Janne Ovesen, Kenneth Holtz, Stig Brorson, Bo S Olsen. Good outcome after elbow hemiarthroplasty in active patients with an acute intra-articular distal humeral fracture. J Shoulder Elbow Surg. 2019 May;28(5):925-930.
PMID: 30630712
DOI: 10.1016/j.jse.2018.10.018
Study II
Ali Al-Hamdani, Jeppe V Rasmussen, Bo S Olsen. Good functional outcomes after open reduction and internal fixation for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in patients aged over 45 years. J Shoulder Elbow Surg. 2022 Jan;31(1):143-150.
PMID: 34474137
DOI: 10.1016/j.jse.2021.07.024
Study III
Ali Al-Hamdani, Jeppe V Rasmussen, Kenneth Holtz, Bo S Olsen. Elbow hemiarthroplasty versus open reduction and internal fixation for AO/OTA type 13 C2 and C3 fractures of distal humerus in patients aged 50 years or above: a randomized controlled trial. Trials. 2020; 21: 497.
PMID: 32513252
PMCID: PMC7278155
DOI: 10.1186/s13063-020-04418-8
Study IV
Ali Al-Hamdani, Jeppe V Rasmussen, Mustafa A Al-Hamdani, Anne Kathrine B Sørensen, Jacob Eschen, Bo S Olsen. The Copenhagen Classification System for Distal Humeral Fractures is useful to identify patients who may require treatment with hemi- or total elbow arthroplasty. JSES International. Available online 16 April 2024.
DOI: 10.1016/j.jseint.2024.03.016