Customized 3D-Printed Resurfacing Arthroplasty for the Treatment of Severely Malunited Distal Humerus Associated With Posttraumatic Elbow Stiffness: A Case Report and Review of the Literature

Abstract

Background: Posttraumatic elbow stiffness together with severe bony deformity of the distal humerus poses a great challenge for elbow surgery specialists. For young and high-demand patients suffering from grievous bony deformity but with no/mild joint degeneration, total elbow arthroplasty is not a suitable option, and hemiarthroplasty often results in a significant amount of bone stock loss, making it difficult to perform a revision procedure. Resurfacing arthroplasty has been applied in the shoulder, hip, and knee joints, as well as the radiocapitellar joint. However, resurfacing arthroplasty for the entire distal humeral articular surface was not available among current clinical studies.

Case Presentation: We report a case of a 66-year-old male patient who presented with elbow stiffness and grievous malunion of the distal humerus due to delayed treatment after a distal humerus fracture. However, there was only mild joint degeneration observed at the proximal ulna and radius owing to long-term functional impairment. Total elbow replacement was not suitable considering certain inevitable manual labor he must attend. We customized a cementless and stemless resurfacing prosthesis for the distal humerus based on contralateral articular anatomy using a 3D-printing technique with Co-Cr-Mo alloy. The traditional cemented stem was replaced with criss-cross screws to provide primary stability. The bone-implant interface was covered with a 3D-printed trabecular-like porous structure for bone in-growth and several grooves designed for bone grafting, eventually forming a stable multinested mortise-and-tenon joint structure at the bone-implant interface. At the last follow-up, significant improvements in functional outcomes of the elbow joint were observed without any prosthesis-related complications. The patient was able to return to his previous manual labor and reported improved weight-bearing capability of the affected upper limb up to 25 kg without pain or instability. While he complained of postoperative ulnar nerve palsy, the symptom markedly improved at the final follow-up.

Conclusion: The novel prosthesis we have designed for resurfacing arthroplasty of the distal humerus can provide adequate primary stability and bone in-growth capability, making it a reliable alternative for patients with severe bony deformity of the distal humerus and no/mild joint degeneration at the proximal ulna and radius, particularly young patients or those with high functional demands.

Keywords

3D-printing / distal humerus / malunion / posttraumatic elbow stiffness / resurfacing arthroplasty

References

[1] C. P. Charalambous and B. F. Morrey, “Posttraumatic Elbow Stiffness,” Journal of Bone and Joint Surgery. American Volume 94, no. 15 (2012): 1428-1437.

[2] D. Zhang, A. Nazarian, and E. K. Rodriguez, “Post-Traumatic Elbow Stiffness: Pathogenesis and Current Treatments,” Shoulder and Elbow 12, no. 1 (2020): 38-45.

[3] Z. Sun, J. Li, H. Cui, H. Ruan, W. Wang, and C. Fan, “A New Pathologic Classification for Elbow Stiffness Based on Our Experience in 216 Patients,” Journal of Shoulder and Elbow Surgery 29, no. 3 (2020): e75-e86.

[4] Z. Sun, H. Cui, J. Ruan, J. Li, W. Wang, and C. Fan, “What Range of Motion and Functional Results Can be Expected After Open Arthrolysis With Hinged External Fixation for Severe Posttraumatic Elbow Stiffness,” Clinical Orthopaedics and Related Research 477, no. 10 (2019): 2319-2328.

[5] L. Willinger, S. Siebenlist, A. Lenich, F. Liska, A. B. Imhoff, and A. Achtnich, “Arthroscopic Arthrolysis Provides Good Clinical Outcome in Post-Traumatic and Degenerative Elbow Stiffness,” Knee Surgery, Sports Traumatology, Arthroscopy 26, no. 1 (2018): 312-317.

[6] C. M. Beck, M. J. Gluck, Y. Zhang, et al., “Outcomes of Arthroscopic Elbow Contracture Release: Improvement for Severe Prosupination and Flexion Contracture,” Arthroscopy 38, no. 2 (2022): 315-322.

[7] A. J. Schreiner, N. Schweikardt, D. Gühring, et al., “Arthroscopic Arthrolysis Leads to Improved Range of Motion and Health-Related Quality of Life in Post-Traumatic Elbow Stiffness,” Journal of Shoulder and Elbow Surgery 29, no. 8 (2020): 1538-1547.

