Instrumented Bone Preserving elbow prosthesis in rheumatoid arthritis: 2-8 year follow-up

Mid-term results of the Latitude primary total elbow arthroplasty

BACKGROUND

The Latitude total elbow prosthesis is a third-generation implant, developed to restore the natural anatomy of the elbow. Literature on this prosthesis is scarce. The aim of this study was to analyze the mid-term results of the Latitude total elbow prosthesis.

METHODS

We retrospectively evaluated 62 patients (21 men and 41 women). The mean age at the time of surgery was 65 years (range, 28-87 years). The main indication for surgery was inflammatory arthritis. The outcome measures were complications, reoperations, self-reported physical functioning, pain, satisfaction, objectively measured physical functioning, and radiologic signs of loosening. Kaplan-Meier survival analysis was used to determine survival with revision as the endpoint.

RESULTS

Sixty-nine primary Latitude prostheses were placed in 62 patients between 2008 and 2019. Six patients (7 prostheses) died, 3 elbows underwent revision, and 9 patients were lost to follow-up. A total of 44 patients (50 prostheses) were available for follow-up. The mean length of follow-up was 51 months (range, 10-144 months). Kaplan-Meier survival analysis showed a survival rate of 82% at 10 years after surgery. The main reason for revision was aseptic loosening. Radial head dissociation was seen in 8 patients (24%), but none had complaints. Self-reported and objectively measured physical functioning yielded good results, although 23 patients (46%) did show radiolucent lines on radiographs.

CONCLUSION

Latitude total elbow arthroplasty is considered a successful procedure with low pain scores, high patient satisfaction, and good physical functioning. Survival rates nonetheless remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties. We recommend biomechanical studies to concentrate on specific postoperative loading instructions to minimize wear and consequent loosening.

Radiocapitellar arthroplasty

This article sets out the evidence demonstrating that the clinical need for a prosthetic arthroplasty designed specifically for the radiocapitellar joint has been underestimated. The prevalence of radiocapitellar degenerative change requiring treatment is discussed and the relationship between 'isolated' radiocapitellar joint arthritis and more generalised elbow arthritis is explained. Current literature now supports our view that radiocapitellar joint arthroplasty is not only an effective long-term solution for patients with localised radiocapitellar arthritis but also for those patients with more severe degenerative changes involving the elbow joint irrespective of their cause. We consider that is important to avoid resection of the radial head and therefore that resurfacing implants rather than joint replacement implants are more likely to provide a good longterm outcome for patients with elbow arthritis.

Total elbow arthroplasty in patients with rheumatoid arthritis

AIMS

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

METHODS

We searched PubMed, MEDLINE, Cochrane Reviews, and Embase from between January 2003 and March 2019. The primary aim was to determine the implant failure rate, the mode of failure, and risk factors predisposing to failure. A secondary aim was to identify the overall complication rate, associated risk factors, and clinical performance. A meta-regression analysis was completed to identify the association between each parameter with the outcome.

RESULTS

A total of 38 studies including 2,118 TEAs were included in the study. The mean follow-up was 80.9 months (8.2 to 156). The implant failure and complication rates were 16.1% (95% confidence interval (CI) 0.128 to 0.200) and 24.5% (95% CI 0.203 to 0.293), respectively. Aseptic loosening was the most common mode of failure (9.5%; 95% CI 0.071 to 0.124). The mean postoperative ranges of motion (ROMs) were: flexion 131.5° (124.2° to 138.8°), extension 29.3° (26.8° to 31.9°), pronation 74.0° (67.8° to 80.2°), and supination 72.5° (69.5° to 75.5°), and the mean postoperative Mayo Elbow Performance Score (MEPS) was 89.3 (95% CI 86.9 to 91.6). The meta-regression analysis identified that younger patients and implants with an unlinked design correlated with higher failure rates. Younger patients were associated with increased complications, while female patients and an unlinked prosthesis were associated with aseptic loosening.

