Incidence and implications of early postoperative wound complications after total elbow arthroplasty

Incidence of and Risk Factors for Reoperation and Revision Following Total Elbow Arthroplasty with an Anatomic Convertible Prosthesis

BACKGROUND

Total elbow arthroplasty (TEA) remains a valuable tool for treating inflammatory, degenerative, and traumatic elbow conditions. This study aimed to understand the incidence of and risk factors for reoperation following TEA at a high-volume center utilizing an implant with a convertible linkage and the potential for anatomic lateral column reconstruction.

METHODS

All patients undergoing primary TEA with the Latitude prosthesis (Stryker) from July 2001 to May 2020 were identified. Patient characteristics, the surgical indication, and implant characteristics were obtained. Additionally, the indications and timing were identified for reoperations. Postoperative radiographs were analyzed to assess cement quality, implant position, lateral column reconstruction, and distal humeral bone loss.

RESULTS

Two hundred and nineteen TEAs were performed in 206 patients; 162 (74.0%) were in female patients, the mean patient age was 61 years (range, 23 to 95 years), and the mean follow-up was 11.8 years (range, 2 to 21 years). The most common indication for surgery was sequelae of trauma (36%). Ninety elbows (41.1%) required 200 reoperations at a mean of 19.6 months. Forty TEAs (18.3%) required revision of nonmodular implants, with 14 (6.4%) undergoing definitive explantation. The 5 and 10-year survivorship was 86.1% and 79.7%, respectively. The most common of the reasons for revision was aseptic loosening (53.8%), and the most common cause for non-revision reoperation was infection (23%). Younger age and greater follow-up duration were associated with greater revision and reoperation risks. Aseptic ulnar loosening was associated with a short ulnar stem length and component linkage (30% of short linked ulnar stems loosened; p < 0.001). Aseptic humeral loosening was associated with less-than-adequate cement-mantle quality (p = 0.04).

CONCLUSIONS

Extended follow-up of the Latitude prosthesis at a high-volume center demonstrates that TEA continues to be hampered by a high reoperation rate, primarily due to infection and aseptic loosening. Technical factors such as good cement-mantle quality, longer stem length, and unlinked implants may play a role in preventing aseptic loosening. Further work is required to optimize long-term outcomes following TEA through improved understanding of appropriate surgical indications, techniques, and implant utilization.

LEVEL OF EVIDENCE

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

The "Bag of Bones" Treatment of Comminuted Intra-articular Distal Humerus Fractures in the Elderly

BACKGROUND

Extensively comminuted intra-articular distal humerus fractures in the elderly present a challenging therapeutic dilemma. The purpose of this study was to investigate the results of nonoperative treatment of these fractures in a select subset of patients.

METHODS

Patients treated with nonoperative management for a comminuted intra-articular distal humerus fracture between 2007 and 2018 were reviewed. Patients were administered 3 elbow-specific functional outcomes instruments.

RESULTS

A total of 8 patients (2 men, 6 women) were treated with brief immobilization followed by early range of motion. All had fractures with extensive comminution of the articular surface such that open reduction and internal fixation was not feasible. Average age was 70 years. At an average of 33 months postinjury, average flexion was 124°, and extension was -27°, with full forearm rotation. No patients required pain medications at the latest follow-up. At 33 months of follow-up, the average Mayo Elbow Performance Score was 92/100 (100 optimal), Oxford Elbow Score was 43/48 (48 optimal), and Quick Disabilities of the Arm, Shoulder, and Hand Score was 10/100 (0 optimal). All patients were satisfied with the nonsurgical treatment that they received.

CONCLUSIONS

Nonoperative treatment for comminuted intra-articular distal humerus fractures results in acceptable functional outcome in elderly patients and should be considered when the fracture is not amenable to internal fixation and in lower-demand patients with higher surgical risk.

Anemia Severity and the Risks of Postoperative Complications and Extended Length of Stay Following Primary Total Elbow Arthroplasty

BACKGROUND

Anemia is a modifiable risk factor that may influence postoperative complications following orthopedic surgical procedures. The objective was to determine the influence of preoperative anemia severity on postoperative complications and length of stay (LOS) following total elbow arthroplasty (TEA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2019 for patients undergoing primary TEA. Using the World Health Organization definitions of anemia, patients undergoing TEA were stratified into 3 cohorts: nonanemia (hematocrit >36% for women, >39% for men), mild anemia (hematocrit 33%-36% for women, 33%-39% for men), and moderate-to-severe anemia (hematocrit <33% for both women and men). Patient demographics, surgical time, LOS, and postoperative complications were compared between the groups. A P value <.004 was considered significant.