[8] Y. Zhou, J. Y. Cai, S. Chen, S. Liu, W. Wang, and C. Y. Fan, “Application of Distal Radius-Positioned Hinged External Fixator in Complete Open Release for Severe Elbow Stiffness,” Journal of Shoulder and Elbow Surgery 26, no. 2 (2017): e44-e51.

[9] J. M. Haglin, D. N. Kugelman, A. Christiano, S. R. Konda, N. Paksima, and K. A. Egol, “Open Surgical Elbow Contracture Release After Trauma: Results and Recommendations,” Journal of Shoulder and Elbow Surgery 27, no. 3 (2018): 418-426.

[10] I. F. Kodde, J. van Rijn, M. P. van den Bekerom, and D. Eygendaal, “Surgical Treatment of Post-Traumatic Elbow Stiffness: A Systematic Review,” Journal of Shoulder and Elbow Surgery 22, no. 4 (2013): 574-580, https://doi.org/10.1016/j.jse.2012.11.010.

[11] S. Y. Yu, W. Wang, S. Liu, et al., “Arthrolysis and Delayed Internal Fixation Combined With Hinged External Fixation for Elbow Stiffness Associated With Malunion or Nonunion of Capitellum Fracture,” Journal of Shoulder and Elbow Surgery 24, no. 6 (2015): 941-946, https://doi.org/10.1016/j.jse.2015.01.019.

[12] Y. Ouyang, Y. Liao, Z. Liu, and C. Fan, “Hinged External Fixator and Open Surgery for Severe Elbow Stiffness With Distal Humeral Nonunion,” Orthopedics 36, no. 2 (2013): e186-e192.

[13] A. Choo and M. L. Ramsey, “Total Elbow Arthroplasty: Current Options,” Journal of the American Academy of Orthopaedic Surgeons 21, no. 7 (2013): 427-437.

[14] L. S. Harmer and J. Sanchez-Sotelo, “Total Elbow Arthroplasty for Distal Humerus Fractures,” Hand Clinics 31, no. 4 (2015): 605-614.

[15] L. J. DeSimone and J. Sanchez-Sotelo, “Total Elbow Arthroplasty for Distal Humerus Fractures,” Orthopedic Clinics of North America 44, no. 3 (2013): 381-387.

[16] D. Zhang and N. Chen, “Total Elbow Arthroplasty,” Journal of Hand Surgery 44, no. 6 (2019): 487-495.

[17] M. S. Davey, E. T. Hurley, M. Gaafar, D. Molony, H. Mullett, and L. Pauzenberger, “Long-Term Outcomes of Total Elbow Arthroplasty: A Systematic Review of Studies at 10-Year Follow-Up,” Journal of Shoulder and Elbow Surgery 30, no. 6 (2021): 1423-1430.

[18] A. Leclerc and G. J. King, “Unlinked and Convertible Total Elbow Arthroplasty,” Hand Clinics 27, no. 2 (2011): 215-227.

[19] K. Nishida, Y. Nasu, K. Hashizume, et al., “Outcome of Unlinked Total Elbow Arthroplasty for Rheumatoid Arthritis in Patients Younger Than 50 Years Old,” Bone & Joint Open 4, no. 1 (2023): 19-26, https://doi.org/10.1302/2633-1462.41.BJO-2022-0151.R1.

[20] J. A. Strelzow, T. Frank, G. S. Athwal, K. J. Faber, and G. King, “Results of Linked Convertible Total Elbow Arthroplasty for the Management of Distal Humeral Fractures in the Elderly,” Journal of Hand Surgery. American Volume 46, no. 5 (2021): 396-402.

[21] A. Celli, M. Ricciarelli, E. Guerra, et al., “Elbow Hemiarthroplasty for Acute Distal Humeral Fractures and Their Sequelae: Medium- and Long-Term Follow-Up of 41 Cases,” Journal of Shoulder and Elbow Surgery 31, no. 5 (2022): 1015-1025.

[22] R. Rotini, M. Ricciarelli, E. Guerra, A. Marinelli, and A. Celli, “Elbow Hemiarthroplasty in Distal Humeral Fractures: Indication, Surgical Technique and Results,” Injury 54, no. Suppl 1 (2023): S36-S45.

[23] E. G. Burden, T. Batten, C. Smith, and J. P. Evans, “Hemiarthroplasty or Total Elbow Arthroplasty for Unreconstructable Distal Humeral Fractures in Patients Aged Over 65 Years: A Systematic Review and Meta-Analysis of Patient Outcomes and Complications,” Bone & Joint Journal 104-B, no. 5 (2022): 559-566, https://doi.org/10.1302/0301-620X.104B5.BJJ-2021-1207.R2.

