Ellenbogenfraktur im Alter – Erhalt oder Ersatz?

Zusammenfassung

Distale Humerusfrakturen zeigen im geriatrischen Patientenkollektiv eine zunehmende Inzidenz. Aufgrund der häufig vorbestehenden osteoporotischen Knochenverhältnisse ist der Chirurg regelhaft mit komplexen intraartikulären mehrfragmentären Frakturen konfrontiert.

Der Erhalt der Selbstständigkeit und das Vermeiden von Pflegebedürftigkeit ist ein Dogma in der Versorgung geriatrischer Patienten. Gerade beim betagten Patienten ist folglich eine stabile postoperative Situation und eine frühfunktionelle Nachbehandlung anzustreben. Die offene anatomische Reposition und stabile Retention mittels Doppelplattenosteosynthese ist der osteosynthetische Versorgungsstandard. Moderne anatomische, winkelstabile Implantate sollen die stabile Retention erleichtern und die Operationsdauer verkürzen. Die wenigen zur Verfügung stehenden Daten mit modernen Plattensystemen zeigen beim geriatrischen Patienten zwar gute funktionelle Ergebnisse, jedoch auch hohe Komplikationsraten.

Wie an anderen großen Gelenken hat sich auch am Ellenbogen die Frakturendoprothetik aufgrund der direkten Primärstabilität als wertvolle therapeutische Alternative beim älteren Patienten etabliert. So zeigen die Register in den letzten Jahrzehnten eine Vervielfachung der Implantationszahlen.

Das Standardimplantat in der Frakturendoprothetik des geriatrischen Patienten ist die zementierte „semi-constrained“ Prothese. Als Nachteile einer primär endoprothetischen Versorgung werden die lebenslange Belastungsrestriktion sowie potenzielle prothesenassoziierte Langzeitkomplikationen wie aseptische Lockerung und periprothetische Frakturen genannt.

Vergleichende Studien mit kurz- und mittelfristigen Nachuntersuchungszeiträumen zeigen gegenüber der Osteosynthese vergleichbare funktionelle Ergebnisse, jedoch weniger Komplikationen und Revisionen sowie eine verkürzte Operationsdauer. Langzeitergebnisse, die potenzielle prothesenassoziierte Komplikationen suffizient erfassen, fehlen jedoch.

In der rekonstruierbaren und für eine frühfunktionelle Beübung stabil retinierbaren Fraktursituation des distalen Humerus bleibt die Osteosynthese folglich auch beim geriatrischen Patienten das Verfahren der ersten Wahl.

Abstract

Distal humerus fractures show increasing incidence with age. Due to preexisting osteoporosis, the surgeon is regularly confronted with complex comminuted intraarticular fractures.

The maintenance of autonomy in daily life and avoidance of permanent care dependency is a dogma in the care of geriatric patients. Accordingly, a stable post-operative situation that allows early functional post-operative treatment is mandatory, especially in the elderly patient. Open reduction and stable internal fixation using double plate osteosynthesis are the current osteosynthetic standard of treatment. Modern precontoured systems with angular stability facilitate stable fixation and reduce surgery time. However, complication rates are high, despite the good functional outcomes in the few available studies which use modern plate systems in a geriatric patient population.

Due to the high rate of primary stability, elbow arthroplasty has become an established treatment option for complex distal humerus fractures in elderly patients. Consequently arthroplasty registry data report a growing number of elbow replacements for fracture in recent decades.

The standard implant design in the fractures in geriatric patients is the cemented “semi-constrained” total elbow arthroplasty. The disadvantages of total elbow replacement are the lifelong stringent weight restriction patients must adhere to, as well as potential long-term complications associated with arthroplasty, such as aseptic loosening and periprosthetic fractures.

Comparative studies with short- and medium-term follow-up show overall comparable functional results for elbow arthroplasty and double plate osteosynthesis, with fewer complications and revisions as well as a shorter duration of surgery within the arthroplasty group. However, long-term outcome studies are necessary to identify potential long-term complications associated with arthroplasty and are pending.

Therefore, in reconstruction of fractures of the distal humerus which allow stable fixation and early functional post-operative treatment, open reduction and double plate internal fixation with modern locking plate systems remains the gold standard even for geriatric patients.

Schlüsselwörter

distale Humerusfraktur - Alterstraumatologie - Endoprothetik - Osteosynthese

Key words

distal humerus fracture - geriatric traumatology - arthroplasty - osteosynthesis

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