RESULTS

After exclusion, 589 patients, of whom 369 (62.6%) did not have anemia, 129 (21.9%) had mild anemia, and 91 (15.5%) had moderate/severe anemia, were included. Increasing severity of anemia was associated with an increased average hospital LOS (2.30 vs 2.81 vs 4.91 days, P < .001). There was a statistically significant increase in blood transfusions (1.08% vs 7.75% vs 17.58%, P < .001), major complications (9.21% vs 17.83% vs 34.07%, P < .001), any complications (11.11% vs 23.26% vs 36.26%, P < .001), and extended LOS ≥6 days (6.23% vs 6.98% vs 31.87%, P < .001) with increasing severity of anemia. Multivariate analysis identified moderate-to-severe anemia was significantly associated with major complications and extended LOS (P < .001).

CONCLUSIONS

Preoperative anemia is a modifiable risk factor for medical and surgical complications within 30 days of TEA.

Total Denervation of the Elbow: Cadaveric Feasibility Study

PURPOSE

Total elbow arthroplasty for the treatment of patients with severe elbow osteoarthritis is associated with postoperative activity limitations and risk of midterm complications. Elbow denervation could be an attractive therapeutic option for young, active patients. The aim of our study was to assess the feasibility of selective total elbow denervation via 2 anteriorly based approaches.

METHODS

Selective total elbow denervation was performed in 14 cadaver elbows by 2 fellowship-trained elbow surgeons. Lateral and medial approaches to the elbow were used. The length of skin incisions and the minimum distance between them were noted. The number of articular branches identified and their respective distances from the lateral or medial epicondyle of the humerus were recorded.

RESULTS

The anterolateral and anteromedial approaches allowed for the identification of all mixed and sensory nerves in all 14 cases. The mean number of resultant articular branches per cadaver was 1 for the musculocutaneous nerve, 2 (range, 1-3) for the radial nerve, 1 (range, 1-3) for the posterior cutaneous nerve of the forearm, 2 (range, 1-3) for the ulnar nerve, and 2 (range, 1-3) for the medial antebrachial cutaneous nerve; the collateral ulnar nerve was connected directly to the capsule. The length of the medial and lateral incisions was 15 cm (range, 12-18 cm) and 12 cm (range, 10-16 cm), respectively. The mean minimum distance between the incisions was 7.5 cm (range, 6.7-8.5 cm).

CONCLUSIONS

The findings suggest that selective elbow denervation via 2 approaches is feasible.

CLINICAL RELEVANCE

Selective elbow denervation via 2 approaches is feasible. Surgeons should target the articular branches of the musculocutaneous, radial, ulnar, and collateral ulnar nerves, posterior cutaneous nerve of the forearm, as well as medial antebrachial cutaneous nerves when carrying out this procedure.

The Association of Body Mass Index with Surgical Time Is Mediated by Comorbidity in Patients Undergoing Total Hip Arthroplasty

Overweight represents a major issue in contemporary orthopaedic practice. A higher body mass index (BMI) is associated with an increase of perioperative complications following several orthopaedic procedures, in particular total hip arthroplasty (THA). However, the influence of overweight on THA surgical time is controversial. In this study, we investigated the association between BMI and surgical time analyzing the role of patients’ comorbidities. We conducted a retrospective study on 748 patients undergoing THA at our institutions between 2017 and 2018. Information regarding medical diseases was investigated and the burden of comorbidity was quantified using the Charlson score (CCI). Surgical time and blood loss were also recorded. Median surgical time was 76.5 min. Patients with surgical time above the median had both a higher BMI (28.3 vs. 27.1 kg/m²; p = 0.002); and CCI (1 vs. 0; p = 0.016). According to linear regression, surgical time was associated with BMI in the unadjusted model (p < 0.0001), after adjusting for age and sex (p < 0.0001), and in the multivariable model (p = 0.005). Furthermore, BMI was associated with increased surgical time only in patients with a Charlson score above the median, but not in others. Obesity is associated with increased surgical time during THA, especially in pluricomorbid patients, with a higher risk of perioperative complications.

Hematoma following total elbow arthroplasty: incidence, management, and outcomes

INTRODUCTION

This study investigates the incidence, risk factors for, and clinical outcomes of hematoma following total elbow arthroplasty.

METHODS

We retrospectively reviewed patient and surgical characteristics as predictors of post-operative hematoma in 382 total elbow arthroplasty (196 primary, 157 revision, and 29 conversion) between May 2004 and February, 2017. For comparison of outcomes, cases were matched (1:2) with controls by age, gender, type of surgery, and surgical indication.

RESULTS

Nineteen post-operative hematomas (5.0%; 19/382) were identified. Total elbow arthroplasty for post-traumatic arthritis (6.7%; 4/60), aseptic loosening (7.9%; 3/38), sequelae of periprosthetic joint infection (6.1%; 5/81), and non-union (28.6%; 2/7) had the highest incidence of hematoma. Clinic aspiration and compressive wrap was performed in 14 patients and avoided a return to the operating room in 78.6% (11/14). Seven patients (36.8%) required a return to the operating room, of which five (71.4%) had positive cultures and required treatment for prosthetic joint infection. Compared to the matched controls, hematoma formation predicted a higher rate of reoperation (36.8% versus 7.9%; p = 0.007) and a higher rate of subsequent prosthetic joint infection (35.7% versus 0%; p = 0.008).

