Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches

Long-term outcomes and trends in elbow arthroplasty with Coonrad-Morrey prosthesis: a retrospective study in large group of patients

PURPOSE

Total Elbow Arthroplasty (TEA) was first developed to treat severe rheumatoid arthritis, but its uses have grown to encompass end-stage osteoarthritis, post-traumatic arthritis, and distal humeral fractures. This study analyzes indications changes, long-term survival, complications, and post-operative functional results of the Coonrad-Morrey prostheses, enhancing the existing literature on this technique and substantial case history.

METHODS

We included 122 arthroplasties in 117 patients, 28 males and 89 females (mean age of 67 years) treated in our hospital between 2002 and 2016. Minimum follow-up was four years. We collect functional parameters of 48 patients (51 elbows), due to death of patients due to old age and loss at follow-up.

RESULTS

Survival rate at five years was 90%, 85% at 10 years and 83% at 15 years. The overall medium Mayo elbow score was 79.7 ± 18.3 with the highest result in osteoarthritis patients (p < 0.005); QuickDASH score was 33.1 ± 25.5 with the worse result in rheumatoid group. Average post-operative arc of motion (ROM) was 95°±27°. There were complications in 46 out of 122 cases (37.7%) and revision surgeries were performed in 12 of them (9.8%): seven aseptic loosening, four late septic loosening, one bushing wear. In 27 instances (22.1%) was reported ulnar nerve involvement.

CONCLUSION

Coonrad-Morrey prosthesis has shown satisfactory clinical results in the treatment of a wide range of pathologies. The long-term implant survivorship was satisfactory, yet the occurrence of failures and complications cannot be overlooked, above all the ulnar nerve paresthesia. There was a good recovery in quality of life, pain-free with limited residual limb disability.

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.

Neglected Bicondylar Fracture of the Distal Humerus Treated With Total Elbow Arthroplasty

A 69-year-old woman suffered a distal humerus fracture including the medial and lateral condyles. She received conservative treatment with a posterior arm splint at a local healthcare center where she was evaluated by a non-specialist physician. Eight months later, she presented to our department complaining about severe instability. An upper limb specialist examined the patient at the time, and after thoroughly explaining the condition, he suggested a surgical approach with total elbow arthroplasty (TEA), which was then performed. At the one-year follow-up, the patient had a full range of motion without any complications or pain complaints. TEA in neglected fractures of the distal humerus is a poorly researched topic in the field of upper limb surgery with only scarce literature available. In this case report, we present the excellent outcomes of the procedure performed on an elderly patient after non-union regaining her quality of life and suggest that TEA can be a viable solution in elderly patients with complicated or non-united elbow fractures.

Recent advances in unlinked total elbow arthroplasty in Japan

Background

Total elbow arthroplasty (TEA) is a valuable therapeutic approach for improving function and relieving pain in severely deformed elbow joints. However, TEA is associated with a high incidence of complications. In Japan, the use of unlinked TEA has a long history, with the development of the Kudo prosthesis marking a significant milestone. Subsequently, various unlinked implant designs have been developed. Although favorable long-term clinical results have been reported, complications remain a concern. To further improve the outcome of unlinked TEA, attempts have been made in recent years to develop various surgical approaches and intraoperative support devices. This review focuses on the clinical outcomes and recent advances in unlinked TEA in Japan.

Methods

A comprehensive review of clinical results and advancements in unlinked TEA in Japan was conducted. The analysis included trends in the number of TEA, medium-term and long-term results for unlinked TEA, surgical approaches, or preoperative planning techniques.

Results

Several implant designs have been developed in Japan. Clinical studies have reported satisfactory long-term outcomes with these implants, but complications, such as infection, fractures, and dislocation, have been observed. In order to enhance the outcomes of unlinked TEA, various triceps-on approaches have been developed as alternatives to the triceps-detaching approach, which compromises the continuity between the triceps tendon and ulna, leading to inevitable complications related to the triceps tendon. Preservation or repair of the surrounding soft tissues is considered critical for preventing postoperative instability due to the absence of a radial head in the current unlinked TEA design. Computed tomography-based 3-dimensional preoperative planning has been pioneered in Japan, demonstrating its effectiveness in predicting implant size and achieving appropriate implant placement. Additionally, augmented reality-assisted surgery is being explored to accurately translate preoperative planning into the surgical procedure.

Conclusion

Unlinked TEA for inflammatory arthritis has exhibited promising long-term results in Japan, with ongoing efforts to improve surgical techniques and preoperative planning. Further advancements are anticipated to prevent complications such as dislocation and peri-implant fractures.

