Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008

Mid-term results of total elbow arthroplasties in the treatment of geriatric distal humerus fractures

BACKGROUND

While double plate fixation is the gold standard treatment for distal humerus fractures in the general population, it is the source of many complications in the elderly. Total elbow arthroplasty (TEA) has been proposed as an alternative treatment, with satisfactory short-term functional outcomes. However, little is known about the longevity of the implant and the mid- and long-term complications of this procedure.

MATERIALS AND METHODS

A total of 58 TEAs were performed in 57 patients with comminuted distal humerus fractures between September 2008 and September 2019. All patients were clinically (ranges of motion, Mayo Elbow Performance Score [MEPS] and Disabilities of the Arm, Shoulder and Hand [QuickDASH] functional scores) and radiographically assessed. The minimum follow-up was 2years, and the mean follow-up was 4.7years.

RESULTS

The overall complication rate was 20.7%, with ulnar nerve damage, complex regional pain syndrome, and severe stiffness being the main complications. The mean MEPS was 85.3, and the mean QuickDASH was 28.1. The mean flexion was 122°, and the mean extension was -23.5°. There were no prosthetic revisions. Of these patients, 17% had radiolucent lines, and 13% had bushing wear at the last follow-up.

DISCUSSION

TEA is an effective technique for treating comminuted distal humerus fractures in the geriatric population. The prosthesis's mid-term survivorship was highly satisfactory, with a complication rate that remained low and was generally lower than that of osteosynthesis, with identical functional outcomes. TEAs are indicated in elderly patients, for whom maintaining the fullest possible autonomy is paramount. Our findings suggest that TEAs have sufficient longevity to guarantee a functional, pain-free elbow with no need for reoperation.

LEVEL OF EVIDENCE

IV; case series.

Morrey Award 2024: If I replace these bushings, how long will they last? An analysis of 58 isolated Coonrad-Morrey bushing exchanges with 21-year average follow-up

BACKGROUND

Reports of bushing exchange (BE) with retention of all other components (isolated BE) after Coonrad-Morrey total elbow arthroplasty (TEA) are limited to small case series. The purpose of this study was to determine the survival of isolated BE after primary or revision TEA. Secondary aims were to determine the survival of the humeral and ulnar stems, the risk factors for failure, and the complications and outcomes after 1 or more BEs.

METHODS

Our Total Joint Registry database was queried to identify all elbows that underwent revision of a primary or revision Coonrad-Morrey TEA between 1981 and 2021. After excluding reoperations for infection, cancer, or inadequate records, 43 patients with 58 isolated BEs with retention of both the humeral and ulnar components were included. The mean age at the time of the initial TEA was 51 ± 12 years and 63% were female. A single BE was performed in 31 patients, while 12 had a revision BE. The mean follow-up was 21 years (range, 7-35 years).

RESULTS

The median time to the first isolated BE was significantly longer than the time to revision BE (11.0 vs. 7.6 years; P = .036). Following the first isolated BE, Kaplan-Meier survivorship free of revision BE was 95% at 2 years, 87% at 5 years, 78% at 10 years, and 60% at 15 and 20 years. A "triceps on" approach during the index TEA was a risk factor (hazard ratio [HR], 27.0) for requiring a revision BE. The survivorship free of any revision was 78% at 5 years, 63% at 10 years, and 49% at 15 and 20 years. A "triceps on" approach during the index TEA (HR, 5.4) and post-traumatic arthritis or osteoarthritis (HR, 2.8) were risk factors for any revision. The overall survival of the humeral and ulnar stems was 73% at 20 years following the index TEA. The overall revision (28%) and complication (19%) rates, Mayo Elbow Performance Score (85 points), pain (1.5 points), and arc of motion (110°) were similar for single and multiple BEs.

CONCLUSIONS

While isolated BE is a relatively rare procedure, it should be considered in patients with substantial bushing wear and stable implants. Patients may experience relatively high revision and complication rates following isolated BE, but more than half retain their bushings and implants at long-term follow-up. Surgical and patient factors may increase the risk of revision following isolated BE, but patients can expect good clinical outcomes.

Total elbow arthroplasty in England

Aims

The aim of this study was to review the provision of total elbow arthroplasties (TEAs) in England, including the incidence, the characteristics of the patients and the service providers, the types of implant, and the outcomes.

Methods

We analyzed the primary TEAs recorded in the National Joint Registry (NJR) between April 2012 and December 2022, with mortality data from the Civil Registration of Deaths dataset. Linkage with Hospital Episode Statistics-Admitted Patient Care (HES-APC) data provided further information not collected by the NJR. The incidences were calculated using estimations of the populations from the Office for National Statistics. The annual number of TEAs performed by surgeons and hospitals was analyzed on a national and regional basis.

Results

A total of 3,891 primary TEAs were included. The annual incidence of TEA was between 0.72 and 0.82 per 100,000 persons before 2020 and declined to 0.4 due to a decrease in elective TEAs during the COVID-19 pandemic, with a slight recovery in 2022. Older patients, those of white ethnicity and females, were more likely to undergo TEA. Those who underwent elective TEA had a median wait of between 89 (IQR 41 to 221) and 122 days (IQR 74 to 189) in the years before 2021, and this increased to 183 days (IQR 66 to 350) in 2021. The number of TEAs performed by surgeons per annum remained unchanged, with a median of two (IQR 1 to 3). The median annual number of TEAs per region was three to six times higher than the median annual case load of the highest volume hospital in a region. Patients in the lowest socioeconomic group had a higher rate of serious adverse events and mortality (11%) when undergoing TEA for acute trauma.

Conclusion

In England, TEA is more common in older age groups, those of white ethnicity, and females. The COVID-19 pandemic affected the incidence of elective TEA and waiting times, and the provision of TEA has not yet recovered. The Getting it Right First Time recommendation of centralizing services to one centre per region could result in up to a six-fold increase in the number of TEAs being performed in some centres.