CONCLUSION

Hematoma formation is associated with both prosthetic joint infection and return to the operating room after total elbow arthroplasty. Strategies to prevent hematoma formation after total elbow arthroplasty may reduce complication rates.

Sonication improves microbiologic diagnosis of periprosthetic elbow infection

BACKGROUND

Periprosthetic joint infection (PJI) is a relatively frequent and oftentimes devastating complication after total elbow arthroplasty (TEA). Its microbiologic diagnosis is usually based on periprosthetic tissue culture (hereafter referred to as tissue culture), but the sensitivity of tissue culture is variable. Although implant sonication culture has been shown to be superior to tissue culture for the diagnosis of hip and knee PJI, only a single small study (of fewer than 10 infected implants) has assessed sonication for PJI diagnosis after elbow arthroplasty.

METHODS

We retrospectively analyzed 112 sonicate fluid cultures from patients who underwent revision of a TEA at a single institution between 2007 and 2019, comparing results to those of tissue cultures. We excluded patients who had fewer than 2 tissues submitted for culture. Using the Infectious Diseases Society of America guidelines to define PJI, there were 49 infected and 63 non-infected cases. Median ages in the PJI and non-infected groups were 66 and 61 years, respectively. In the non-infected group, 65% were female vs. 63% in the PJI group. We reviewed clinical characteristics and calculated the sensitivity and specificity of tissue compared with sonicate fluid culture. In addition, we compared the sensitivity of tissue culture to the combination of tissue and sonicate fluid culture.

RESULTS

The most common pathogens were coagulase-negative Staphylococcus sp (49%), followed by Staphylococcus aureus (12%). Sensitivity of tissue culture was 63%, and sensitivity of sonicate fluid culture was 76% (P = .109). Specificity of tissue culture was 94% and specificity of sonicate fluid culture was 100%. Sensitivity of sonicate fluid culture in combination with tissue culture was 84% (P = .002 compared to tissue culture alone).

CONCLUSION

In this study, we found that the combination of sonicate fluid and tissue culture had a greater sensitivity than tissue culture alone for microbiologic diagnosis of PJI after TEA.

Interposition arthroplasty: Current indications, technique and expectations

The ultimate means of functional restoration of joints with end stage arthritis is prosthetic replacement. Even though there is reluctance to replace the joint of a younger individual, the mean age of joint replacement continues to decrease. This is due to three factors: 1) social expectations, 2) uncertainty with many joint preservation procedures and 3) the ever-increasing reliability and longevity of prosthetic replacement. Unfortunately, the elbow does not share in these advantageous trends to the extent as is the case for the hip, knee and shoulder. Social pressure for restoration of normal or near normal function is certainly present, but the desired improvement of longevity and fewer restrictions of activity have not been documented. Hence, possibly somewhat disproportionately to other joints, there is great need for a reliable and functional non replacement joint reconstruction option. For most other joints, fusion is the ultimate non replacement option. Further, for most joints an optimum position has been defined to allow the greatest chance of normal function of the individual. Unfortunately, there is no truly 'optimum' functional position of elbow fusion, and the recommended 90° of flexion is considered the 'least worse' position. Further, unfortunately, elbow fusion dysfunction cannot be mitigated by compensated shoulder motion. Hence, while there is little experience in general with interposition arthroplasty of the elbow, in the authors' opinion it remains the treatment of choice in some individuals and in certain circumstances for the reasons explained above. In our judgment, the reason for avoiding this procedure is that it is technically difficult, the absolute frequency of need is not great, and outcomes do appear to be a function of experience and technique. Based on these considerations, in this chapter we review the current indications and assessment and selection considerations. Emphasis is placed on our current technique with technical tips to enhance the likelihood of success and longevity. We conclude with a review of expectations based on current literature.

Complications of modern design total elbow replacement

Total elbow arthroplasty is an important surgical option for advanced arthritis of the elbow. Semi-constrained linked prosthesis is still a popular choice, however, complications and revisions after TER remain high. Aseptic loosening and infection are two most common mode of failure. Periprosthetic fracture, implant failure, and triceps insufficiency have also been reported. Revision arthroplasty needs careful preoperative planning to tackle deficiency in soft tissue and osseous structure. Impaction, strut allograft or allograft prosthesis composite graft should be considered for failed TER.

Revision Total Elbow Arthroplasty with the Semiconstrained Coonrad/Morrey Prosthesis: Follow-up to 21 Years

BACKGROUND

Revision total elbow arthroplasty (TEA) has increased, especially in young patients with high functional expectations. The objective of this study was to evaluate the long-term results of revision TEA with a single semiconstrained prosthesis.