CONCLUSION

TEA continues to provide satisfactory results for patients with RA. However, it is associated with a substantially higher implant failure and complication rates compared with hip and knee arthroplasties. The patient's age, sex, and whether cemented fixation and unlinked prosthesis were used can influence the outcome. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Joint J 2020;102-B(8):967-980.

Long-term outcomes after Instrumented Bone Preserving total elbow arthroplasty: a radiostereometric study with a minimum follow-up of 10 years

BACKGROUND

Aseptic loosening is a main concern in elbow arthroplasty. Evaluation of implant migration using radiostereometric analysis (RSA) might increase understanding of implant loosening. Previously, 2-year RSA results of 16 Instrumented Bone Preserving (IBP) elbow prostheses showed migration of the humeral component in the first weeks but most components stabilized within 6 months postoperatively. In follow-up, the present study evaluated long-term survival, the relation between early migration and survival, and the long-term migration and clinical outcomes.

METHODS

Sixteen patients who received an IBP prosthesis were prospectively followed with a median follow-up time of 136 months (range 82-165). Migration was measured using RSA. Clinical results were described using the Elbow Function Assessment (EFA), Broberg and Morrey elbow functional rating index, Oxford Elbow Score (OES), and visual analog scale (VAS) for pain and satisfaction.

RESULTS

Four patients underwent a revision within 10 years, and 2 more were planned for revision surgery after 14 years. Five patients died with their prosthesis in situ. Early migration was not associated with survival. Long-term migration patterns varied widely. Median EFA score was 58.5, Broberg and Morrey score was 50, and OES score was 32. Median VAS score for pain was 2 and that for satisfaction was 7.5.

CONCLUSION

Ten-year survival of the IBP total elbow prosthesis was 75%, decreasing to 63% after 14 years of follow-up. Long-term implant failure could not be predicted by 2-year migration results in this study. Although short-term clinical results were promising, long-term outcomes worsened in all patients.

Long-term results of the iBP elbow prosthesis: beware of destructive metallosis!

Background

The aim of this study was to review the long-term results of the instrumented Bone Preserving (iBP) elbow prosthesis.

Methods

Thirty-one patients (10 M, 21F, 28-77 year) were retrospectively evaluated using the Oxford Elbow Score (OES), Disabilities of Arm, Shoulder and Hand Outcome Measure (DASH), Mayo Elbow Performance (MEPS), physical examination and standard radiographs. Kaplan-Meier survival analysis was used.

Results

Thirty-seven primary iBPs have been placed in 31 patients between 2000 and 2007. Six patients (8 prostheses) had died, 10 elbows had been revised and three patients (4 prostheses) were lost to follow-up. Fourteen patients (15 prostheses) were available for follow-up. The main indication for surgery was rheumatoid arthritis. Mean follow-up was 11 years (8–15). Kaplan-Meier survival analysis showed a survival of 81% at 10 years after surgery. Main reason for revision was particle disease and loosening due to instability and malalignment. Eleven of 14 patients were satisfied, although radiographs showed radiolucencies in 11 patients.

Conclusion

The iBP elbow prosthesis gives a survival rate of 81% 10 years after surgery with a progressive decline beyond 10 years. However, many patients have radiolucencies. Discrepancy between clinical signs and radiological results warrants structural follow-up, to assure quality of bone stock in case revision surgery is indicated.

The study was reviewed and approved by the Medical Ethical Committee of University Medical Center Groningen (METc2016/038).

Level of evidence

Level IV, Case series.

Total elbow replacement - patient selection and perspectives

Total joint replacements for elbow arthritis were developed in the late 1960s at the same time as total joint replacements for knee joint arthritis. Since then, there has been a continuing annual increase in the number of patients treated with total knee joint replacement for arthritis, in line with replacement arthroplasty of the other major limb joints, but in contrast to total elbow joint replacement which is falling, since reaching a peak in the 1990s. Which raises the question, why? Continuing controversy about implant design, the relatively high reported complication rates associated with total elbow replacement (TER) and the difficulties encountered in revision surgery are identified as reasons together with changes in the patient population currently treated with TER. The purpose of this review is to explore the reasons for this in the context of the patient population requiring implant surgery for elbow arthritis and our current perspective of elbow pathology requiring treatment. This is not a systematic review of the whole of the literature concerning total elbow joint replacement arthroplasty but is drawn largely from the supporting literature that reflects my own clinical experience and illustrated with teaching materials I have commissioned together with radiographs and intraoperative photographs of patients I have treated.