Quantifying the Positional Deviation Between the True Flexion-Extension and Epicondylar Axes of the Elbow: A 3D Computational Study

Background and objective The epicondyles are commonly used surgical reference landmarks for elbow arthroplasty and external fixator application. This study aimed to investigate whether the epicondylar axis differed from the elbow's true flexion-extension (F-E) axis in terms of both rotational difference and translational offset. Methods Three-dimensional (3D) models of 15 cadaver elbows were created. The epicondylar, true F-E, and distal humeral axes were defined using the medial and lateral epicondyles and the normal vector through the trochlear groove's center respectively. Rotational difference along internal-external, varus-valgus, and flexion-extension rotation plane and translational offset in the anterior-posterior (A-P), medial-lateral (M-L), and inferior-superior (I-F) direction with reference to the distal humerus's long axis were measured. Results Minimal rotational differences of 1.9 ± 4.5, 2.1 ± 3.4, and 0.5 ± 2.7 degrees for flexion-extension, varus-valgus, and internal-external rotation were obtained respectively. Considerable translational offsets greater than 10 mm were found for the absolute medial and lateral translational offset with a statistically significant difference recorded in the M-L direction. Conclusions Small rotational differences exist between the epicondylar and true F-E axes. Significant differences are observed in the translational offset in the M-L direction and should be considered during implant alignment in order to reduce malalignment and prevent failure.

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.

Total Elbow Arthroplasty Versus Open Reduction and Internal Fixation for Distal Humerus Fractures: A Propensity Score Matched Analysis of 30-Day Postoperative Complications

Introduction

Open reduction and internal fixation (ORIF) is an established surgical procedure for distal humeral fractures; however, total elbow arthroplasty (TEA) has become an increasingly popular alternative for elderly patients with these injuries. Using a large sample of recent patient data, this study compares the rates of short-term complications between ORIF and TEA and evaluates complication risk factors.

Methods

Patients who underwent primary TEA or ORIF from 2012 to 2021 were identified by Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared.

Results

A total of 1539 patients were identified, with 1365 (88.7%) and 174 (11.3%) undergoing ORIF and TEA, respectively. Patients undergoing TEA were older on average (ORIF: 56.2 ± 19.8 years, TEA: 74.3 ± 11.0 years, P < .001). 348 patients were included in the matched analysis, with 174 patients in each group. TEA was associated with an increased risk for postoperative transfusion (OR = 6.808, 95% CI = 1.355 - 34.199, P = .020). There were no significant differences in any adverse event (AAE) between procedures (P = .259). A multivariate analysis indicated age was the only independent risk factor for the development of AAE across both groups (OR = 1.068, 95% CI = 1.011 - 1.128, P = .018).

Conclusion

The risk of short-term complications within 30-days of ORIF or TEA procedures are similar when patient characteristics are controlled. TEA, however, was found to increase the risk of postoperative transfusions. Risks associated with increasing patient age should be considered prior to either procedure. These findings suggest that long-term functional outcomes can be prioritized in the management of distal humerus fractures.

Prognostic factors associated with failure of total elbow arthroplasty

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

Methods

Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used.

Results

A total of 19 studies met the inclusion criteria, investigating 28 possible prognostic factors. Most QUIPS domains (84%) were rated as moderate to high risk of bias. The quality of the evidence was low or very low for all prognostic factors. In low-quality evidence, prognostic factors with consistent associations with failure of TEA in more than one study were: the sequelae of trauma leading to TEA, either independently or combined with acute trauma, and male sex. Several other studies investigating sex reported no association. The evidence for other factors was of very low quality and mostly involved exploratory studies.

Conclusion

The current evidence investigating the prognostic factors associated with failure of TEA is of low or very low quality, and studies generally have a moderate to high risk of bias. Prognostic factors are subject to uncertainty, should be interpreted with caution, and are of little clinical value. Higher-quality evidence is required to determine robust prognostic factors for failure of TEA.

Treatment of post-traumatic complete bony ankylosed elbow using total arthroplasty and hernia patch - A case report

INTRODUCTION AND IMPORTANCE

The elbow is one of the most mobile joints, and its movement is very important. Bony ankylosed elbow is an uncommon condition leading to complete loss of activity of elbow, and then lead to severe disability and limitation in activities of daily living.

CASE PRESENTATION

A 63-year-old woman sustained comminuted fracture of left distal humerus. She underwent open reduction and internal fixation by plates. After the plates were removed in 2016，stiffness developed.The elbow was stable but fixed at 90°，there was no vascular injury or deficit in sensory and motor function of the ulnar nerve. She hopes to eliminate pain and restore normal mobility compatible with ADL.

CLINICAL DISCUSSION

Complete bony ankylosis of the elbow joint may be caused by trauma, rheumatic disease, burns, congenital stiffness and other conditions. Even with the compensation of shoulder and wrist, it will still have a great impact on upper limb function. Whether to treat mainly depends on whether the patient has the require to improve the functionality and return to daily activities. Treatment methods are very limited, including interposition arthroplasty and TEA. Defect of soft tissue appeared was seen in our case, Hernia Patch was innovatively applied to reconstruct the defect of soft tissue and maintain continuity of elbow extension mechanism.

CONCLUSION

Patients with post-traumatic elbow joint ankylosis were suffered from severe bony abnormalities, but also soft tissue contracture or defects due to multiple operations and trauma. We present a case of complete bony ankylosed elbow treated with total elbow arthroplasty and Hernia Patch.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial

BACKGROUND

Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.

MATERIAL AND METHODS

This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength.

RESULTS

Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group.

CONCLUSION

In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Outcomes After Acute Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures

Purpose

Compare outcomes of acute versus delayed total elbow arthroplasty (TEA) following distal humerus fractures (DHF).

Methods

This retrospective study included 39 patients who underwent primary TEA with semiconstrained implants for DHF, either within 4 weeks of their injury or after failing initial open reduction and internal fixation (ORIF) or nonsurgical management, between June 1, 2003 and February 1, 2018 with minimum 1-year follow-up. Our outcome measures included QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score, complications, reoperations, and range of motion (ROM). Demographics, clinical variables, and outcomes were compared using the Student's t-test, Mann-Whitney U test, and Fisher's exact test as appropriate. Kaplan-Meier curves for mortality, implant survivorship, and reoperation were created.

