The outcome of total elbow arthroplasty in juvenile idiopathic arthritis (juvenile rheumatoid arthritis) patients

Surgical Treatment of Juvenile Idiopathic Arthritis in the Era of Novel Drug Therapies

Juvenile idiopathic arthritis is the most common chronic rheumatic disease encountered in children under the age of sixteen and causes significant impairments in daily life. Over the last two decades, the introduction of new drug treatments (including disease-modifying antirheumatic drugs and biologics) has changed the course of this disease, thus reducing the indication for surgery. However, some patients fail to respond to drug therapy and thus require personalized surgical management, e.g., the local reduction of joint effusion or a synovial pannus (via intra-articular corticosteroid injections, synovectomy, or soft tissue release), and management of the sequelae of arthritis (such as growth disorders and joint degeneration). Here, we provide an overview of the surgical indications and outcomes of the following interventions: intra-articular corticosteroid injections, synovectomy, soft tissue release, surgery for growth disorders, and arthroplasty.

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.

Shoulder and Elbow Surgery in Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory arthropathy that manifests itself prior to the age of sixteen years with symptoms lasting six weeks or longer. As JIA frequently effects the upper extremities, activities of daily living become compromised during the stages of development when young adults are striving for independence. Symptomatology includes ankylosing, pain and early growth plate closure. Patients with joint involvement prior to growth plate closure have the most destruction in terms of joint abnormality and surgical complexity.Medical management of JIA has allowed for better non-surgical management, yet, there is a continued need to understand the appropriate surgical intervention and order for the greatest functional gains. Comparative studies have shown that varied results as to whether the shoulder replacement should supersede the elbow replacement or should that be reversed or both joint replacements done simultaneously. Our experience found a more significant functional improvement after total elbow replacement due to the unpredictable nature from the shoulder replacement outcomes and an inability for patients to do simple tasks such as bringing a cup to their mouths or handling a toothbrush. The exception to this occurs if the ipsilateral shoulder joint is severely limited to the point that the stressors placed on the elbow due to compensation will lead to early loosening or failure of the elbow joint replacement.Various methods for performing joint replacement of the shoulder and elbow in the JIA population will be discussed. Soft tissue integrity including the functional status of the rotator cuff will be a consideration for which surgical procedure should be considered. Surgical approaches for the elbow present fewer options for improving pain and function in this patient population. Pre, peri and postoperative management is reviewed as careful attention to irregular bony dimensions and dysmorphic anatomy precludes the use of standard implants.Total shoulder and total elbow arthroplasty should be considered in the JIA population where pain and significant functional compromise are present. The order of procedures is dependent on multiple factors and expected outcomes. Educating patients on postoperative expectations over the lifespan is an important part of surgical management for patients with JIA.

Juvenile Idiopathic Arthritis for the Pediatric Orthopedic Surgeon

Juvenile idiopathic arthritis includes conditions characterized by joint inflammation of unknown etiology lasting longer than 6 weeks in patients younger than 16 years. Diagnosis and medical management are complex and best coordinated by a pediatric rheumatologist. The mainstay of therapy is anti-inflammatory and biologic medications to control pain and joint inflammation. Orthopedic surgical treatment may be indicated for deformity, limb length inequality, or end-stage arthritis. Evaluation of the cervical spine and appropriate medication management in consultation with a patient's rheumatologist are essential in perioperative care. Preoperative planning should take into account patient deformity, contracture, small size, osteopenia, and medical comorbidities.

Resurfacing hemiarthroplasty of the shoulder for patients with juvenile idiopathic arthritis

BACKGROUND

This study reports the outcome of resurfacing hemiarthroplasty (RHA) in a cohort of patients with juvenile idiopathic arthritis (JIA) affecting the shoulder joint METHODS: Fourteen uncemented RHA procedures were performed for 11 consecutive patients who required surgery because of JIA. Mean age at surgery was 36.4 years. Mean clinical follow-up was 10.4 years (range, 5.8-13.9 years). A significant humeral head defect (up to 40% surface area) was found in 5 shoulders and filled with autograft from the distal clavicle or femoral head allograft.

RESULTS

At latest follow-up, no patient required revision. There was excellent relief from pain. The mean Oxford Shoulder Score and Constant-Murley Score improved significantly. No shoulder had a poor outcome, and 6 had a very good or excellent outcome. Worse outcome was associated with an intraoperative finding of significant humeral head erosion. Two shoulders required early arthroscopic subacromial decompression, but there were no other reoperations. There were no instances of radiographic implant loosening or proximal migration. Painless glenoid erosion was seen in 5 shoulders but was not associated with worse outcome.

CONCLUSIONS

The midterm results of RHA for JIA are at least comparable to those for stemmed hemiarthroplasty, with the added benefit of bone conservation.

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.

Linked semiconstrained and unlinked total elbow replacement in juvenile idiopathic arthritis: a case comparison series with mean 11.7-year follow-up

BACKGROUND

Few series report the results of total elbow replacement (TER) in patients with juvenile idiopathic arthritis (JIA). Most report the use of a linked implant. There are theoretical benefits to using an unlinked prosthesis, and thus we report our experience of the clinical benefit and survivorship of both this implant and a linked semiconstrained prosthesis.

METHODS

There were 21 elbows replaced in 14 JIA patients (12 women and 2 men; 14 unlinked, 7 linked). Mean age at surgery was 39.5 years (range, 26-52 years). Mean clinical follow-up was 11.7 years (range, 5.4-17.6 years).

RESULTS

Reoperation, including implant revision, was required in 9 elbows (42.9%). Using revision as an end point, survivorship was 95% (95% confidence interval [CI], 74%-99%) at 5 years and 68% (95% CI, 45%-86%) at 10 years. The 10-year survival was 70% (95% CI, 40%-89%) for the unlinked group and 69% (95% CI, 28%-94%) for the linked group. The need for bilateral TER was found to be a risk factor for revision within 10 years of primary surgery (6/11 vs. 0/7 elbows; P = .037). The rate of aseptic loosening seen on radiographs was high in the unlinked group (12/14, 85.7%), but many of these patients continue to function well without need for revision.

CONCLUSION

Both the unlinked Kudo 5 and linked Coonrad-Morrey prostheses for TER can provide benefits in the long-term for most patients with JIA. The need for bilateral TER in this group is associated with higher rate of revision at 10 years.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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