Outcome after total elbow arthroplasty: a retrospective study of 167 procedures performed from 1981 to 2008

[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.

Reliability, validity and critical appraisal of the cross-cultural adapted German version of the Mayo Elbow Performance Score (MEPS-G)

Background

The Mayo Elbow Performance Score (MEPS) is a rating system consisting of four dimensions to evaluate elbow performance. It is a common tool for assessment of elbow impairments worldwide. We determined the validity and reliability of its German version (MEPS-G) after cross-cultural adaptation.

Methods

Six investigators examined 57 patients with elbow pathologies. The MEPS-G was compared to validated elbow scores such as the German versions of DASH, the Oxford Elbow Score, pain level and subjective elbow performance on a VAS. Inter-rater reliability (IRR) and validity of the score and its dimensions were also reviewed. Verification was performed using the intraclass correlation coefficient (ICC), the prevalence and bias with adjusted Kappa (PABAK) and the Spearman correlation.

Results

The IRR of the MEPS-G score was moderate (ICC (2.1) = 0.65). The IRR of the four individual dimensions was moderate to high (K_PABAK = 0.55 -0.81). Validity for the sum score (r = 0.52–0.65) and the dimensions pain (r = 0.53–0.62), range of motion (r = 0.7) and stability (r = − 0.61) was verified. The function subscale reached insufficient validity (r = 0.15–0.39).

Conclusion

The MEPS-G is not sufficiently valid, which is consistent with its English version. The patient-based dimensions were a weakness, demonstrating high risk of bias. There is no general recommendation for the utilization of the MEPS-G as outcome measurement for patients with elbow pathologies.

Total elbow arthroplasty in elderly trauma patients: adding a new perspective for functional evaluation

PURPOSE

Total elbow arthroplasty (TEA) has evolved over the last years, with satisfactory early results, mainly not only in degenerative arthritis, but also increasingly after trauma. Outcome studies in recently published papers are mainly based on the range of motion (ROM), complication rate as well as patient-reported outcome scales and questionnaires. The purpose of this study was to add a new perspective with the "Purdue Pegboard" skill tests in a homogenous set of elderly trauma patients to contribute to a more precise objective outcome measurement in this specific population.

METHODS

A retrospective review was performed on a consecutive cohort of all patients with age above 60 years that received TEA after trauma. Data from follow-up examinations over a standardized time-schedule within 2 years after TEA were included. Mayo Elbow Performance Score (MEPS), "Disability of Arm, Shoulder and Hand" (DASH) Questionnaire, ROM as well as test-scores using the Pegboard test were evaluated.

RESULTS

Mean age was 76.0 years ± 10.3. Indications for TEA were posttraumatic arthrosis in 68.8% (n = 11) and extensive fractures that could not be reconstructed surgically in 31.3% (n = 5). The mean score of MEPS was 82.81 ± 16.63 and 29.18 ± 12.01 in the DASH. ROM presented with a mean of 109.7° ± 15.4. Patients demonstrated good, but marginally reduced test scores in the Pegboard skill tests in comparison with the healthy reference population. No relevant differences between the arm with and the arm without TEA (0.3 ± 3.6; p = 0.715) were noted after 2 years.

CONCLUSION

In the elderly trauma patient with complex fractures of the elbow, TEA is a good alternative to joint reconstruction using various osteosynthesis techniques. TEA is able to avoid revision surgery after open reduction and internal fixation of complex fractures. In cases of failed reconstruction, it is also a viable secondary procedure in posttraumatic arthrosis. Good outcomes in functionality and dexterity can be achieved. Skill tests like the Purdue Pegboard could add a valuable perspective in assessing functional outcomes after TEA.

Outcomes following revision of the revision total elbow arthroplasty

BACKGROUND

There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure.

METHODS

We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification.

RESULTS

We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases.

CONCLUSIONS

RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

Long-term outcomes of total elbow arthroplasty: a systematic review of studies at 10-year follow-up

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the functional outcomes, dislocation, and revision rates following total elbow arthroplasty (TEA) at a minimum 10 years' mean follow-up.

MATERIALS AND METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and Cochrane Library databases. Studies were only included if they focused on outcomes post-TEA at a minimum 10 years' mean follow-up.

RESULTS

Our search found 23 studies including 1429 elbows (60.4% linked TEA) that met our inclusion criteria. There were 1276 patients (79.0% female), with an average age of 64.7 years (19-93) and a mean follow-up of 137.2 months (120-216). At final follow-up, the mean Mayo Elbow Performance Score, Oxford Elbow Score, and Quick Disabilities of the Arm, Shoulder, and Hand scores were 89.1 (35-100), 64.4 (16-48), and 39.2 (3-93), respectively, and 63.3% of patients reported having no pain. The rates of aseptic loosening, infection, implant dislocation, and nerve injury were 12.9%, 3.3%, 4.2%, and 2.1%, respectively. The overall complication and revision rates were 16.3% and 14.6%, respectively.

DISCUSSION AND CONCLUSION

Our systematic review established that TEA offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term.

Total elbow replacement - patient selection and perspectives

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

Clinical outcome of Niigata-Senami-Kyocera modular unconstrained total elbow arthroplasty for destructive elbow in patients with rheumatoid arthritis

BACKGROUND

Total elbow arthroplasty (TEA) is a treatment option for destructive and painful unstable elbows in rheumatoid arthritis (RA). We evaluated the clinical outcomes of unconstrained TEA (Niigata-Senami-Kyocera modular system).