METHODS

Thirty-four revision TEAs were performed with a Coonrad/Morrey prosthesis in 32 patients; 2 patients had bilateral procedures. The mean patient age was 61 years (range, 22 to 76 years), and the revision TEA was performed at a mean time of 7.8 years (range, 1.6 to 21 years) after the primary TEA. Etiologies for revisions were humeral and ulnar aseptic loosening (n = 14), ulnar aseptic loosening (n = 8), humeral aseptic loosening (n = 6), septic arthritis (n = 4), and unstable unlinked prostheses (n = 2). Clinical and radiographic evaluations were performed with systematic preoperative infection workup and quantification of bone loss. The mean follow-up was 11.4 years (range, 2 to 21 years).

RESULTS

The Mayo Elbow Performance Score (MEPS) at the last follow-up was excellent in 6 cases, good in 18 cases, fair in 8 cases, and poor in 2 cases, with a mean improvement (and standard deviation) between the preoperative values at 42.4 ± 16.1 points and the postoperative values at 81.8 ± 12 points (p < 0.001). The mean pain scores improved significantly from 6.7 ± 1.3 points preoperatively to 1.4 ± 1.4 points postoperatively (p < 0.001). The flexion-extension arc increased significantly (p = 0.02) from 74° ± 27° preoperatively to 100° ± 31° postoperatively. The total number of complications was 29 in 19 revision TEAs (56%). Twenty of the 29 complications simply required monitoring without surgical intervention. Six repeat surgical procedures were required, and 3 implant revisions (9%) were performed.

CONCLUSIONS

Revision TEA with a semiconstrained prosthesis can provide good clinical results that can be maintained during follow-up. The rate of complications is high. Proper evaluation of the risk-benefit ratio is essential for each revision TEA and should be discussed with the patient.

LEVEL OF EVIDENCE

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

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.

The transition of total elbow arthroplasty into the outpatient theater

Background

Outpatient total joint arthroplasty is increasing in frequency as reimbursement models change. Potential benefits include same-day surgery for patients and decreased exposure to nosocomial pathogens. This study aims to determine if total elbow arthroplasty (TEA) is also trending toward an outpatient setting, and if there is any impact on complication rates as a result.

Methods

A retrospective chart review of the American College of Surgeons National Surgical Quality Improvement Program was performed. Specifically, the database was queried for all patients with CPT code 24363 from 2010-2017. The percentage of TEAs performed each year as an outpatient was trended from 2010-2017. Additionally, the complication rate between the inpatient and outpatient cohorts was compared.

Results

A total of 524 TEAs were analyzed. Of these, 111 procedures (21.2%) were performed as an outpatient. There was a statistically significant increase in the percentage of outpatient TEAs from 2010-2017 (P = .0016). In 2010, 2.4% of TEAs were outpatient, compared with 34.5% in 2017. The total complication rate trended toward being lower in the outpatient group, but this difference was not statistically significant (P = .08).

Conclusions

There is a significant trend toward TEA being performed as an outpatient procedure, with more than one-third currently being performed in this manner. In our study, there was no difference in the complication rate between inpatient and outpatient TEAs; in fact, outpatient TEAs trended toward having a lower complication rate than inpatient TEAs. Taken together, the outpatient setting comprises an ever-increasing segment of TEA without an increase in morbidity to patients.

Surgical Exposures for Total Elbow Arthroplasty

Indications for total elbow arthroplasty (TEA) were traditionally reserved for patients with advanced rheumatoid disease and posttraumatic conditions of the elbow. The indications have expanded for TEA to include patients with acute elbow trauma, dysfunctional instability, and end-stage osteoarthritis. Many of these patients are younger and place a greater demand on their TEA. This evolution of TEA use combined with the concern of soft tissue handling and triceps function has led to increased interest regarding surgical exposure for TEA. Three generalized approaches to TEA are predicated on the handling of the triceps tendon: triceps reflecting, triceps splitting, and triceps sparing. Each of these approaches has its own inherent advantages and disadvantages. As indications grow for TEA and the possibility of revision surgery increases with use in younger, higher demand patients, it is important for treating surgeons to use these various exposures so that they are capable of treating patients in a variety of settings.

Clinical outcomes and complications following primary total elbow arthroplasty using the Latitude prosthesis

BACKGROUND

The Latitude total elbow arthroplasty (TEA) is an implant with limited published data on its performance and outcomes. The aim of this study was to report the short-term outcomes of the Latitude TEA as well as to describe the radiographic outcomes and complications.

METHODS

The Latitude was implanted in 20 patients (23 elbows) in a linked configuration. Patients were recalled to clinic for the assessment of their range-of-motion and compared to preoperative values. Administration of functional outcome measures was also performed.