[24] J. D. Werthel, B. Schoch, J. Adams, and S. Steinmann, “Outcomes After Hemiarthroplasty of the Elbow for the Management of Posttraumatic Arthritis: Minimum 2-Year Follow-Up,” Journal of the American Academy of Orthopaedic Surgeons 27, no. 19 (2019): 727-735.

[25] D. L. Burgess, M. S. McGrath, P. M. Bonutti, D. R. Marker, R. E. Delanois, and M. A. Mont, “Shoulder Resurfacing,” Journal of Bone and Joint Surgery. American Volume 91, no. 5 (2009): 1228-1238.

[26] M. Palazzuolo, A. Bensa, S. Bauer, W. G. Blakeney, G. Filardo, and M. Riegger, “Resurfacing Hip Arthroplasty Is a Safe and Effective Alternative to Total Hip Arthroplasty in Young Patients: A Systematic Review and Meta-Analysis,” Journal of Clinical Medicine 12, no. 6 (2023): 2093.

[27] C. Chillemi, C. Paglialunga, G. De Giorgi, R. Proietti, S. Carli, and M. Damo, “Outcome and Revision Rate of Uncemented Humeral Head Resurfacing: Mid-Term Follow-Up Study,” World Journal of Orthopaedics 12, no. 6 (2021): 403-411, https://doi.org/10.5312/wjo.v12.i6.403.

[28] K. Soudy, C. Szymanski, C. Lalanne, et al., “Results and Limitations of Humeral Head Resurfacing: 105 Cases at a Mean Follow-Up of 5 Years,” Orthopaedics & Traumatology, Surgery & Research 103, no. 3 (2017): 415-420.

[29] C. Watkins, D. W. Elson, J. Harrison, and J. Pooley, “Long-Term Results of the Lateral Resurfacing Elbow Arthroplasty,” Bone & Joint Journal 100-B, no. 3 (2018): 338-345.

[30] F. Schmidutz, C. M. Sprecher, S. Milz, F. Gohlke, R. Hertel, and V. Braunstein, “Resurfacing of the Humeral Head: An Analysis of the Bone Stock and Osseous Integration Under the Implant,” Journal of Orthopaedic Research 33, no. 9 (2015): 1382-1390.

[31] L. E. Pidhorz, R. M. Urban, J. J. Jacobs, D. R. Sumner, and J. O. Galante, “A Quantitative Study of Bone and Soft Tissues in Cementless Porous-Coated Acetabular Components Retrieved at Autopsy,” Journal of Arthroplasty 8, no. 2 (1993): 213-225.

[32] A. Tonino, C. Oosterbos, A. Rahmy, M. Thèrin, and C. Doyle, “Hydroxyapatite-Coated Acetabular Components. Histological and Histomorphometric Analysis of Six Cups Retrieved at Autopsy Between Three and Seven Years After Successful Implantation,” Journal of Bone and Joint Surgery. American Volume 83, no. 6 (2001): 817-825.

[33] R. B. Ruben, P. R. Fernandes, and J. Folgado, “On the Optimal Shape of Hip Implants,” Journal of Biomechanics 45, no. 2 (2012): 239-246.

[34] M. Jasty, C. Bragdon, D. Burke, D. O'Connor, J. Lowenstein, and W. H. Harris, “In Vivo Skeletal Responses to Porous-Surfaced Implants Subjected to Small Induced Motions,” Journal of Bone and Joint Surgery. American Volume 79, no. 5 (1997): 707-714.

[35] R. P. Piggott, O. Hennessy, and N. A. Aresti, “Distal Humerus Hemiarthroplasty for Trauma: A Systematic Review of the Outcomes and Complications,” Journal of Shoulder and Elbow Surgery 31, no. 7 (2022): 1545-1552.

[36] J. S. Park, Y. T. Kim, and S. J. Choi, “Crisscross-Type Screw Fixation for Transcondylar Fractures of Distal Humerus in Elderly Patients,” Archives of Orthopaedic and Trauma Surgery 135, no. 1 (2015): 1-7.

[37] B. Santos, C. Quental, J. Folgado, M. Sarmento, and J. Monteiro, “Bone Remodelling of the Humerus After a Resurfacing and a Stemless Shoulder Arthroplasty,” Clinical Biomechanics (Bristol, Avon) 59 (2018): 78-84.