Revision Arthroplasty in the Challenging Elbow

Compared with hip and knee arthroplasty, total elbow arthroplasty (TEA) has a higher complication rate and lower survivorship. Modern TEA implants most commonly require revision due to implant loosening, infection, and periprosthetic fracture. Concerns with revision TEA include handling of the soft tissues and possible necessity of flap coverage, triceps management, preservation of bone stock, and management of concurrent infection or fracture. In this review, we will discuss preoperative evaluation of the failed elbow arthroplasty, surgical approaches, techniques for revision, outcomes, and complications following revision total elbow arthroplasty.

Clinical and Radiographic Outcomes of Total Elbow Arthroplasty Using a Semi-constrained Prosthesis with a Triceps-preserving Approach over a Minimum Follow-up Period of 4 Years

OBJECTIVE

Complications related to triceps after total elbow arthroplasty (TEA) have become a major surgical concern. The triceps-preserving approach has the advantage of not disturbing the insertion of triceps but is disadvantaged by the reduced exposure of the elbow joint. The aim of this study was to investigate the clinical and radiological outcomes of TEA with a triceps-preserving approach and to compare the outcomes of TEA to treat arthropathy with that of TEA to treat acute distal humerus fracture.

METHODS

From January 2010 to December 2018, 23 patients undergoing primary TEAs were retrospectively reviewed with a mean follow-up time of 92.6 months (range, 52-136 months). Each TEA was performed using the triceps-preserving approach with a semi-constrained Coonrad-Morrey prosthesis. Patient demographics, range of motion (ROM), pain visual analogue scale (VAS), and triceps strength (Medical Research Council [MRC] scale) were compared before and after surgery. The Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiographic outcome, and complications were evaluated at follow-up.

RESULTS

In total, seven males and 16 females were included in this study, with a mean age of 66.1 years (range:46-85 years). By the last follow-up, pain had been significantly relieved in all patients. The average MEPS in the arthropathy group and fracture group were 90.8 ± 10.3 points (range: 68-98 points) and 91.7 ± 0.4 (range: 76-100 points), respectively. The average DASH of the arthropathy group and fracture group was 37.3 ± 18.8 points (range: 18-52 points) and 38.4 ± 20.1 (range: 16-60 points). At the last follow-up after surgery, the mean flexion arcs in the arthropathy group and fracture group were 100.4° ± 24.1° and 97.8° ± 28.1°, respectively. The mean pro-supination arcs in the arthropathy group and fracture group were 142.4° ± 15.2° and 139.2° ± 17.5°, respectively. There were no significant differences in clinical outcomes between the two groups (P ≥ 0.05). Triceps strength was normal (MRC grade V) in 15 elbows and good in eight elbows. None of the cases experienced weakness of the triceps strength, infection, periprosthetic fractures, or prosthesis breakage.

CONCLUSIONS

The clinical and radiographical outcomes of TEA with the triceps-preserving approach were satisfactory in patients with distal humerus fracture, osteoarthritis and rheumatoid arthritis.

[Elbow prosthesis after acute fractures : Indications and technique]

Good to very good clinical results can be achieved in older patients with the implantation of a total elbow prosthesis in cases of distal humeral fractures by taking the morphological features of the fractures, the bone quality as well as the individual patient requirements and variables into account. The most commonly used design is the cemented semiconstrained linked total elbow endoprosthesis. The unlinked prosthesis design and hemiarthroplasty require intact or adequately reconstructable musculoligamentous structures or condyles and a preserved or replaced radial head. The recommended weight limit after total elbow prosthesis as well as potential intraoperative and postoperative complications must be considered and discussed with the patients. A secondary total elbow arthroplasty is also possible after primary conservative treatment approaches, e.g., in the case of contraindicated surgery in the fracture situation, persistent pain and functional restrictions. This article provides an overview of the technique and the appropriate indications.

Biomechanical Evaluation of 2 Common Approaches for Total Elbow Arthroplasty: Triceps Tongue Compared With Triceps Reflecting

PURPOSE

We hypothesize that the triceps tongue approach will be equivalent in strength to the triceps reflecting approach in load to failure following a cyclic preload.

METHODS

Seven paired fresh-frozen cadaveric arms were dissected using the triceps reflecting approach or triceps tongue approach to the posterior elbow. The triceps was then repaired in each specimen, and the elbows were placed in a testing jig. Elbows were preloaded in a cyclic fashion at 5 lbs (2.3 kgf) for 200 cycles in flexion/extension, followed by load to failure. The stiffness and ultimate failure strength for each specimen were determined. We defined ultimate failure as gapping in the suture construct of 4 mm or suture breakage.