Results

Our patients were categorized into acute TEA (n = 22), ORIF to TEA (n = 10), and nonsurgical to TEA (n = 7) treatment groups. Additional analysis was performed comparing acute to delayed TEA, which combined data from failed ORIF and nonsurgical cohorts. The median follow-up, average age, and median Charlson comorbility index were similar between groups. The most common fracture pattern was AO13C. At median follow-up of 5.8 years, QuickDASH differed between cohorts: mean of 31 (SD 19) in acute TEA and 52 (SD 27) in delayed TEA, which further subdivided to 44.2 (SD 25) in failed ORIF and 76 (SD 23) in failed nonsurgical management. Poorer QuickDASH scores at final follow-up were associated with delayed TEA, initial nonsurgical management, and depression. Surgical complications were associated with delayed TEA. Higher Charlson comorbidity index was associated with death. No variables were associated significantly with ROM, revision, or reoperation.

Conclusion

Comminuted DHFs are difficult to treat in the elderly with high rates of complication and poor function after surgery. Our study suggests TEA performed acutely result in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management.

Type of Study/Level of Evidence

Therapeutic, III.

Prognostic factors associated with failure of total elbow replacement: a protocol for a systematic review

INTRODUCTION

Total elbow replacement (TER) has higher failure rates requiring revision surgery compared with the replacement of other joints. Understanding the factors associated with failure is essential for informed decision-making between patients and clinicians, and for reducing the failure rate. This review aims to identify, describe and appraise the literature examining prognostic factors for failure of TER.

METHODS AND ANALYSIS

This systematic review will be conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Electronic literature searches will be conducted using Medline, EMBASE, PubMed and Cochrane. The search strategy will be broad, including a combination of subject headings (MESH) and free text search. This search will be supplemented with a screening of reference lists of the included studies and relevant reviews. Two independent reviewers will screen all search results in two stages (title and abstract, and full text) based on the Population, Index prognostic factor, Comparator prognostic factor, Outcome, Time and Setting criteria. The types of evidence included will be randomised trials, non-randomised trials, prospective and retrospective cohort studies, registry studies and case-control studies. If the literature lacks enough studies, then case series with 50 or more TERs will be considered for inclusion. Data extraction and risk of bias assessment for included studies will be performed by two independent reviewers using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies for Prognostic Factors and Quality In Prognostic Studies tools.Meta-analyses of prognostic estimates for each factor will be undertaken for studies that are deemed to be sufficiently robust and comparable. Several challenges are likely to arise due to heterogeneity between studies, therefore, subgroup and sensitivity analyses will be performed to account for the differences between studies. Heterogeneity will be assessed using Q and I2 statistics. If I2>40% then pooled estimates will not be reported. When quantitative synthesis is not possible, a narrative synthesis will be undertaken. The quality of the evidence for each prognostic factor will be assessed using the Grades of Recommendation Assessment, Development and Evaluation tool.

PROSPERO REGISTRATION NUMBER

CRD42023384756.

Intraoperative modification of total elbow arthroplasty implants

BACKGROUND

Modification of total elbow arthroplasty (TEA) implants may be necessary in selected patients with substantial anatomic bone deformity or those undergoing revision surgery. The purpose of this study was to investigate the prevalence and consequences of implant modifications during TEA at our institution. We hypothesized that TEA implant modification would be more common in revisions than in primary replacements, and that it would not be associated with worse clinical outcomes or increased rates of radiographic or surgical complications directly related to the implant modification.

METHODS

Elbows that had undergone TEA by any of 3 surgeons at our institution with use of intraoperative implant modification between January 1992 and October 2019 were retrospectively reviewed for the type of modification and complications. Complications were classified as definitely related, probably related, possibly related, or nonrelated to the implant's modification according to the consensus review by the 3 senior surgeons. A survey was sent out to surgeons outside of our institution to investigate whether intraoperative modification to TEA implants is a common clinical practice.

RESULTS

A total of 106 implant components were modified during 94 of 731 TEA procedures (13%) in 84 of 560 patients. Implant modifications were performed in 60 of 285 revision cases (21%) compared with 34 of 446 (8%) primary cases (P < .0001). These included shortening the stem in 40 (44%), bending the stem in 16 (15%), notching the stem in 16 (15%), tapering the stem in 9 (9%), and a combination of 2 or more of these modifications in 19 implants (17%). Among the 55 index surgeries available for complication analysis, 40 complications occurred in 28 index surgeries (11 primary and 17 revisions; 25 patients), making the overall complication rate 51%. Of these 40 complications, 23 were considered independent of any implant modification. Of the remaining 17 complications, 9 were considered nonrelated to the implant modification, 6 were possibly related, and 2 were probably related to the implant modification. Therefore, the complication rate possibly related or probably related to implant modification was 15% (8 of 55). No complication was classified as definitely related to the implant modification. No implant breakage or malfunction occurred after any modification. A total of 442 survey responses were received representing 29 countries, of which 144 surgeons (39%) performed modification to implants during TEA procedures.

DISCUSSION

This study confirmed our hypothesis that modification of TEA implants is not uncommon at our institution, particularly in revision arthroplasty. Surgeons should keep in mind that complications possibly related or probably related to implant modification were at minimum 15% and could have been as high as 30% if the patients lost to follow-up had all had complications. Implant modification may be necessary in some cases but should be exercised with thoughtful consideration and caution.

[The shoulder and elbow register of the DVSE-trend monitoring or early warning system? : A literature-based analysis]

The endoprosthesis register (SEPR) of the D‑A-CH Association for Shoulder and Elbow Surgery e. V. (DVSE) collects data on the implantation of shoulder and elbow endoprostheses. The question arises as to whether the data is only used to monitor trends in arthroplasty, or whether it can also be used as an early warning system for risks and possible complications. The existing literature on the SEPR was analyzed and compared with other national endoprosthesis registries. The SEPR of the DVSE enables the collection and analysis of epidemiological data on primary implantation, follow-up and revision in shoulder and elbow endoprosthetics. It is an instrument of quality control and contributes to ensuring the greatest possible patient safety. It is used for the early detection of risks and potential requirements associated with shoulder and elbow arthroplasty.

Testing of Novel Total Elbow Prostheses Using Active Motion Experimental Setup

PURPOSE

The goal of this study was to test a novel uncemented and unconstrained total elbow arthroplasty (Kaufmann total elbow) design that is stabilized through a ligament reconstruction.

METHODS

We quantified the implant stability after 25,000 cycles, which represents the time between implantation and when ligament and bone healing has occurred. We used an active motion experimental setup that applies tendon loads via pneumatic cylinders and reproduces the forearm-originating dynamic stabilizers of the elbow. The novel total elbow arthroplasty was actuated for 5,000 full flexion-extension cycles at 5 different shoulder positions. Four Sawbones and 4 cadaver elbows were employed. Angular laxity and implant stability were recorded prior to testing and after each 5,000-loading cycle.