Long-term Outcome of Open Synovectomy with Radial Head Resection for Rheumatoid Elbow

BACKGROUND

We reviewed our surgical results of open synovectomy with radial head resection for rheumatoid elbow.

METHODS

We reviewed the 20 patients (22 elbows) underwent open synovectomy for rheumatoid elbows retrospectively. The minimum follow-up period is over 10 years, and the average was 13 years 4 months. Surgical outcomes were evaluated using the VAS pain scale, range of motion, and radiologic outcomes including Larsen's grade and carrying angle.

RESULTS

The mean VAS score was 39 (range, 10-90) at last follow-up. The only one patient underwent revision surgery. The mean flexion-extension range of elbow was -28°-112° and arc of motion was 82° before surgery. The mean flexion-extension range of elbow was -23°-114°, and arc of motion was 90° at last follow-up. Radiologic findings of nine elbows in 21 elbows worsened at last follow-up according to the Larsen-s grade. Carrying angle increased by mean 4.2°, and it increased by 10° or more in four elbows.

CONCLUSIONS

Our results show that open synovectomy with radial head resection resulted in functional motion maintenance and pain control for a long time, but often resulted in an elbow valgus deformity. Our findings suggest open synovectomy can be considered as palliative treatment for painful rheumatoid elbow.

Why does total elbow arthroplasty fail today? A systematic review of recent literature

BACKGROUND

Total elbow arthroplasty is a relatively uncommon type of arthroplasty, which has undergone several design changes in the past four decades. However, research on improvement requires knowledge of failure mechanisms that can be addressed. Therefore, we conducted a systematic review on modes of failure of total elbow arthroplasty.

METHODS

We conducted searches on PubMed/Medline, Embase and Cochrane databases to identify studies describing modes of failure of primary total elbow arthroplasties. The results were coupled per type of total elbow arthroplasty and individual arthroplasty models.

RESULTS

A total of 70 articles were included in this systematic review. 9308 individual total elbow arthroplasties were identified with 1253 revisions (13.5%). Aseptic loosening was the most prevalent reason for revision (38%), followed by deep infection (19%) and periprosthetic fractures (12%).

CONCLUSION

Revision rates have been found similar to a systematic review published in 2003. The revision percentage of total elbow arthroplasty for rheumatoid arthritis is significantly higher than for trauma and post-traumatic osteoarthritis. Aseptic loosening was seen less in linked implants. Infections and periprosthetic fractures did not differ between linkage design groups. Aseptic loosening remains the most frequent cause for revision of primary total elbow arthroplasty. Therefore, more research on the occurrence, progression and risk factors of aseptic loosening should be performed and lead to higher implant survival.

Primary Linked Semiconstrained Total Elbow Arthroplasty for Rheumatoid Arthritis: A Single-Institution Experience with 461 Elbows Over Three Decades

BACKGROUND

Elbow arthroplasty is the treatment of choice for end-stage rheumatoid arthritis (RA). The purpose of this study was to determine the long-term outcome of a linked semiconstrained elbow arthroplasty implant design in patients with RA.

METHODS

Between 1982 and 2006, 461 primary total elbow arthroplasties using the Coonrad-Morrey prosthesis were performed in 387 patients with RA. Fifty-five of the arthroplasties were performed to treat concurrent traumatic or posttraumatic conditions. There were 305 women (365 elbows, 79%) and 82 men (96 elbows, 21%). Ten patients (10 elbows) were lost to follow-up, 9 patients (10 elbows) died, and 6 patients (6 elbows) underwent revision surgery within the first 2 years. For the 435 elbows (362 patients, 94%) with a minimum of 2 years of follow-up, the median follow-up was 10 years (range, 2 to 30 years).