RESULTS

One of the triceps tongue specimens was excluded due to a testing error, resulting in 6 elbows in this group. There were no tendon repair failures during the cyclic preload. The median ultimate failure of the reflecting group occurred at 65 pounds, compared to 115 pounds in the tongue group. This was significantly different. The reflecting approach consistently failed along the entire bone-tendon interface. The tongue approach failed at the proximal repair site in 4 of 6 specimens, while the longitudinal aspect of the tendon repair remained intact.

CONCLUSIONS

Following a cyclic preload of 5 lbs for 200 cycles, the triceps tongue repair is stronger than triceps reflecting in ultimate failure. The mode of failure of triceps tongue repair may be superior to that of triceps reflecting.

CLINICAL RELEVANCE

This study may help guide surgeons when choosing a "triceps off" approach to total elbow arthroplasty.

Histologic Evaluation of the Triceps Brachii Tendon Insertion: Implications for Triceps-Sparing Surgery

PURPOSE

Triceps detachment and olecranon osteotomy are 2 techniques used to enhance exposure in elbow surgery. Both the techniques can potentially add considerable morbidity and lengthen the recovery after surgery. Triceps-sparing surgery can potentially mitigate those issues. The purpose of this study was to evaluate the triceps tendon insertion at a histologic level to help improve triceps-sparing surgical techniques used in elbow trauma and arthroplasty.

METHODS

Seventeen fresh-frozen cadaveric elbow specimens were collected. The olecranon and its soft tissue attachments were isolated. We performed gross measurements and sectioned the specimens for histologic evaluation in the saggital or coronal planes. The proximal-to-distal and medial-to-lateral dimensions of the tendon and the distance from the proximal tip of the olecranon to the proximal tendon insertion were measured microscopically on stained embedded sections.

RESULTS

The proximal-to-distal dimension of the triceps tendon insertion was less than previously reported, whereas the medial-to-lateral dimension was similar. The true distance from the tip of the olecranon to the proximal tendon insertion was greater than the previously reported distance obtained via gross measurement.

CONCLUSIONS

Gross measurement of the triceps tendon insertion overestimates and inaccurately represents the true insertional footprint. Gross measurement has been shown to demonstrate consistent disparity compared with histologic measurement. Histologic investigation provides a more accurate description.

CLINICAL RELEVANCE

The finding that the distance from the articular tip of the olecranon to the proximal tendon insertion is greater than previously reported may have clinical implications. A triceps split approach may allow more visualization and exposure of the posterior joint and, therefore, lessen the need for triceps detachment or olecranon osteotomy.

The Van Gorder approach for total elbow arthroplasty

BACKGROUND

Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA.

METHODS

All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed.

RESULTS

A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits.

CONCLUSIONS

This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.

Efficacy of 2-stage revision using a prosthesis of antibiotic-loaded acrylic cement spacer with or without cortical strut allograft in infected total elbow arthroplasty

PURPOSE

We aimed to evaluate the efficacy of a self-manufactured prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) spacer with or without cortical strut allograft in infected total elbow arthroplasty.

METHODS

Between March 2009 and February 2018, we enrolled 18 patients (mean age, 66.9 years) who underwent 2-stage revision arthroplasty for prosthetic infection following total elbow arthroplasty. After implant removal in the first stage, we performed débridement and PROSTALAC insertion. During the second stage, we performed reimplantation using a cortical strut allograft for patients with a considerably severe bone defect. The mean follow-up period was 34 months (range, 25-60 months), during which we evaluated the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and blood markers.

RESULTS

In all 18 patients, infection control was ensured using intravenous (IV) antibiotic therapy for 6 weeks or IV antibiotics for 4 weeks converting to oral antibiotics for 2 weeks following PROSTALAC insertion. The mean visual analog scale score improved from 8 points preoperatively to 2 points postoperatively, and the mean MEPS improved from 32 points preoperatively to 82 points postoperatively (P < .05). The average ROMs at the last follow-up were 9° to 132° from extension to flexion, respectively. Two patients experienced ulnar nerve neuropraxia after surgery, from which they were resolved. Moreover, 2 and 4 patients developed superficial wound infection and triceps insufficiency, respectively, and there was no infection recurrence.

CONCLUSION

In the management of elbow prosthetic infection, 2-stage revision arthroplasty using PROSTALAC spacer insertion in the first stage and cortical strut allograft in the second stage for patients with severe bone defect revealed good clinical results and relatively low infection recurrence rates. However, the complication rate is substantial.