RESULTS

Four Sawbones and 4 cadaver elbows were implanted with the uncemented total elbow arthroplasty and did not demonstrate fixation failure or substantial laxity after 25,000 cycles of loading imparted at different shoulder positions.

CONCLUSIONS

Our findings demonstrate that the Kaufmann total elbow replacement implanted into cadaver and Sawbones specimens did not exhibit fixation failure or excessive laxity after 25,000 cycles.

CLINICAL RELEVANCE

An uncemented, nonmechanically linked total elbow arthroplasty that gains component fixation using intramedullary screws and employs a ligament reconstruction to stabilize the elbow has the potential to be a valuable management option, particularly in younger patients.

Implant survival of total elbow arthroplasty: analysis of 514 cases from the Dutch Arthroplasty Registry

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions.

Non-drug and surgical treatment algorithm and recommendations for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis-secondary publication

OBJECTIVES

The aim of this study was to update the Japan College of Rheumatology (JCR) clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) and prepare an algorithm for non-drug and surgical treatments. This article is a digest version of the guidelines.

METHODS

The Japanese Ministry of Health, Labour and Welfare's research group, in collaboration with the JCR, used the Grading of Recommendations, Assessment, Development, and Evaluation method to update the 2014 JCR CPG for RA. The consensus was formed by CPG panel members.

RESULTS

We raised 19 clinical questions regarding non-drug and surgical treatments for RA and developed recommendations. The treatments included exercise therapy; occupational therapy; joint injection of corticosteroids; and orthopaedic surgeries including cervical spine surgery, wrist and foot arthroplasty, ankle arthrodesis, and replacement arthroplasty of the shoulder, elbow, finger, hip, knee, and ankle. Recommendations regarding the risks of surgery and perioperative discontinuation of medications have also been developed. Based on these recommendations, we created an original algorithm for the non-drug and surgical treatment of RA.

CONCLUSIONS

These recommendations are expected to serve rheumatologists, health care professionals, and patients with RA as tools for shared decision-making to treat residual limb joint symptoms and functional impairment.

The Impact of Cement Mantle Characteristics on Early Loosening in Primary Total Elbow Arthroplasty

PURPOSE

To assess the association between cement mantle characteristics and early radiographic loosening in total elbow arthroplasty (TEA). We aimed to determine whether shorter mantle heights (<20 mm) were associated with loosening.

METHODS

We reviewed primary TEAs from a single healthcare system from 2006 to 2020. TEAs complicated by infection or performed for oncologic conditions were excluded. Initial postoperative radiographs were reviewed to determine cement mantle and component characteristics (mantle quality, mantle height, and component angulation). One-year postoperative radiographs were reviewed to assess for implant loosening, and we compared demographics and radiographic criteria for cases with and without early loosening. We noted whether cases underwent subsequent revision for aseptic osteolysis.

RESULTS

A total of 54 TEA cases were included. Forty percent of ulnar and 24% of humeral mantles were classified as short (between 1 and 19 mm). According to the Morrey classification, 6 (11%) cases had an inadequate cement mantle Twenty-four (45%) cases had radiographic evidence of loosening at 1 year. Of the cases with early loosening, 6 (25%) had initial inadequate mantle quality. There were no inadequate mantles in the group without loosening. There were no statistically significant differences in mantle heights for cases with and without loosening at 1 year after surgery. Eight (33%) cases underwent revision in the group with early loosening compared with 1 (3%) case without early loosening.

CONCLUSIONS

Inadequate cement mantle quality was associated with an increased risk of early aseptic loosening after primary TEA. Cement mantles that extended past the tip of the prosthesis were not associated with loosening. Considering the potential need for future revision and morbidity of cement removal, surgeons should focus on mantle quality and carefully plan mantle height because shorter heights may not be associated with early implant failure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Postoperative management of total elbow arthroplasty: Results of a European survey among orthopedic surgeons

Background

The number of complications after total elbow arthroplasty (TEA) is high and survival rates are low compared to hip and knee arthroplasties. The most common reason for revision is aseptic loosening, which might be caused by overloading of the elbow. In an attempt to lower failure rates, current clinical practice is to restrict activities for patients with a TEA. However, postoperative management of TEA is a poorly investigated topic, as no evidence-based clinical guidelines exist and the aftercare is often surgeon-based. In this study we evaluated the current postoperative management of TEA among orthopedic surgeons.

Methods

An online survey of 30 questions was sent to 635 members of the European Society for Surgery of the Shoulder and the Elbow (SECEC/ESSSE), about 10% (n = ± 64) of whom are considered dedicated elbow specialists. The questions were on characteristics of the surgeon and on the surgeon’s preferred postoperative management, including items to be assessed on length of immobilization, amount of weight bearing and axial loading, instructions on lifelong activities, physiotherapy, and postoperative evaluation of the elbow.

Results

The survey was completed by 54 dedicated elbow specialists from 17 different countries. Postoperative immobilization of the elbow was advised by half of respondents when using the triceps-sparing approach (52%), and even more with the triceps-detaching approach (65%). Postoperative passive movement of the elbow was allowed in the triceps-sparing approach (91%) and in the triceps-detaching approach (87%). Most respondents gave recommendations on weight bearing (91%) or axial loading (76%) by the affected elbow, but the specification shows significant variation.

Conclusion

The results from this survey demonstrate a wide variation in postoperative care of TEA. The lack of consensus in combination with low survival rates stresses the need for clinical guidelines. Further research should focus on creating these guidelines to improve follow-up care for TEA.

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.

Trends in arthroplasty in Japan by a complete survey, 2014-2017

BACKGROUND

Precise knowledge of the prevalence and trends of arthroplasty can facilitate the design of medical plans for efficient treatments. The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan provides statistics about the annual number of arthroplasties (knee, hip, shoulder, finger, elbow, and foot/ankle) through health insurance claim numbers for these surgeries. The purpose of this study was to document the annual arthroplasty numbers between 2014 and 2017 in Japan and to analyze their four-year trends, gender differences, age distributions, and regional differences as revealed by the complete survey.