METHODS

Seventy-five unconstrained TEAs were performed in patients with RA (mean age, 64 years; age range, 41-79 years; follow-up rate, 97%). Outcome measures included the Japanese Orthopaedic Association (JOA) functional evaluation score for the elbow joint (JOA score), range of motion, and arc. Bone ingrowth of the humeral component, the incidence of stress shielding around the humeral component, the incidence of loosening of the ulnar component, complications, and the survival rate were investigated.

RESULTS

The mean follow-up period was 5.2 years (range, 2-11.3 years). The JOA elbow score improved from 42 points preoperatively to 87 points postoperatively (P < .0001). Each specified item improved (P < .0001). Flexion improved from 109° to 134°; the flexion-plus-extension arc improved from 70° to 108° (P < .0001). Bone ingrowth of the humeral implant was achieved in all elbows. Stress shielding of the humeral component was detected in 11 elbows (14%); it was significantly higher in 10- and 9-mm-diameter humeral stems than in 8-mm-diameter humeral stems (P = .008). The ulnar component showed no loosening except in 1 elbow owing to infection. Complications were detected in 9 patients (9 elbows, 12%): periprosthetic infection (3), fracture (4), and dislocation (2). The survival rates were 97% at 5 years and 93% at 10 years postoperatively.

DISCUSSION

The Niigata-Senami-Kyocera modular system for patients with RA showed good outcomes. Stress shielding can be avoided by using an 8-mm-diameter humeral stem.

Good outcome after elbow hemiarthroplasty in active patients with an acute intra-articular distal humeral fracture

BACKGROUND

This study reported the clinical outcomes and complications after elbow hemiarthroplasty (EHA) for acute distal humeral fractures Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type C2 and C3.

METHOD

During a 6-year period, 24 active patients with acute intra-articular and multifragmentary distal humeral fractures were treated with an EHA by 1 of 4 experienced elbow surgeons. Mean age was 65 years (range, 47-80 years). Median follow-up time was 20 months (range, 12-70 months).

RESULTS

The median Oxford Elbow Score was 40 points (range, 17-48 points), where 48 points represents a normal elbow. Outcomes were "good to excellent results" in 21 patients, "fair" in 2 patients, and "poor" in 1 patient. The median Mayo Elbow Performance Score was 85 points (range, 50-100 points), where 100 points represents a normal elbow. Outcomes were "good to excellent" in 19 patients, "fair" in 4 patients, and "poor" in 1 patient. The median pain severity score was 2 (range, 0-7) in a scale from 0 to 10 where 0 represents a pain-free elbow. The median flexion/extension and supination/pronation arcs were 110° (range, 60°-140°) and 160° (range, 115°-180°), respectively. Complications were recorded in 7 patients, and 3 of them underwent reoperation because of stiffness, which was treated with open release.

CONCLUSIONS

EHA provides a good and reliable option in the treatment of an acute intra-articular distal humeral fracture unsuitable for open reduction and internal fixation, especially in active patients.

Outcomes after revision total elbow arthroplasty: a systematic review

BACKGROUND

Although revision arthroplasty surgery is a frequently used treatment for failed total elbow arthroplasty (TEA), published results are conflicting. The aim of this systematic review was to provide an overview of the outcomes of revision TEA surgery.

METHODS

A systematic literature search was performed in major databases to find articles relating to outcomes after revision of TEA. Two reviewers independently screened the articles for inclusion, and a third reviewer screened them before final inclusion.

RESULTS

Twenty-one articles containing 532 cases were included. The mean age at revision was 61 years. The mean interval between primary and revision arthroplasty was 77 months, and the average follow-up period was 65 months. Different types of prostheses were included, with 69% of the revision prostheses having linked designs and 31% having unlinked designs. The visual analog scale score, Mayo Elbow Performance Score, Oxford Elbow Score, and range of motion improved significantly after revision surgery. Complications were reported in 232 of 532 cases (44%), leading to reoperations in 22%. After revision with linked prostheses, the Mayo Elbow Performance Score, range of flexion-extension, and pronation improved significantly more than with unlinked designs.

CONCLUSION

Improved functional outcomes can be expected after revision TEA, but the complication rate remains high. Revision TEA should still be considered a salvage procedure for failed TEA. Linked designs for revision TEA result in better outcomes than unlinked designs in the midterm follow-up.

Rounded data have a high potential for false comparative statistical results as shown with elbow arc of motion

BACKGROUND AND HYPOTHESIS

Visually measured range-of-motion (ROM) data are usually rounded to the nearest 5° interval and then recorded. Rounding might significantly influence the outcome of statistical tests.

METHODS

We performed numerical simulation of t test application on 2 datasets, as typically reported for the elbow flexion-extension arc of motion. The test was performed on exact data and then repeated on the same data rounded to the nearest 5° interval. The simulation input parameters were as follows: difference in means (1°-30°), standard deviation (1°-30°), and number of cases (15, 30, 60, and 120). Diverging results were counted to find the rate of failure.

RESULTS

Depending on the given difference in means, the given standard deviation, and the number of cases, the failure rate of the t test after rounding reached up to 40%.

DISCUSSION AND CONCLUSION

The accuracy of statistical tests performed on rounded ROM data is limited because of loss of information after rounding to the nearest 5° interval. This affects parametric and nonparametric tests, as well as paired and unpaired tests. In the future, authors should specify how ROM has been measured and recorded, explicitly addressing rounding. Furthermore, to test a zero hypothesis on rounded ROM data, authors should apply our P value (α) correction.