Triceps Insufficiency After Total Elbow Arthroplasty: A Systematic Review

BACKGROUND

The incidence of triceps insufficiency after total elbow arthroplasty (TEA) varies in the literature, and a consensus on treatment strategy is lacking. We review the incidence, the risk factors, the clinical presentation, and the diagnosis and treatment of triceps insufficiency after TEA. Based on this information, we have formulated recommendations for clinical practice.

METHODS

We performed a systematic review of the literature from January 2003 to April 2020 to identify studies that investigated triceps function following TEA by searching the PubMed, Cochrane, and Embase databases. Eligible studies (1) reported on triceps function following primary or revision TEA for every indication, regardless of technique (e.g., bone grafts), (2) included ≥6 adult patients, (3) had the full-text article available, and (4) had a minimum follow-up of 1 year.

RESULTS

Eighty studies with a total of 4,825 TEAs were included. The quality was low in 15 studies, moderate in 64 studies, and high in 1 study. The mean incidence of triceps insufficiency was 4.5%. The rates were highest in patients after revision TEA (22%), in those with posttraumatic arthritis as an indication for surgery (10.2%), and after a triceps-reflecting approach (4.9%). Most studies used the Medical Research Council scale to score triceps function, although cutoff points and the definition of triceps insufficiency differed among studies. Surgical treatment showed favorable results with anconeus tendon transfer and Achilles allograft repair when compared with direct repair.

CONCLUSIONS

The incidence of triceps insufficiency varies greatly, probably due to a lack of consensus on the definition of the term. Therefore, we recommend the guidelines for clinical practice that are presented in this article. These guidelines assist clinicians in providing the best possible treatment strategy for their patients and help researchers optimize their future study designs in order to compare outcomes.

LEVEL OF EVIDENCE

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

Complications of modern design total elbow replacement

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

Prospective cohort study comparing a triceps-sparing and triceps-detaching approach in total elbow arthroplasty: a protocol

BACKGROUND

New surgical approaches have been developed to optimise elbow function after total elbow arthroplasty (TEA). Currently, there is no consensus on the best surgical approach. This study aims to investigate the functional outcomes, prosthetic component position and complication rates after a triceps-sparing and a triceps-detaching approach in TEA.

METHODS AND ANALYSIS

A multicentre prospective comparative cohort study will be conducted. All patients with an indication for primary TEA will enrol in either the triceps-sparing or the triceps-detaching cohort. Primary outcome measure is elbow function, specified as fixed flexion deformity. Secondary outcome parameters are self-reported and objectively measured physical functioning, including triceps force, prosthetic component position in standard radiographs and complications.

DISCUSSION

The successful completion of this study will clarify which surgical approach yields better functional outcomes, better prosthetic component position and lower complication rates in patients with a TEA.

ETHICS AND DISSEMINATION

The Medical Ethics Review Board of University Medical Center Groningen reviewed the study and concluded that it is not clinical research with human subjects as meant in the Medical Research Involving Human Subjects Act (WMO), therefore WMO approval is not needed (METc2019/544).

TRIAL REGISTRATION NUMBER

NTR NL8488.

A case series of a rare tendon rupture

The distal triceps tendon rupture is a rare finding. Only 1% of tendon ruptures are related to it. The triceps brachii muscle has three parts. All of them insert together at the posterior surface of olecranon. Mostly, the tendon ruptured at this level of insertion. The typically trauma mechanism is a fall on the hand with fully extended elbow or a direct trauma. There are also some cases described after weightlifting or secondary due to insufficiency after total joint replacement of the elbow. The diagnosis is based on clinical findings. Ultrasound or magnetic resonance imaging diagnostic is secondary but might help to differentiate between partial or complete rupture as well as to assess tendon retraction. The diagnosis should be treated operatively. Until today, there is no standard of art of surgery techniques. We describe three cases with traumatic triceps tendon rupture fixed by a transosseous refixation.

A Clinical Comparison of Triceps-Sparing and Triceps-Detaching Approaches for Revision Total Elbow Arthroplasty

PURPOSE

Triceps-sparing (TS) approaches have been reported to provide improved triceps strength, better patient outcomes, and a lower incidence of complications in primary total elbow arthroplasty (TEA). It remains unclear whether the advantages of this approach are similar in the revision setting, especially in cases with prior triceps detachment. The purpose of this study was to compare triceps strength and clinical outcomes between TS and triceps-detaching (TD) approaches in revision TEA.

METHODS

All revision TEAs performed over a 17-year period with a minimum 1-year follow-up were retrospectively reviewed. Elbows with preoperative triceps insufficiency or subsequent component removal for infection were excluded. Patients were grouped according to the surgical approach performed at the last revision TEA. Outcome measures included triceps strength, range of motion, visual analog scale (VAS), Mayo Elbow Performance Score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores.