RESULTS

Mean follow-up was 4.7 years (range, 1 to 7.5 years) with four elbows requiring revision. The flexion-extension arc improved from 86.6 to 101.3 (range, 76 to 126) postoperatively (p = 0.04). The average Disabilities of the Arm, Shoulder, and Hand score was 28.1 (range, 5.8 to 50.4) and the average Mayo Elbow Performance Score was 89.6 (range, 76 to 100), with 83% of elbows scoring in the good or excellent range. Radiolucencies were detected in 60% of patients and 31% of these lucencies progressed in size at the time of follow-up.

CONCLUSIONS

The Latitude prosthesis provides patients with favorable clinical outcomes with improvements in their range-of-motion and a complication rate comparable to other elbow arthroplasty implants.

Scoping review: Diagnosis and management of periprosthetic joint infection in elbow arthroplasty

BACKGROUND

Total elbow arthroplasty is an effective treatment for patients with painful elbow arthritis. Infection can be a serious complication. The aim of this scoping review was to document the available evidence on periprosthetic elbow infection.

METHODS

A search of Medline, Embase and PubMed was performed; two authors screened results independently. Systematic reviews, randomised controlled trials, cohort studies, case-control studies and case series including periprosthetic elbow infection were eligible.

RESULTS

A total of 46 studies were included. The median rate of periprosthetic elbow infection reported from recent published studies is 3.3%. The most commonly identified causative organisms are Staphylococcus aureus and Staphylococcus epidermidis. Risk factors include younger age, rheumatoid arthritis, obesity, previous surgery or infection to the elbow, and postoperative wound complications. Debridement, antibiotics and implant retention results in implant survival rates of 50-90%. Two-stage revision results in improved functional outcome scores, but with recurrent infection rates of 12-28%.

CONCLUSIONS

Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. The current body of literature is limited and is almost exclusively low volume retrospective case series. The best management of periprosthetic elbow infection is difficult to determine, but two-stage revision appears to be the gold standard.

The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review

» The use of preoperative antibiotic prophylaxis is not supported for elective cases of patients undergoing soft-tissue hand procedures that are ≤2 hours in length.

» The use of preoperative antibiotic prophylaxis is not supported for patients with diabetes undergoing elective, soft-tissue hand surgical procedures.

» There is a paucity of literature evaluating the use of preoperative antibiotic prophylaxis in patients with rheumatoid arthritis, those with cardiac valves, and those taking corticosteroids; because of this, there is no evidence to vary from our general recommendations.

Risk factors associated with periprosthetic joint infection after total elbow arthroplasty

BACKGROUND

For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present?

METHODS

The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI.

RESULTS

Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% (n = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections.

CONCLUSIONS

Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis.

LEVEL OF EVIDENCE

Level III: prognostic study.

Timely recognition of total elbow and radial head arthroplasty adverse events: an analysis of reports to the US Food and Drug Administration

BACKGROUND

Recent recalls of several commonly used elbow arthroplasty implants have prompted interest in the modes by which elbow implants fail and the timing of reports of these failures.

METHODS

We reviewed the adverse event reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database from 2012 to 2015 regarding elbow arthroplasty to determine the event date and the type of each adverse event.

RESULTS

Among 179 total elbow adverse event reports, the most common modes of failure were implant dissociation (23%), loosening (22%), and infection (16%). The most common modes of failure among 58 radial head replacement reports were component dissociation (19%) and linkage screw failure (19%). The percentage distribution of adverse event types differed among different arthroplasty systems and from that reported in published reviews of elbow arthroplasty. Three implant recalls were implemented 2, 5, and 9 years after the first adverse event report in the MAUDE database. For 2 of the recalls, the first reports of the device failures were published 2 and 5 years after the first MAUDE reports.

CONCLUSIONS

The MAUDE database is a publicly funded and publicly available means by which surgeons can identify adverse events for the prostheses they use before such information becomes available through journal publication or recall notification. In this study, MAUDE data revealed a higher relative frequency of mechanical dissociation of elbow implants than what has been represented in the literature. Early identification of these adverse events may help surgeons by informing their implant selection and surgical technique.

A Cadaveric Study of Cutaneous Vascular Anatomy about the Elbow Using Computed Tomography Angiography

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc.

Inserting the Ulnar Prosthesis into Radius as a Novel Salvage Surgery for Revision Total Elbow Arthroplasty with Massive Bone Defect

Background:

Infection and aseptic loosening are common complications of total elbow arthroplasty (TEA) and often require revision surgery. However, bone defects, along with other complications, bring an extra difficulty to the second surgery, especially for patients with a massive bone defect in the proximal ulna. Several methods including allograft or autograft have been introduced into practice, but none sufficiently solves these problems.

Methods:

We conducted a new surgical method for patients with a massive ulnar bone defect needing revision TEA. During revision arthroplasty, the ulnar prosthesis was inserted into the radius as a salvage procedure. Four consecutive patients received revision arthroplasty with this method between 2013 and 2016. Patients’ data were collected to evaluate the clinical outcome.

