Trends, complications, and comorbidity risk in total elbow arthroplasty versus open reduction and internal fixation for distal humerus fractures

Background: Treatment of distal humerus fractures (DHF) in older patients presents challenges due to high complication rates. Total elbow arthroplasty (TEA) has emerged as an alternative to open reduction and internal fixation (ORIF). This study investigates trends, outcomes, and risk factors associated with TEA and ORIF for the treatment of DHF. Methods: Using the PearlDiver Mariner database, patients aged 55 years and older treated with either TEA or ORIF for DHF between 2010 and 2021 were identified. Trends in procedure volume, 90-day complications (postoperative bleeding, wound disruption, thromboembolic events, infection), and 12-month revision rates were analyzed. Risk factors (age, gender, diabetes, tobacco use, obesity, chronic kidney disease) were assessed using exact matching (1:4 ratio) and multivariable logistic regression. Results: A total of 16,572 patients were reviewed, including 1825 treated with TEA and 14,747 with ORIF. TEA utilization peaked in 2014 but declined thereafter. Both TEA and ORIF showed decreased complication and revision rates over time. After exact matching (n = 8989; 1800 TEA, 7189 ORIF), TEA was associated with significantly higher 90-day postoperative bleeding (OR: 2.51, p < 0.001) and infection rates (OR: 1.83, p < 0.0001). Multivariable logistic regression showed that tobacco use increased wound disruption (OR: 1.71, p = 0.002), while chronic kidney disease was a predictor of infection (OR: 1.62, p < 0.001). Conclusion: TEA utilization for DHF has declined, possibly due to its association with a 2.5-fold higher risk of postoperative bleeding and 1.8-fold higher risk of infection compared to ORIF. Further assessment of treatment trends and their impact on clinical practice is needed.