RESULTS

Ten TS and 6 TD elbows were evaluated. Four elbows within the TS group had documented TD surgery prior to revision. Median follow-up was longer in the TD group (137 ± 75 months vs 53 ± 20 months). Functional strength and DASH scores were significantly better in the TS group. Arc of motion, VAS, and MEPS were similar between the TS and the TD groups.

CONCLUSIONS

The TS approach preserves greater postoperative functional triceps strength after revision TEA, regardless of the type of approach used previously.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Surgical Exposures for Total Elbow Arthroplasty

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

Total Elbow Arthroplasty: Clinical Outcomes, Complications, and Revision Surgery

Total elbow arthroplasty is a common surgical procedure used in the management of advanced rheumatoid arthritis, posttraumatic arthritis, osteoarthritis, and unfixable fracture in elderly patients. Total elbow prostheses have evolved over the years and now include the linked, unlinked, and convertible types. However, long-term complications, including infection, aseptic loosening, instability, and periprosthetic fracture, remain a challenge. Here, we introduce each type of implant and evaluate clinical outcomes and complications by reviewing the previous literature.

Surgical approaches for total elbow arthroplasties using data from the Dutch Arthroplasty Register

BACKGROUND

Total elbow arthroplasty (TEA) is a relatively infrequently performed procedure. Therefore, nationwide databases help to provide more insight into factors that might influence implant survival, for example, the surgical approach used. Using data from the Dutch Arthroplasty Register, we aimed to reveal whether high-volume centers use different approaches than low-volume centers and whether the approach is implant specific.

METHODS

Using data from 2014 to 2017, we compared the surgical approaches used for high- vs. low-volume centers, as well as for the 2 most frequently used types of TEA, by use of χ² tests.

RESULTS

We analyzed 276 procedures. In 2016 and 2017, when posterior approaches were further specified, the triceps-on approach was used most frequently in the high-volume center (27 of 42 procedures, 64%) and the triceps-flap approach was used most often in the low-volume centers (48 of 84 procedures, 57%) (P < .001). For the 2 most frequently used types of TEA, the Coonrad-Morrey and Latitude EV arthroplasties, the surgical approaches did not differ. When the high-volume center was compared with the low-volume centers, implant choice differed, with the Coonrad-Morrey arthroplasty being most often used in the high-volume center and the Latitude EV arthroplasty, in the low-volume centers.

CONCLUSION

The posterior triceps-flap approach was the most frequently used surgical approach in primary TEA in the Netherlands, yet the triceps-on approach was used more often in the high-volume center. The surgical approaches did not differ between the 2 most frequently used types of TEA in the Netherlands.

Comparison of isometric triceps brachii force measurement in different elbow positions

PURPOSE

Objective and reliable force measurement is necessary to monitor the rehabilitation after triceps brachii pathology, injuries, and posterior approach-based surgery. It is unclear at which amount of extension the triceps is best tested and if comparison to the uninjured sided is reliable. This study aims to identify the most reliable elbow position at which elbow extension force is measured using a dynamometer. Furthermore, it aims to compare the extension strength of the dominant arm with that of the nondominant arm.

METHODS

Isometric elbow extension force of the dominant and nondominant arms of healthy subjects was measured. The measurements were taken in three sequences per arm in 0, 30, 60, 90, and 120 degrees of flexion. A subgroup repeated the measurements to analyze test-retest reliability using intraclass correlation.

RESULTS

We included a total of 176 volunteers. The repeated measures analysis of variance for within-subject effect showed the lowest variation coefficient at 30 degrees of flexion. Extension forces showed a mean difference of 3.2-6.9 N in advantage of the dominant arm, resulting in ratios from 1.05 to 1.09. Learning curve analysis showed that during the first session in dominant and nondominant arms, less forces were exerted.

CONCLUSION

The most reliable isometric triceps brachii muscle strength measurement was at 30 degrees of flexion of the elbow. Considering the learning curve, a first tryout session for both arms is indicated. Then, a second measurement suffices as no further learning curve is observed.

[Effectiveness of total elbow arthroplasty with preservation of triceps brachii insertion approach]

Objective

To investigate the effectiveness of total elbow arthroplasty (TEA) with preservation of triceps brachii insertion approach.