Results:

All patients had a Grade III ulnar bone defect. At the last follow-up session, all patients reported a painless, functional elbow joint. Three patients suffered from a periprosthetic infection that was completely cured using the two-stage method. No major complications, including infection, aseptic loosening, or wound problems were found. One patient had a transient ulnar neuritis, and another had a transient radial neuritis. Both patients had full recovery at the last follow-up session.

Conclusions:

Inserting an ulnar prosthesis into the radius is a novel procedure for patients with a massive bone defect due to infection or aseptic loosening. It is a safe, quick, and effective treatment with a promising short-term outcome. This method should be provided as a salvage procedure for patients with a nonreconstructable ulnar bone defect.

Total Elbow Arthroplasty in the United States: Evaluation of Cost, Patient Demographics, and Complication Rates

Total elbow arthroplasty (TEA) is utilized in the treatment of rheumatoid and post-traumatic elbow arthritis. TEA is a relatively low volume surgery in comparison to other types of arthroplasty and therefore little is known about current surgical utilization, patient demographics and complication rates in the United States. The purpose of our study is to evaluate the current practice trends and associated in-patient complications of TEA at academic centers in the United States. We queried the University Health Systems Consortium administrative database from 2007 to 2011 for patients who underwent an elective TEA. A descriptive analysis of demographics was performed which included patient age, sex, race, and insurance status. We also evaluated the following patient clinical benchmarks: hospital length of stay (LOS), hospital direct cost, in-hospital mortality, complications, and 30-day readmission rates. Our cohort consisted of 3146 adult patients (36.5% male and 63.5% female) with an average age of 58 years who underwent a total elbow arthroplasty (159 academic medical centers) in the United States. The racial demographics included 2334 (74%) Caucasian, 285 (9%) black, 236 (7.5%) Hispanic, 16 (0.5%) Asian, and 283 (9%) other patients. The mean LOS was 4.2±5 days and the mean total direct cost for the hospital was 16,300±4000 US Dollars per case. The overall inpatient complication rate was 3.1% and included mortality <1%, DVT (0.8%), re-operation (0.5%), and infection (0.4%). The 30-day readmission rate was 4.4%. TEA is a relatively uncommon surgery in comparison to other forms of arthroplasty but is associated with low in-patient and 30-day perioperative complication rate. Additionally, the 30-day readmission rate and overall hospital costs are comparable to the traditional total hip and knee arthroplasty surgeries.

Arthroscopic management of the painful total elbow arthroplasty

BACKGROUND

Failure of total elbow arthroplasty is more common than after other major joint arthroplasties and is often a result of aseptic loosening, peri-prosthetic infection, fracture and instability. Infection can be a devastating complication, yet there are no established guidelines for the pre-operative diagnosis of total elbow peri-prosthetic infection. This is because pre-operative clinical, radiographic and biochemical tests are often unreliable.

METHODS

Using three case examples, a standardized protocol for the clinical and arthroscopic assessment of the painful total elbow arthroplasty is described. This is used to provide a mechanical and microbiological diagnosis of the patient's pain.

RESULTS

There have been no complications resulting from the use of this technique in the three patients described, nor in any other patient to date.

CONCLUSIONS

The staged protocol described in the present study, utilizing arthroscopic assessment, has refined the approach to the painful total elbow arthroplasty because it directly influences the definitive surgical management of the patient. It is recommended that other surgeons follow the principles outlined in the present study when faced with this challenging problem.

Obesity is associated with increased postoperative complications after total elbow arthroplasty

BACKGROUND

Obesity has become a significant public health concern in the United States. Few published data have examined the association between obesity and postoperative complications after total elbow arthroplasty (TEA).

METHODS

Patients who underwent TEA were identified using the PearlDiver database Current Procedural Terminology codes. Patients were divided into obese and nonobese cohorts using International Classification of Diseases, Ninth Revision codes. Each cohort was then assessed for major and minor complications within 90 days postoperatively. Odds ratios, 95% confidence intervals, and χ(2) tests were calculated, with P < .05 considered significant.

RESULTS

From 2005 to 2011, 7580 patients who underwent TEA were identified, of whom 1030 patients (14%) were coded as obese (body mass index > 30) and 611 patients (8%) were coded as morbidly obese (body mass index > 40). The obese TEA patients had increased risk of 90-day major and minor complications. The rate of postoperative venous thromboembolism differed significantly between groups, with a trend toward a higher venous thromboembolism rate in obese patients (2.2%) vs. nonobese patients (0.7%). Rate of postoperative stiffness was similar between groups. Infection rates were higher in obese patients compared with nonobese patients. Medical complications were higher in obese patients (16.7%) compared with the nonobese cohort (4.7%). A significant difference in implant removal was notable at 6 months and 1 year in morbidly obese patients compared with nonobese counterparts.

CONCLUSIONS

Obesity and associated medical comorbidities place patients at increased risk for complications after TEA. Obese patients and especially morbidly obese patients thinking of undergoing TEA should be appropriately counseled preoperatively about their increased risk for complications.