RESULTS

At the most recent follow-up, 49 (11%) of the elbows had undergone component revision or removal (deep infection, 10 elbows; and mechanical failure, 39 elbows). Eight additional elbows were considered to have radiographic evidence of loosening. For surviving implants followed for a minimum of 2 years, the median Mayo Elbow Performance Score (MEPS) was 90 points. Bushing wear was identified in 71 (23%) of the surviving elbows with a minimum of 2 years of radiographic follow-up; however, only 2% of the elbows had been revised for isolated bushing wear. The rate of survivorship free of implant revision or removal for any reason was 92% (95% confidence interval [CI] = 88% to 94%) at 10 years, 83% (95% CI = 77% to 88%) at 15 years, and 68% (95% CI = 56% to 78%) at 20 years. The survivorship at 20 years was 88% (95% CI = 83% to 92%) with revision due to aseptic loosening as the end point and 89% (95% CI = 77% to 95%) with isolated bushing exchange as the end point. Risk factors for implant revision for any cause included male sex, a history of concomitant traumatic pathology, and implantation of an ulnar component with a polymethylmethacrylate surface finish.

CONCLUSIONS

Elbow arthroplasty using a cemented linked semiconstrained elbow arthroplasty provides satisfactory clinical results in the treatment of RA with a reasonable rate of survivorship free of mechanical failure at 20 years. Although bushing wear was identified on radiographs in approximately one-fourth of the patients, revision for isolated bushing wear was uncommon.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Results of custom-fit, noncemented, semiconstrained total elbow arthroplasty for inflammatory arthritis at an average of eighteen years of follow-up

BACKGROUND

The literature available on the results after noncemented total elbow arthroplasty (TEA) in inflammatory arthritis is limited.

METHODS

Ten patients (7 women, 3 men; 14 elbows total) who underwent custom, noncemented TEA from 1988 to 1995 were retrospectively reviewed. The average age was 28 years (range, 17-45 years). Four patients (4 elbows) had rheumatoid arthritis, and 6 patients (10 elbows) had juvenile rheumatoid arthritis. The mean follow-up was 18 years. All patients underwent a custom, noncemented, semiconstrained TEA with a plasma spray surface designed from preoperative computed tomography scan to achieve metaphyseal fit. The primary outcome was the Mayo Elbow Performance Score, and secondary outcomes were flexion and rotation arc of motion. Intraoperative and postoperative complications and revisions performed were also recorded. Radiographs taken at final follow-up were evaluated for evidence of loosening.

RESULTS

The Mayo Elbow Performance Score improved from a mean of 35 preoperatively to a mean of 91 postoperatively. Flexion arc of motion improved from 50° preoperatively to 111° postoperatively, and rotation arc improved from 75° preoperatively to 145° postoperatively. Four patients underwent bushing revision at 8, 8, 22, and 22 years (29%), respectively, and there was 1 deep infection (7%). One patient had an intraoperative fracture in the humerus that did not require further treatment. On final radiographic follow-up at a mean of 18 years, all the components were fully ingrown, and there was no evidence of loosening or loss of fixation.

CONCLUSION

In the younger population with inflammatory arthritis, noncemented TEA has reliable outcomes clinically and radiographically at long-term follow-up.

Radial head, radiocapitellar and total elbow arthroplasties: a review of recent literature

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.

Long-term outcome of elbow resurfacing

BACKGROUND

The purpose of this study is to review the long term results the Kudo and instrumented Bone Preserving elbow prostheses. The instrumented Bone Preserving prosthesis is the successor of the Kudo prosthesis, and both of these are nonconstrained elbow resurfacing prostheses.

METHODS

Fifty-five nonconstrained elbow prosthesis were implanted in 51 patients. Patients were evaluated with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm Shoulder and Hand score. Revision or the necessity of revision was regarded as failure of the prosthesis.