Methods

Between January 2012 and September 2017, 17 patients with elbow disease were treated with TEA with preservation of triceps brachii insertion approach. There were 3 males and 14 females, with an average age of 65.2 years (range, 48-85 years). The injuries located on left elbow in 5 cases and on right elbow in 12 cases. There were 11 cases of distal humerus fracture (AO type C1 in 2 cases and type C3 in 9 cases); the interval between fracture and operation was 3-10 days (mean, 4.1 days). There were 3 cases of osteoarthritis and 3 cases of rheumatoid arthritis, with the disease duration of 2-26 years (mean, 8.7 years). The postoperative elbow function and pain was assessed by Mayo elbow performance score (MEPS) and visual analogue scale (VAS) score, respectively. The prosthesis position, heterotopic ossification, and periprosthetic fracture were observed by X-ray films.

Results

All incisions healed by first intention. Sixteen patients were followed up 18-69 months (mean, 40.6 months). Intraoperative ulnar nerve injury occurred in 2 cases, and healed after symptomatic treatment. At last follow-up, the MEPS score was 55-100 (mean, 90.3). The results were excellent in 11 cases, good in 2 cases, fair in 2 cases, and poor in 1 case, with an excellent and good rate of 81.3%. The VAS score was 0-2 (mean, 0.4). X-ray reexamination showed that no polyethylene wear, prosthesis loosening and fracture, abnormal prosthesis position, periprosthetic fracture occurred during the follow-up period, and the prosthesis survival rate was 100%. Heterotopic ossification occurred in 2 and 3 months after operation in 2 cases, respectively.

Conclusion

The triceps on approach for TEA are satisfactory for distal humerus fracture, osteoarthritis, and rheumatoid arthritis.

[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.

Triceps on, alignment off? A comparison of total elbow arthroplasty component positioning with a triceps-on and a triceps-off approach

Introduction This retrospective review investigates whether the triceps-on approach obtains alignment of total elbow arthroplasty implants equivalent to a triceps-off approach. Methods The last 30 consecutive total elbow arthroplasties performed by the senior author were reviewed to identify the approach used and pathology treated. Initially, a triceps split and reflection approach was used, then a triceps-preserving approach. Two blinded reviewers measured the component alignment in standardised radiographs. Pearson's correlation coefficient was calculated to investigate inter/intra-observer and error. The two groups were compared using an unpaired Student t-test. Results There were 13 elbows in the triceps-off group and 17 in the triceps-on group. Pearson's coefficient was 0.75 for interobserver error, 0.89 for intra-observer error. There was no statistical difference between the achieved alignment. All ulna components were flexed with a mean angle deviation of 4.5 degrees in the triceps-off group and 5.7 degrees in the triceps on. Two (15%) ulna components in the triceps-off group were placed in over 5 degrees of flexion, compared with seven (44%) in the triceps-on group. Conclusion These results demonstrate no statistical difference in the achieved alignment between the two groups. Surgeons should beware of the tendency to place the ulna component in a flexed position, especially in the triceps-on approach.

Total Elbow Arthroplasty Gives Good Functional Outcome in Distal Humerus Fracture with Pre-existing Chronic Elbow Dislocation

Distal humerus fracture with concomitant chronic elbow dislocation is difficult to manage by open reduction and internal fixation, while total elbow arthroplasty (TEA) is an effective treatment for acute fracture or failed internal fixation of distal humerus fracture in elderly patients with osteoporosis. We present a case of an 86-year-old woman who suffered from acute distal humerus fracture in the presence of chronic elbow deformity from elbow dislocation since childhood at the age of 10 years. This was treated with TEA using Coonrad/Morrey prosthesis with long stem and long flange humerus components and cerclage wiring of humeral condyle. Postoperatively, elbow mobilization was started early within a hinged elbow brace. There was no operative complication. At the last follow-up 22 months after surgery, there was no pain and good elbow motion (20–130° flexion–extension arc, full supination and pronation to neutral) was obtained. The Mayo Elbow Performance Score was 100. There was incorporation of the bone graft at the anterior flange with no radiographic loosening of the prosthesis. This case shows that TEA can yield a gratifying clinical result and efficiently resolves two problems with one solution.

The History and Future of Unlinked Total Elbow Arthroplasty

Unlinked total elbow arthroplasty (TEA), which has no mechanical connection between the humeral and ulnar components, has theoretical advantages based on its near-normal elbow kinematics and the preservation of bone stock. Unlinked TEA is appropriate only for patients who have limited bone loss or limited deformity and good ligamentous function. This is because postoperative instability has been a major complication of unlinked prostheses. The concept and goal of unlinked TEA is to share the loading stress on the bone implant interface with the surrounding tissues. Although the loosening rate of unlinked prostheses theoretically should be lower than that of linked prostheses (which have a mechanical connection between the humeral and ulnar components), there is no clear evidence that unlinked TEAs are superior to linked TEAs in this respect. However, we believe that primary TEA should be performed using an unlinked TEA, especially for younger patients, because revision surgery for unlinked TEA results in longer prosthesis survival than revision surgery for linked TEA. Improvement of the design of unlinked prostheses and the introduction of less invasive surgical techniques are required to reduce postoperative instability.