METHODS

Numbers of arthroplasty surgeries were extracted from the NDB Open Data Japan for 2014-2017. For "knee", "hip", "shoulder", "finger", "elbow", and "foot/ankle" arthroplasties, we showed the annual arthroplasty numbers, annual arthroplasty numbers by age group, annual arthroplasty numbers in individual prefectures, and annual arthroplasty numbers per 100,000 population in individual prefectures.

RESULTS

The annual arthroplasty numbers in 2017 were 146,189 for all joints, 82,304 for knees, 59,029 for hips, 2454 for shoulders, 1551 for fingers, 536 for elbows, and 291 for feet/ankles. For the four years up to 2017, the rate of alteration in the number of arthroplasties was +14% for total arthroplasties, +9% for knees, +21% for hip joints, +97% for shoulders, + 8% for fingers, -10% for elbows, and +25% for feet/ankles. The proportion of females was 70-90% and the peak age was between the late 60s and late 70s for all joints. Variations in arthroplasty numbers per population by prefecture appeared to be small for knees and hips and large for other joints.

CONCLUSIONS

We revealed the annual total number of arthroplasties for each joint in Japan using the NDB Open Data Japan for the first time.

Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System

PURPOSE

Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system.

METHODS

All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated.

RESULTS

A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively.

CONCLUSIONS

This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Complex fractures of the distal humerus in the elderly: primary total elbow arthroplasty or open reduction and internal fixation? Mid-term follow-up

OBJECTIVE

To compare the mid-term outcomes in intra-articular distal humerus fracture (AO/OTA type C) treated with either open reduction-internal fixation (ORIF) or total elbow arthroplasty (TEA) in patients older than 75 years and with more than five years of follow-up.

METHODS

Retrospective study including 24 patients (11 TEA vs. 13 ORIF) with a mean age of 82 years and being all females. Results assessed included (1) radiographic measures; (2) functional results: range of motion, Mayo Elbow Performance Score (MEPS), quick-DASH; and (3) complications.

RESULTS

TEA group vs. ORIF group achieved a mean flexion of 117° ± 9.6° vs. 106° ± 14°, extension loss of 38° ± 17° vs. 30.8° ± 16°, pronation 75° ± 5° vs. 85° ± 7° and supination 75° ± 4° vs. 70° ± 5°. Mean MEPS score was 71.6 vs. 83.6 (p = .183) and mean quick-DASH was 44.8 vs. 42.6 (p = .789). All 13 patients in the ORIF group demonstrated radiographic signs of bone union and none underwent conversion to TEA. Sixty-three percent of the patients in the TEA group underwent re-operation at an average of 72 months (62.4-75.2 months), including three  for periprosthetic fracture and four  for implant loosening. Whereas in the ORIF group, 23% of the patients were re-operated upon excluding olecranon osteotomy hardware, two  for stiffness, and one  for an olecranon tension band wire failure.

CONCLUSIONS

Although there were no differences in mid-term functional outcomes between either treatment, our results suggest that the recent trend towards the use of TEA instead of ORIF in the elderly should be re-examined due to the high rate of complications beyond five  years of follow-up with TEA.

Survival and outcome of total elbow arthroplasty for distal humeral fracture at long term follow-up

Background Total elbow arthroplasty is an accepted procedure for the treatment of acute comminuted distal humeral fractures in elderly. Few long-term outcomes are available. The purpose of this study was to examine long-term clinical and radiological outcomes of prosthesis performed (January 2002-June 2015) for complex intra- fractures of the distal humerus (AO/C) in patients older than 65 years with low functional demands. Materials and Methods Further inclusion criteria were: the availability of a clinical and radiological follow-up of minimum 5 years and pattern of closed fracture. Demographic data and characteristics of patients were collected. All patients were clinically and radiographically assessed after 2 and 5 years from surgery. Results Twelve patients were included with complete available data. The mean follow-up was 7.6 years. Five patients reported a worsening of the elbow functionality through the follow-ups. Five subjects had complications. There were no cases of revision surgery. The quality of fixation showed a progressive worsening with increase of radiolucency both on humeral and ulnar side. The recorded MEPS showed no correlation with the grade of periprosthetic osteolysis. Polyethylene bushing wear was scored of grade 2 in one subject who had showed type 4 Morrey radiolucency. Discussion and Conclusions Total elbow arthroplasty is an effective and reliable procedure for comminuted fractures of the distal humerus in elderly, although the incidence of complications can not be considered as negligible. For the majority of these patients, a well-performed implant will give them a well-functioning elbow for their remaining life.

Indications and outcome in total elbow arthroplasty: A systematic review

BACKGROUND

Total elbow arthroplasty (TEA) is the established treatment for end-stage rheumatoid arthritis but improved surgical techniques have resulted in expanded indications. The aim of this study is to review the literature to evaluate the evolution of surgical indications for TEA.

METHODS

A systematic review of PubMed and EMBASE databases was conducted. Case series and comparative studies reporting results after three types of primary TEA were eligible for inclusion.

RESULTS

Forty-nine eligible studies were identified (n = 1995). The number of TEA cases published annually increased from 6 cases in 1980 to 135 cases in 2008. The commonest indication for TEA throughout the review period was rheumatoid arthritis but its annual proportion reduced from 77% to 50%. The mean Mayo Elbow Performance Score significantly improved for all indications. Three comparative studies reported statistically improved functional outcomes in rheumatoid arthritis over the trauma sequelae group. Complication and revision rates varied; rheumatoid arthritis 5.2-30.9% and 11-13%, acute fracture 0-50% and 10-11%, trauma sequelae 14.2-50% and 0-30%, osteoarthritis 50% and 11%, respectively.

DISCUSSION

TEA can provide functional improvements in inflammatory arthritis, acute fractures, trauma sequelae and miscellaneous indications. Long-term TEA survivorship appears satisfactory in rheumatoid arthritis and fracture cases; however, further research into alternative surgical indications is still required.

Coronoid Impingement Causing Early Failure of Total Elbow Arthroplasty

Total elbow arthroplasty (TEA) is a well-established treatment for end-stage rheumatoid arthritis of the elbow. With improved surgical techniques and implant designs, TEA is also effective in treating elbow osteoarthritis, posttraumatic arthritis, distal humerus nonunion, and comminuted distal humerus fractures in the elderly population. There have been multiple reports of greater than 90% survival rate, free of reoperation at 10 years. We present a case of early failure of TEA caused by coronoid impingement, to provide a surgical pearl for others to avoid this complication.