[38] S. Spencer, R. Carter, H. Murray, and R. M. Meek, “Femoral Neck Narrowing After Metal-On-Metal Hip Resurfacing,” Journal of Arthroplasty 23, no. 8 (2008): 1105-1109.

[39] A. Shimmin, P. E. Beaulé, and P. Campbell, “Metal-On-Metal Hip Resurfacing Arthroplasty,” Journal of Bone and Joint Surgery. American Volume 90, no. 3 (2008): 637-654.

[40] M. R. Whitehouse, N. S. Atwal, M. Pabbruwe, A. W. Blom, and G. C. Bannister, “Osteonecrosis With the Use of Polymethylmethacrylate Cement for Hip Replacement: Thermal-Induced Damage Evidenced In Vivo by Decreased Osteocyte Viability,” European Cells & Materials 27 (2014): 50-62.

[41] N. A. Hodges, E. M. Sussman, and J. P. Stegemann, “Aseptic and Septic Prosthetic Joint Loosening: Impact of Biomaterial Wear on Immune Cell Function, Inflammation, and Infection,” Biomaterials 278 (2021): 121127.

[42] K. L. Ong, S. M. Kurtz, M. T. Manley, N. Rushton, N. A. Mohammed, and R. E. Field, “Biomechanics of the Birmingham Hip Resurfacing Arthroplasty,” Journal of Bone and Joint Surgery. British Volume 88, no. 8 (2006): 1110-1115.

[43] M. Zhang, T. Gregory, U. Hansen, and C. K. Cheng, “Effect of Stress-Shielding-Induced Bone Resorption on Glenoid Loosening in Reverse Total Shoulder Arthroplasty,” Journal of Orthopaedic Research 38, no. 7 (2020): 1566-1574.

[44] J. Nagels, M. Stokdijk, and P. M. Rozing, “Stress Shielding and Bone Resorption in Shoulder Arthroplasty,” Journal of Shoulder and Elbow Surgery 12, no. 1 (2003): 35-39.

[45] D. Vogel, M. Wehmeyer, M. Kebbach, H. Heyer, and R. Bader, “Stress and Strain Distribution in Femoral Heads for Hip Resurfacing Arthroplasty With Different Materials: A Finite Element Analysis,” Journal of the Mechanical Behavior of Biomedical Materials 113 (2021): 104115.

[46] O. Levy and S. A. Copeland, “Cementless Surface Replacement Arthroplasty of the Shoulder. 5-to 10-Year Results With the Copeland Mark-2 Prosthesis,” Journal of Bone and Joint Surgery. British Volume 83, no. 2 (2001): 213-221.

[47] O. Alizadehkhaiyat, A. Kyriakos, M. S. Singer, and S. P. Frostick, “Outcome of Copeland Shoulder Resurfacing Arthroplasty With a 4-Year Mean Follow-Up,” Journal of Shoulder and Elbow Surgery 22, no. 10 (2013): 1352-1358.

[48] F. U. Verstraelen, L. A. Horta, M. Schotanus, N. P. Kort, S. K. Samijo, and E. Jansen, “Clinical and Radiological Results 7 Years After Copeland Shoulder Resurfacing Arthroplasty in Patients With Primary Glenohumeral Osteoarthritis: An Independent Multicentre Retrospective Study,” European Journal of Orthopaedic Surgery and Traumatology 28, no. 1 (2018): 15-22.

[49] T. James Karssiens, R. Zhou, J. Ritchie Gill, and R. C. Paul, “Clinical Results and 10-Year Survivorship of the Synthes Epoca Resurfacing Total Shoulder Arthroplasty,” Shoulder and Elbow 14, no. 6 (2022): 615-624.

[50] G. C. Smith and J. S. Hughes, “Unreconstructable Acute Distal Humeral Fractures and Their Sequelae Treated With Distal Humeral Hemiarthroplasty: A Two-Year to Eleven-Year Follow-Up,” Journal of Shoulder and Elbow Surgery 22, no. 12 (2013): 1710-1723.

[51] M. Schultzel, R. Rangarajan, C. Blout, I. Manuputy, B. K. Lee, and J. M. Itamura, “Hemiarthroplasty for the Treatment of Distal Humerus Fractures: Long-Term Clinical Results,” Journal of Shoulder and Elbow Surgery 31, no. 7 (2022): 1510-1514.

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.