Current concepts in elbow arthroplasty

Distal humeral replacement and the total elbow are two commonly-used arthroplasties

Each prosthesis has evolving indications and surgical techniques

Recent changes in device design and implantation methods are due to biomechanical and clinical outcome-based research

New prostheses and methods provide: better elbow kinematics, more durable bearings and longer-lasting joint replacement potential

Cite this article: EFORT Open Rev 2017;2:83-88. DOI: 10.1302/2058-5241.2.160064

Clinical and radiographic outcome of revision surgery of total elbow prosthesis: midterm results in 19 cases

BACKGROUND

The aim of this study is to report on the midterm outcomes and complications of revision surgery of total elbow arthroplasty.

METHODS

All patients who had undergone total elbow arthroplasty revision surgery between 2009 and 2014 with semiconstrained total elbow prostheses were prospectively enrolled in the study. Records were reviewed for demographic data; baseline measurements; and several follow-up assessments including the Mayo Elbow Performance Score (MEPS), visual analog scale (VAS) score for pain, Oxford Elbow Score, range of motion, satisfaction, and radiographs.

RESULTS

A total of 19 revision arthroplasties were included. At a mean follow-up of 57 months, there had been 1 rerevision and 2 removals. One patient was excluded from follow-up because of confounding comorbidity. At last follow-up, MEPS values and VAS pain scores both improved (P < .01). The rate of combined good and excellent results on the MEPS was 53%. The mean VAS scores for pain at rest and with activity were 2 and 4, respectively. Fair results for the Oxford Elbow Score were reported, with a mean score of 28 points. Range of motion improved to an average flexion-extension arc of 108° (P < .01), and the pronation-supination arc improved to an average of 123° (P < .01). All elbows were stable at last follow-up (P < .01). Radiographs showed nonprogressive osteolysis around the prosthesis in 3 cases (19%) and suspicion of loosening in 1 (6%). In 11 patients postoperative complications occurred. Of 15 patients, 13 (87%) were satisfied with the result of the revision procedure.

CONCLUSION

Revision of total elbow prostheses leads to satisfactory results, less pain, and better elbow function. This procedure is related to a relatively high complication rate.

Triceps on approach for total elbow arthroplasty: worth preserving? A review of approaches for total elbow arthroplasty

Total elbow arthroplasty can be a rewarding operation and is becoming increasingly used in the elderly fracture population. Multiple approaches are represented in the literature and deciding on the best approach is difficult. This review discusses approaches and their reported outcomes, aiming to allow surgeons to make an informed choice about which approach to use.

The anconeus-triceps lateral flap approach for total elbow arthroplasty in rheumatoid arthritis

BACKGROUND

The posterior approaches to the elbow are considered as to allow an excellent joint exposure for total elbow arthroplasty. One complication that is well recognized is the insufficiency of the extensor mechanism in particular with the patients with poor tendon quality as in the rheumatoid diseases. The purpose of this paper is to present a new triceps-splitting exposure for total elbow arthroplasty used in rheumatoid patients with their preliminary results.

METHODS

Fifteen consecutive patients with rheumatoid disease at grades III to V of the Larsen grading scale underwent total elbow replacement using the new triceps-splitting exposure called anconeus-triceps lateral flap and it preserves the integrity of the medial proper triceps tendon. The assessments were performed with a minimum follow-up of 2 years.

RESULTS

The mean Mayo Elbow Performance Score increased from 24 points to 95 points at a mean follow-up of 38 months. The pain was calculated using the visual analogue score, it had a mean pre-operative value of 8.9 points and it became 0.5 points. Although elbow motion in flexion-extension and pronosupination was allowed from the day after surgery, we did not observe any insufficiency or secondary detachments of the triceps tendon reporting grade 4 to 5 according to the Medical Research Council scale.

CONCLUSIONS

These preliminary outcomes suggest that the decision to preserve the medial proper triceps tendon insertion allows to start an earlier active unrestricted rehabilitation programme. This new triceps management improves the surgical exposure of the olecranon surface.

LEVEL OF EVIDENCE

Level IV.