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.

Use and outcome of 1,220 primary total elbow arthroplasties from the Australian Orthopaedic Association National Joint Arthroplasty Replacement Registry 2008-2018

Background and purpose - The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) was analyzed to determine trends in use of primary total elbow arthroplasty (TEA), the types of prostheses used, primary diagnoses, reasons for and types of revision, and whether the primary diagnosis or prosthesis design influenced the revision rate.Patients and methods - During 2008-2018, 1,220 primary TEA procedures were reported of which 140 TEAs were revised. Kaplan-Meier estimates of survivorship were used to describe the time to first revision and hazard ratios (HR) from Cox proportional hazard models, adjusted for age and sex, were used to compare revision rates.Results - The annual number of TEAs performed remained constant. The 3 most common diagnoses for primary TEA were fracture/dislocation (trauma) (36%), osteoarthritis (OA) (34%), and rheumatoid arthritis (RA) (26%). The cumulative percentage revision for all TEAs undertaken for any reason was 10%, 15%, and 19% at 3, 6, and 9 years. TEAs undertaken for OA had a higher revision rate compared with TEAs for trauma (HR = 1.8, 95% CI 1.1-3.0) and RA (HR = 2.0, CI 1.3-3.1). The Coonrad-Morrey (50%), Latitude (30%), Nexel (10%), and Discovery (9%) were the most used prosthesis designs. There was no difference in revision rates when these 4 designs were compared. The most common reasons for revision were infection (35%) and aseptic loosening (34%).Interpretation - The indications for primary and revision TEA in Australia are similar to those reported for other registries. Revision for trauma is lower than previously reported.

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.

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.

Treatment of complete ankylosed elbow with total arthroplasty

We reported the case of a 38-year-old patient who in 2017 presented to our institution after post-traumatic complete ankylosis of the elbow. He complained of stiffness and pain, and the radiographs revealed complete fusion of the humeroulnar joint. The Mayo Elbow Performance Score (MEPS) on admission was 31, and the elbow was fused at 90° flexed position. The patient underwent semiconstrained total elbow arthroplasty with Bryan-Morrey approach; after a 2.1 years follow-up, active arc of movement was 120°. The MEPS was excellent with a 100 points score, the patient was able to complete all activities of daily living. We did not report any complications. Total elbow arthroplasty has shown to be a good therapeutic option that make it possible to restore adequate functional range of motion and relieve pain in young patients with post-traumatic stiffness/arthritis of the elbow.

Total Elbow Arthroplasty

Total elbow arthroplasty design has evolved in recent decades. Indications for total elbow arthroplasty include advanced rheumatoid arthritis to osteoarthritis, post-traumatic arthritis, adverse sequelae of trauma, and unreconstructable acute fractures. This article summarizes the current evidence for total elbow arthroplasty, including the history of total elbow arthroplasty, an overview of the recent trends and designs, and current evidence-based outcomes. Outcomes are assessed for specific indications, namely rheumatoid arthritis, osteoarthritis, post-traumatic arthritis, acute trauma, and younger patients. Complication rates, reoperation rates, and survivorship of modern prostheses are discussed. Technical pearls and pitfalls are discussed for primary and revision cases.

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.

Arthroplasty as primary treatment for distal humeral fractures produces reliable results with regards to revisions and adverse events: a registry-based study

BACKGROUND

Primary prosthetic replacement has become an accepted method for the treatment of complex distal humeral fractures. The present study investigated implant survival and adverse events related to this procedure based on available Swedish registries and examined the completeness of the Swedish Elbow Arthroplasty register.

MATERIALS AND METHODS

Patients treated in Sweden with a primary elbow replacement due to a distal humeral fracture between 1999 and 2014 were identified through 3 different registries: The Swedish Elbow Arthroplasty Register, National Board of Health and Welfare inpatient register, and local registries of all orthopedic departments. Prosthetic survival was examined using Cox regression analysis with Kaplan-Meier plots. Adverse events, defined as medical treatment of the affected elbow besides revision, were analyzed separately. The study included 406 elbows in 405 patients, and no register was complete.

RESULTS

Implant survival at 10 years was 90% (95% confidence interval, 85%-96%), but only 45 patients had an observation time of 10 years or more because 46% of the patients had died, resulting in a mean observation time of 67 (standard deviation, 47) months. An increase in the use of hemiarthroplasties and a proportional decrease of total elbow arthroplasties was detected. There were 18 revisions (4%), and 26 patients (6%) experienced an adverse event, of whom 16 (4%) required surgery. The completeness of the Swedish Elbow Arthroplasty Register regarding primary arthroplasty was 81%.

CONCLUSION

Primary arthroplasty as treatment of distal humeral fractures produces reliable results with regards to revisions and other adverse events.

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.

The effect of implant linking and ligament integrity on humeral loading of a convertible total elbow arthroplasty

BACKGROUND

Both unlinked and linked total elbow arthroplasty (TEA) implants have been employed with no consensus as to the optimal design. The present study aimed to evaluate the effect of collateral ligament integrity and implant linkage on wear-inducing loads in a convertible TEA.

METHODS

Eight fresh frozen upper extremities were tested in an elbow motion simulator. A convertible TEA with an instrumented humeral stem was inserted using computer navigation. Elbow kinematics and humeral loading were recorded with the TEA both linked and unlinked. The collateral ligaments were then sectioned and testing was repeated.

RESULTS

In the dependent position, there was no effect of implant linkage or ligament sectioning on humeral loading. Humeral loading was significantly greater following sectioning of the collateral ligaments but not after linking the TEA with the arm in the valgus position. Humeral loading was significantly greater after linking the TEA but not after sectioning of the collateral ligaments and with the arm in the varus position.

CONCLUSIONS

Collateral ligament integrity reduces wear-inducing loads for both an unlinked and linked TEA. Linkage of a convertible TEA increases humeral loading, which may have detrimental effects on implant longevity.

Computed tomography-based 3-dimensional preoperative planning for unlinked total elbow arthroplasty

HYPOTHESIS

Three-dimensional (3D) surgical planning for unlinked total elbow arthroplasty (TEA) would be helpful for estimation of the implant size and accurate placement of implants.