No improvement in the post-TKA infection prognosis when the implant is not reimplanted: Retrospective multicentre study of 72 cases

INTRODUCTION

For the surgeon and patient, permanent removal of an infected knee prosthesis is an unwelcome decision taken out of necessity because unfavourable local or general conditions may increase the likelihood of mechanical or infectious failure upon prosthesis reimplantation. The purpose of this study was to determine if permanent removal of an infected total knee arthroplasty (TKA) implant controls the infection and prevents above-the-knee amputation when reimplantation turns out to be too risky. It was hypothesized that removal without reimplantation contributes to eradicating the infection and helps to avoid amputation.

PATIENTS AND METHODS

Seventy-two consecutive patients who underwent TKA removal between 2000 and 2010 at 14 hospitals were reviewed. The TKA removal was followed by knee fusion in 29 cases or implantation of a permanent cement spacer in 43 cases.

RESULTS

If failure is defined as clinically obvious recurrence of the infection, the survival rate was 65 ± 5% at 2 years; 44% of patients had a recurrence of the infection, 8% had undergone amputation and 19% presented with nonunion at the last follow-up. The male gender and the presence of multiple co-morbidities were predisposing factors for failure.

DISCUSSION

Control of the infection is not guaranteed upon TKA implant removal; the success rate is lower than in cases of two-stage reimplantation. The outcomes in this study are worse than those of other published studies. This is likely due to the heterogeneity in the patient population and treatments, along with the presence of co-morbidities. This treatment option should be the last recourse before amputation.

Subcutaneous Suture Can Accelerate Wound Healing of Lower Midline Incision: A Randomized Controlled Trial

Poor wound healing is one of the most common complications after laparotomy, especially in lower abdominal midline incisions. The aims of this trial are to assess the value of subcutaneous suture and identify risk factors to prevent poor wound healing. From October 2010 to October 2011, a total of 180 patients were randomized to the subcutaneous suture group (n = 89) or control group (n = 91) after laparotomy with a lower midline incision. Univariate and multivariate analyses were performed to determine the predictive significance of variables of poor wound healing. Patients’ demographics, preoperative laboratory values, and operative details were comparable between the two groups. The overall rate of poor wound healing was 16.7 per cent (30 of 180). Patients randomized to subcutaneous suture group (n = 89) had poor healing in 10.1 per cent (nine of 89) and those without suture (n = 91) in 23.1 per cent (21 of 91) ( P = 0.020). Multivariate logistic regression analysis revealed that American Society of Anesthesiologists (ASA) score (3 to 4) (odds ratio [OR], 2.933), subcutaneous suture (OR, 0.323), and blood loss (greater than 200 mL) (OR, 5.995) were independent risk factors for poor wound healing. Subcutaneous suture can effectively accelerate wound healing. Nonsubcutaneous suture, ASA score (3 to 4), and blood loss (greater than 200 mL) are independent risk factors for poor would healing.

Flexor carpi ulnaris muscle flap for soft tissue reconstruction after total elbow arthroplasty

The soft tissue at the tip of the olecranon is very thin, leading to the frequent occurrence of wound complications after total elbow arthroplasty. To cover a soft tissue defect of the elbow, the flexor carpi ulnaris muscle flap is thought to be appropriate for reconstruction of the elbow with regard to its size, location, and blood supply. We got positive clinical results, so we report our experiences of using a flexor carpi ulnaris muscle flap for soft tissue reconstruction after total elbow arthroplasty.

Comparison of perioperative complications after total elbow arthroplasty in patients with and without diabetes

BACKGROUND

Few studies have analyzed the effect of diabetes on outcomes after total elbow arthroplasty (TEA). We investigated the perioperative complications after TEA in patients with and without diabetes.

METHODS

We evaluated the Nationwide Inpatient Sample (NIS) database from 2005 to 2010 for patients who underwent a TEA. Our retrospective study included 3184 patients based on International Classification of Diseases-Ninth Revision, Clinical Modification codes. We compared outcomes in 488 patients with diabetes and in 2696 patients without diabetes.

RESULTS

Patients with diabetes had a significantly older mean age (66.8 vs 58.5 years, P < .001). There was no statistically significant difference when comparing length of stay (4.1 vs 3.7 days, P = .056) and cost of surgery ($56,582 vs $56,092, P = .833). A significantly higher percentage of diabetic patients underwent TEA for the indication of fracture (73.4% vs 65.3%), but a lower percentage for rheumatoid arthritis (10.2% vs 19.2%). They also had significantly increased rates of pneumonia (odds ratio [OR], 2.7), urinary tract infection (OR, 2.2), blood transfusion (OR, 2.1), and nonroutine discharge (OR, 1.9). After adjusting for significantly increased rates of comorbidities in diabetic patients, our multivariate analysis showed that having diabetes was independently associated with an increased risk of pneumonia (relative risk [RR], 2.6), urinary tract infection (RR, 1.9), and cerebrovascular accident (RR, 9.1). However, diabetes was not independently associated with hospital length of stay (P = .75), after correction, hospital cost (P = .63), or proportion of routine discharges (P = .12).