A new posterior triceps approach for total elbow arthroplasty in patients with osteoarthritis secondary to fracture: preliminary clinical experience

BACKGROUND

During the past decade, total elbow arthroplasty (TEA) procedures have increased because of an increase in the number of trauma patients. Even though most current posterior approaches to the elbow provide excellent joint exposure, they involve the risk of extensor mechanism injury and of eventual insufficiency, particularly in patients with osteoarthritis (OA) secondary to fracture. I describe a new triceps exposure approach for TEA, the anconeus-triceps lateral flap, which has proved valuable in patients with distal humeral and olecranon fracture malunion, and its preliminary results at a minimum follow-up of 24 months.

METHODS

Twenty consecutive patients with OA due to distal humeral and olecranon fracture malunion underwent TEA by the anconeus-triceps lateral flap approach, which preserves the olecranon insertion of the medial portion of the triceps proper tendon.

RESULTS

At a mean follow-up of 33 months, the mean Mayo Elbow Performance Score rose from 41.3 to 94.3. The mean pain score on the visual analog scale fell from 7.1 to 1.1. There were no patients with insufficiency, secondary detachment of the triceps tendon, or grade 4 to 5 of the Medical Research Council scale.

DISCUSSION

These preliminary data suggest that preservation of the insertion of the medial portion of the triceps proper tendon enables earlier active rehabilitation. Moreover, the new approach provides optimum exposure of the olecranon also in patients with OA secondary to intra-articular fracture of the distal humerus and olecranon, where scarring and bone deformity usually hamper joint exposure.

Total elbow arthroplasty is moving forward: Review on past, present and future

The elbow joint is a complex joint, which, when impaired in function, leads to severe disability. In some cases however, an arthroplasty might be an appropriate treatment. In the past four decades, large steps have been taken to optimize this treatment in order to achieve better post-operative outcomes. To understand these progresses and to discover aspects for upcoming improvements, we present a review on the past developments, the present state of affairs and future developments which may improve patient care further.

Total elbow arthroplasty in distal humeral nonunion: clinical and radiographic evaluation after a minimum follow-up of three years

BACKGROUND

Total elbow arthroplasties (TEAs) are usually indicated in chronic inflammatory arthropathies. This procedure has also recently been used in complex distal humeral fractures and nonunions in selected patients. This study analyzed the clinical and radiographic outcomes in patients treated for nonunions around the elbow region with a minimum follow-up of 3 years.

METHODS

Between May 2002 and June 2012, 20 patients affected with distal humeral nonunions were treated with TEA. All patients were assessed clinically using the Mayo Elbow Performance Score and radiographically to evaluate the positioning of the prosthetic components and signs of loosening. Statistical analyses were performed to investigate the presence of clinical and radiographic variables as predictive factors of poor functional outcomes.

RESULTS

The Mayo Elbow Performance Score of the affected arm improved significantly between the preoperative period and follow-up. Results were good or excellent in 90% of the patients even if a high rate of complications (30%) was encountered. The development of complications after surgery and stages II, III, and IV radiolucency, according to the Morrey criteria, were predictive factors of poor outcomes.

CONCLUSIONS

According to the satisfactory results observed in this study, TEA could be indicated in selected patients aged older than 70 years with low functional demands and affected with distal humeral nonunions in which obtaining a stable fixation is difficult.

Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty

PURPOSE

Ulnar nerve (UN) lesions are a significant complication after total elbow arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a center, which routinely performs an in situ release of the nerve without transposition, were investigated.

METHODS

Eighty-three primary TEAs were retrospectively reviewed for the intraoperative management of the UN and presence of postoperative UN symptoms.

RESULTS

Three patients had documented preoperative UN symptoms. One patient had a prior UN transposition. The nerve was transposed at the time of TEA in 4 of the remaining 82 elbows (5%). The indication for transposition in all cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. Of the 4 patients who underwent UN transposition, 2 had postoperative UN symptoms. Both were neuropraxias, which resolved in the early postoperative period. The remaining 78 TEAs received an in situ release of the nerve. The incidence of postoperative UN symptoms in the in situ release group was 5% (4 of 78). Two patients had resolution of symptoms, whereas 2 continued to experience significant UN symptoms requiring subsequent transposition. Seven patients had preoperative flexion of less than 100°. Of these, 2 had a UN transposition at the time of TEA. Of the remaining 5 elbows with preoperative flexion less than 100°, 2 had postoperative UN symptoms after in situ release, with 1 requiring subsequent UN transposition.

CONCLUSIONS

A 3% incidence of significant UN complications after TEA compares favorably with systematic reviews. We do not believe that transposition, which adds to the handling of the nerve and increases surgical time, is routinely indicated and should rather be reserved for cases with marked limitation of preoperative elbow flexion or when intraoperative assessment by the surgeon deems it necessary.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.