METHODS

We included 28 patients who underwent TEA with an unlinked total elbow implant in this study. All patients underwent computed tomography scans of the elbow before surgery, and a 3D digital model of the elbow was reconstructed. After the appropriate size and position of the prosthesis were determined, 10 points around the bone tunnel (4 on the humerus and 6 on the ulna) were measured to plan the insertion of the humeral and ulnar stems. Two-dimensional planning was also performed using anteroposterior and lateral radiographs. Intraoperatively, the surgeon measured the planned parameters using a slide gauge to reproduce the 3D planned position of the stem insertion.

RESULTS

The stem sizes were accurately estimated in 57% of patients for the humerus and 68% for the ulna with 2-dimensional planning and in 86% for the humerus and 96% for the ulna with 3D planning. The mean differences between the positions of the prostheses after surgery with reference to the planned positions were 0.8° of varus and 1.5° of flexion for the humeral component and 0.7° of varus and 2.9° of flexion for the ulnar component. We did not evaluate rotational positioning in this study.

CONCLUSIONS

The 3D surgical planning allowed accurate estimation of the implant size and appropriate placement of implants. This method may contribute to a reduced incidence of complications and improved long-term outcomes from TEA.

[Elbow prostheses in rheumatic diseases]

When the elbow is destroyed due to rheumatic diseases, the joint can be replaced by a prosthesis and total arthroplasty. Improved pharmaceutical treatment for rheumatic diseases has, however, reduced the number of implantations in these patients. Reported 10-year survival rates of the implant currently achieve 81-90%.; however, due to limited long-term survival of the implant and high complication rates, total elbow arthroplasty should still be used with caution. Continuous technical improvements in the available prostheses and in surgical techniques could lead in the future to a decline in complications, such as aseptic loosening and infections.

Mid-term results of alumina ceramic unlinked total elbow arthroplasty with cement fixation for patients with rheumatoid arthritis

Aims

The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA).

Patients and Methods

We retrospectively reviewed 87 elbows, in 75 patients with RA, which was replaced using a cemented JACE total elbow arthroplasty (TEA) between August 2003 and December 2012, with a follow-up of 96%. There were 72 women and three men, with a mean age of 62 years (35 to 79). The mean follow-up was nine years (2 to 14). The clinical condition of each elbow before and after surgery was assessed using the Mayo Elbow Performance Index (MEPI, 0 to 100 points). Radiographic loosening was defined as a progressive radiolucent line of >1 mm that was completely circumferential around the prosthesis.

Results

The mean MEPI scores significantly improved from 40 (10 to 75) points preoperatively to 95 (30 to 100) points at final follow-up (p < 0.0001). Complications were noted in ten elbows (ten patients; 11%). Two had an intraoperative humeral fracture which was treated by fixation and united. One had a postoperative fracture of the olecranon which united with conservative treatment and one had a radial neuropathy which resolved. Further surgery was required for one with a dislocation, three with an ulnar neuropathy and one with a postoperative humeral fracture. Revision with removal of the components was performed in one elbow due to deep infection. There was no radiographic evidence of loosening around the components.With any revision surgery or revision with implant removal as the endpoint, the rates of survival up to 14 years were 93% (95% confidence interval (CI), 83.9 to 96.6) and 99% (95% CI 91.9 to 99.8), respectively, as determined by Kaplan-Meier analysis.

Conclusion

With the appropriate indications, the mid-term clinical performance of the cemented JACE TEA is reliable and comparable to other established TEAs in the management of the elbow in patients with RA.

Cite this article: Bone Joint J 2018;100-B:1066–73.

The Influence of Obesity on Total Elbow Arthroplasty

Total elbow arthroplasty (TEA) has undergone a significant evolution in indications and outcomes in the past decade. Although rheumatoid patients once had the overwhelming number of TEAs, now TEAs for the sequelae of trauma predominate. Furthermore, as obesity has mirrored the increase in the posttraumatic population, TEA complications have increased whereas the durability of implants under these loads has decreased. Solutions are urgently needed to address the complications and revision burden related to posttraumatic deformity and obesity.

Implant Arthroplasty: Selection of Exposure and Implant

This review analyzes various surgical exposures and implant designs for proximal interphalangeal (PIP) joint pathology. Our literature review found that silicone implants using a volar approach had the best arc of motion, least extension lag, and lowest complication rates compared with all the other implant designs and approaches. Surface replacement arthroplasties had more frequent surgical revisions compared with silicone implants. Continued efforts toward the development of improved PIP joint implants are necessary.

A survivorship study of 838 total elbow replacements: a report from the Norwegian Arthroplasty Register 1994-2016

BACKGROUND

The aim of this study was to present the long-term survivorship (20 years) of total elbow arthroplasty (TEA) for a relatively large population and to compare different prosthesis brands and patient subgroups.

METHODS

Between 1994 and 2017, a total of 838 primary TEAs were reported to the Norwegian Arthroplasty Register. Implant survival was calculated using the Kaplan-Meier method. Risk differences were examined using Cox regression analyses and exact Cox regression for rare events. We compared the survivorship of the 8 most frequently used implant brands, the different diagnoses leading to TEA, and the influence of the fixation technique.

RESULTS

The overall 5-, 10-, 15-, and 20-year survival rates for all elbow arthroplasties were 92%, 81%, 71%, and 61%, respectively. Risk factors for revision were a diagnosis of sequelae after trauma and cementless fixation of the ulna component. There were some differences between the implant brands. The Norway prostheses had higher survival compared with the Kudo after 15 years of follow-up (78% and 66%, respectively; P < .001). Among the implants with shorter follow-up, the IBP and NES had inferior survivorship compared with the Norway. The frequently used Discovery had promising survivorship up to 5 years. The most frequent reason for revision surgery was aseptic loosening, followed by defective polyethylene, infection, and dislocation. The revision causes were to some degree implant specific.

CONCLUSION

Fairly good results in terms of prosthesis survival were obtained with TEA, although results were poorer than for knee and hip arthroplasties.

Total elbow arthroplasty under unfavourable soft tissue conditions

PURPOSE

To evaluate the clinical and radiographic outcomes of patients with total elbow arthroplasty (TEA) and soft tissue reconstruction.

METHODS

We investigated six patients who underwent TEA and soft tissue reconstruction (two elbows with 1-stage surgery and four elbows with 2-stage surgery). The mean patient age at the time of the surgical procedure was 43.2 years; the mean follow-up duration was 88.2 months.