RESULTS

Twenty-one prostheses (of which 3 instrumented Bone Preserving prostheses) were revised or needed revision, yielding a revision rate of 15.1% after 5 years and 36.5% after 10. The major reasons for revision were loosening in 10 cases and instability in 5. Eleven of the nonrevised patients died of unrelated causes, having little or no subjective problems until the time of death. There was no statistical difference between Kudo and instrument Bone Preserving implant survival. Most nonrevised patients were satisfied, according to the Visual Analog Scale for satisfaction. The median MEPS indicated fair to good results.

CONCLUSION

When comparing our results to those of other elbow prosthesis we must conclude that our revision rate is high, however, the outcome of the nonrevised patients is good. This study shows that the results of the Kudo prosthesis, which have been reported twice before by our department, have clearly deteriorated after an average follow-up of 174 months (the last study had an average follow-up of 58 months).

Update on the state of outcome measurement in total elbow arthroplasty research: identifying a need for consensus

BACKGROUND

There is little consensus for a standard set of metrics to express outcome after total elbow arthroplasty. In order to set the stage for future work toward a core set of measurement tools, our goal was to gather a complete view of the outcomes used in total elbow arthroplasty research, the concepts of their focus, and their quality as measures of the target concept.

METHODS

We reviewed the outcome measures for total elbow arthroplasty presented in the literature from 2004 to 2011 in terms of the instruments used and their concepts of focus. We reviewed the reliability, validity, and responsiveness of the prevailing measurement tools.

RESULTS

Of the seventy-two articles identified, 90% (sixty-five) used elbow-specific aggregate outcome measures, which combine concepts, such as physiological variables, with symptom status and functional status. The Mayo Elbow Performance Score, or a variation of that scoring system, was used in fifty-four (75%) of the seventy-two articles. Most outcomes pertained to biological and physiological variables, with fewer outcomes focusing on symptoms, function, or overall health status. A review of the measurement properties of the elbow-specific aggregate outcome measures did not reveal one to be superior.

CONCLUSIONS

Overall, total elbow arthroplasty outcomes are heterogeneous in their reporting and lack standardization. The total elbow arthroplasty literature relies on several physician-derived elbow-specific aggregate measures and focuses primarily on physiological variables. The relative merits of aggregating findings into a single scoring system versus as separate components should be explored further. Finally, consideration should be given to patient-reported outcome measures in total elbow arthroplasty research.

CLINICAL RELEVANCE

This study of the current "state of practice" for outcome measurement in total elbow arthroplasty revealed gaps in the breadth of measurement and a lack of comparability in elbow scoring systems that could hinder our ability to clearly and fully understand outcome after total elbow arthroplasty. Future consensus work could address both concerns and assist in the development of a core set of outcome measures.

Biomechanical analysis of total elbow replacement with unlinked iBP prosthesis: an in vitro and finite element analysis

BACKGROUND

Numerous models of elbow prostheses are being used and can be divided into two categories: one being a semi-constrained, linked type; and the other being non-constrained, unlinked type. Recent reports of National Elbow Arthroplasty Registers reveal no significant differences in the survival rates between linked and unlinked prosthesis brands, and the main cause appointed for revision for both types is loosening. Some previous biomechanical studies confirm the presence of abnormal bone stresses for the linked type, which can be associated with the risk of loosening. However for the unlinked type, biomechanical studies are not available that corroborate a loosening risk. It seems, that issue has not yet been fully answered and requires further analysis.

METHODS

Cortex strains adjacent to the elbow joint were measured with strain gauges in synthetic humeri and ulnae, before and after replacement. To assess cancellous bone strains and cement stresses around the implant finite element models validated relative to measured strains were used.

FINDINGS

Bone strains adjacent to the implant tip increased several times in the humerus and ulna. At the epiphyseal regions a generalised cancellous bone strain reduction was observed for both humerus and ulna relatively to the intact bones.

INTERPRETATION

The unlinked elbow prostheses can be associated with the risk of bone fatigue failure by overload, particularly in the ulna, and bone resorption by stress-shielding at the epiphyseal regions. The identical structural behaviour relative to linked prostheses associated with the same loosening risks corroborates the results of recent arthroplasty published register reports.