CONCLUSION

Patients with diabetes have higher rates of comorbidities and perioperative complications after TEA.

[Periprosthetic infections in systemic inflammatory rheumatic disease. Review article on diagnostics and therapy]

BACKGROUND

Patients with an inflammatory disease have an elevated risk for periprosthetic joint infections due to impairment of the immune system caused by the disease itself in combination with disease-modifying antirheumatic drugs (DMARD). These infections can cause life-threatening sepsis. Unfortunately recommendations on the diagnostics and treatment are mostly based on studies with a level of evidence grade IV or V.

OBJECTIVES

This article gives an overview of recent publications evaluating the level of evidence of recommendations on diagnostics and treatment of periprosthetic joint infections in patients with inflammatory diseases.

METHODS

A systematic literature search was performed in the Medline database in January and February 2014. The search included all articles on diagnostic and/or treatment of periprosthetic joint infections in patients with inflammatory diseases. Articles in languages other than English or German were excluded, as well as case reports, studies with less than 20 patients and articles only referring to patients with inflammatory diseases without periprosthetic infections.

RESULTS

Nearly all recommendations are based on retrospective studies or expert opinions (level of evidence IV or V). Conflicting results are common but there is good evidence on preoperative aspiration of joint fluid (level of evidence I) and a doubled risk of joint infections under treatment with anti-tumor necrosis factor (level of evidence II). An increased mortality has been reported in multiple studies. Two-stage revision seems to have a slightly better outcome than retention of prosthesis or one-stage revision. Generally, therapeutic recommendations for periprosthetic joint infections lack a good level of evidence. Future studies are urgently needed.

Experience with the Coonrad-Morrey total elbow arthroplasty: 78 consecutive total elbow arthroplasties reviewed with an average 5 years of follow-up

BACKGROUND

The Coonrad-Morrey total elbow arthroplasty is a linked implant. This study investigated the hypotheses that reliable results can be obtained in rheumatoid patients and in traumatic conditions and that the survival rate is similar to or better than what has been published for nonlinked implants.

METHODS

Surgery was performed on 70 consecutive patients (78 elbows) for an inflammatory arthritis (45 elbows) or a traumatic condition (33 elbows: 18 acute fractures of the distal humerus, 10 nonunions, and 5 post-traumatic arthritis).

RESULTS

At an average of 5 years of follow-up (2 to 11 years), the mean Mayo Elbow Performance Score for the group that had inflammatory arthritis (89 ± 13 points) was significantly higher than that for the group with a traumatic condition (80 ± 17 points). The QuickDASH score was not significantly different according to the etiology. Radiolucencies were observed in 17 cases around the humeral component and in 14 cases around the ulnar component. Bushing wear was observed in 14 cases. There were 27 complications, and 9 of them went to a revision procedure. The survival rate was 97.7% at 5 years and 91.0% at 10 years if we consider revision for aseptic loosening as an endpoint.

CONCLUSIONS

The Coonrad-Morrey total elbow arthroplasty allows treatment of a large spectrum of causes with satisfactory results. Better results have been obtained for rheumatoid patients than for patients with trauma. The rate of complication remains high even if the rate of implant revision stays low. However, the increased incidence of lucent lines around the ulnar component with follow-up and bushing wear are of concern.

Hinged external fixator and open surgery for severe elbow stiffness with distal humeral nonunion

Joint stiffness is a common complication of elbow trauma. Treating elbow stiffness is challenging, especially in patients with severe elbow stiffness with distal humeral nonunion. To improve treatment outcomes, the authors applied a hinged external fixator after performing open reduction and internal fixation and evaluated the clinical outcome. Between 2005 and 2011, eleven patients with elbow stiffness and distal humeral nonunion underwent open arthrolysis, surgical reduction, internal fixation, hinged external fixation, and selective bone grafting. The ulnar nerve was anteriorly transposed in all patients. Elbow range of motion, Mayo Elbow Performance Score, and radiographs were assessed pre- and postoperatively. All patients achieved solid union in an average of 5.6 months. Preoperatively, mean flexion was 86.8°, mean extension was 45.5°, and mean total range of motion was 41.3°. Postoperatively, mean flexion was 125.9°, mean extension was 11.8°, and mean total range of motion was 114.1°. Mean Mayo Elbow Performance Score also significantly improved from 59 points preoperatively to 87.2 points postoperatively, and 6 patients were scored as excellent (more than 90 points), 3 good (75-90 points), and 2 fair (60-74 points) according to the Mayo Elbow Performance Score. A stiff elbow with distal humeral nonunion can be treated successfully using a unilateral hinged external fixator to supplement the open reduction and internal fixation. A hinged external fixator was an effective rehabilitation method for improving range of motion and maintaining joint stability.