RESULTS

The mean pain visual analogue scale (VAS) during motion was improved from 6.3 pre-operatively to 0.7 at the last follow-up. The mean Mayo Elbow Performance Score (MEPS) improved from 26.7 pre-operatively to 81.7 at the last follow-up. The mean flexion-extension arcs of the 1- and 2-stage surgery groups increased from 12.5° and 13.8° pre-operatively to 72.5° and 100° at the last follow-up, respectively. The mean MEPS of the one and two stage surgery groups were 75 and 85, respectively, at the last follow-up. One of the six elbows had loosening on the simple radiograph at the last follow-up, and there were no cases with bushing wear. Three elbows needed additional skin debridement owing to wound complications (2/2 elbows in the 1-stage surgery group and 1/4 elbows in the 2-stage surgery group).

CONCLUSIONS

Under unfavorable soft tissue conditions, performing soft tissue reconstruction with TEA provides satisfactory functional improvement and pain relief. The two stage surgery provided a lower rate of wound complication and better elbow function than the one stage surgery, which led to high patient satisfaction post-operatively.

LEVEL OF EVIDENCE

Therapeutic Level IV.

First-line management of distal humerus fracture by total elbow arthroplasty in geriatric traumatology: Results in a 21-patient series at a minimum 2years' follow-up

INTRODUCTION

Total elbow arthroplasty (TEA) is one option in distal humerus fracture in elderly osteoporotic patients.

HYPOTHESIS

The study hypothesis was that, in patients aged 70years or more, TEA provides functional results and ranges of motion compatible with everyday activity, with a complications rate equal to or lower than with internal fixation, and no loss of autonomy or cognitive impairment.

MATERIAL AND METHODS

In this retrospective study, 21 patients receiving TEA for distal humerus fracture were included. Mean follow-up was 3.2years, with functional (Quick DASH and MEPS), cognitive (MMSE), autonomy-related (ADL) and radiological assessment (Morrey).

RESULTS

Mean MEPS was 84 and QuickDASH 32.4. Mean extension deficit was 22°, and mean flexion 125°. There was no loss of autonomy or cognitive impairment. The complications rate was 9.5%. There were no revision surgeries.

DISCUSSION

TEA proved reliable in comminuted distal humerus fracture in elderly patients. Functional results were comparable to those in the literature, and the complications rate was lower. Long-term implant survival needs confirmation to validate this option as a treatment of choice in these indications in geriatric traumatology.

TYPE OF STUDY

Retrospective non-comparative, single-center.

LEVEL OF EVIDENCE

4.

Elbow vascularized composite allotransplantation-surgical anatomy and technique

BACKGROUND

Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA.

METHODS

We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique.

RESULTS

The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs.

CONCLUSIONS

Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.

Kudo type-5 total elbow arthroplasty for patients with rheumatoid arthritis

Aims

We assessed the long-term (more than ten-year) outcomes of the Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis (RA).

Materials and Methods

We reviewed 41 elbows (Larsen Grade IV, n = 21; Grade V, n = 20) in 31 patients with RA who had undergone a Kudo type-5 total elbow arthroplasty (TEA) between 1994 and 2003, and had been followed up for more than ten years. The humeral component was cementless and the all-polyethylene ulnar component cemented in every patient. Clinical outcome was assessed using the Mayo elbow performance score. We calculated the revision rate and evaluated potential risk factors for revision. The duration of follow-up was a mean 141 months (120 to 203).

Results

Aseptic loosening of the ulnar component occurred in 11 elbows. There was no radiolucency around any humeral component. There was one deep infection. The survival rate according to Kaplan-Meier survivorship analysis was 87.8% after five years and 70.7% after ten years. The range of extension/flexion was a mean -38° (-80° to 0°)/105° (30° to 150°) before surgery and -40° (-70° to -20°)/132° (100° to 150°) at the final follow-up, while the mean Mayo elbow performance score was 43 before surgery and 80 at final follow-up. Disease duration of RA up to the TEA of < 15 years and a pre-operative range of movement (ROM) of > 85° were significant risk factors for revision or aseptic loosening.

Conclusion

Although Kudo type-5 prostheses gave satisfactory results in the short-term, aseptic loosening increased after five years. In most cases, elbow function was maintained in the long-term without loosening of the implant. A short duration from the onset of RA to TEA and a large pre-operative ROM were significant risk factors for revision or aseptic loosening. Cite this article: Bone Joint J 2017;99-B:818–23.

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.

The accuracy and precision of radiostereometric analysis in upper limb arthroplasty

Background and purpose - Radiostereometric analysis (RSA) is an accurate method for measurement of early migration of implants. Since a relation has been shown between early migration and future loosening of total knee and hip prostheses, RSA plays an important role in the development and evaluation of prostheses. However, there have been few RSA studies of the upper limb, and the value of RSA of the upper limb is not yet clear. We therefore performed a systematic review to investigate the accuracy and precision of RSA of the upper limb. Patients and methods - PRISMA guidelines were followed and the protocol for this review was published online at PROSPERO under registration number CRD42016042014. A systematic search of the literature was performed in the databases Embase, Medline, Cochrane, Web of Science, Scopus, Cinahl, and Google Scholar on April 25, 2015 based on the keywords radiostereometric analysis, shoulder prosthesis, elbow prosthesis, wrist prosthesis, trapeziometacarpal joint prosthesis, humerus, ulna, radius, carpus. Articles concerning RSA for the analysis of early migration of prostheses of the upper limb were included. Quality assessment was performed using the MINORS score, Downs and Black checklist, and the ISO RSA Results - 23 studies were included. Precision values were in the 0.06-0.88 mm and 0.05-10.7° range for the shoulder, the 0.05-0.34 mm and 0.16-0.76° range for the elbow, and the 0.16-1.83 mm and 11-124° range for the TMC joint. Accuracy data from marker- and model-based RSA were not reported in the studies included. Interpretation - RSA is a highly precise method for measurement of early migration of orthopedic implants in the upper limb. However, the precision of rotation measurement is poor in some components. Challenges with RSA in the upper limb include the symmetrical shape of prostheses and the limited size of surrounding bone, leading to over-projection of the markers by the prosthesis. We recommend higher adherence to RSA guidelines and encourage investigators to publish long-term follow-up RSA studies.