Radiocapitellar prosthetic arthroplasty: short-term to midterm results of 19 elbows

How Does the Subchondral Bone Density Distribution of the Distal Humerus Change Between Early and Advanced Stages of Osteoarthritis?

BACKGROUND

The distribution of subchondral bone density in a joint represents stress that is applied to the joint. Knowing this information is important for understanding the pathophysiology of osteoarthritis (OA). In the elbow, however, this has not been studied before.

QUESTIONS/PURPOSES

(1) Is advanced-stage elbow OA associated with more radially distributed subchondral bone density than earlier stages? (2) What demographic (age and sex) and radiographic (osteophyte location and carrying angle) factors are associated with increased radial shift in subchondral bone density?

METHODS

Between March 2001 and December 2021, we treated 301 patients for elbow OA. We considered patients with plain radiographs and conventional CT scans as potentially eligible. Thus, 68% (206 patients) were eligible; a further 27% (80 patients) were excluded because of a history of any injury or surgery or known inflammatory joint disease, leaving 42% (126 patients) for analysis here. Their mean ± standard deviation age was 60 ± 10 years. Early OA with minimal joint space narrowing and osteophyte formation was found in 33% (42 of 126) of patients, and advanced OA was found in the remaining 67% (84 of 126). Three-dimensional distal humerus subchondral bone models were derived from CT images, and in the central intra-articulating portion, we measured the subchondral bone density in two different sites: where it articulates with the radius (SBD rad ) and with the ulna (SBD ulna ). We further defined the SBD ratio as the percent ratio of SBD rad to SBD ulna . We also evaluated osteophyte severity based on its size at the radiocapitellar and ulnotrochlear joints, and alignment through measuring the carrying angle on radiographs. To assess interobserver reliability, two orthopaedic surgeons took measurements independently from each other. All measurements had excellent intraoberver and interobserver reliabilities. Then, we compared the subchondral bone parameters between early and advanced OA and performed a multivariable analysis of the factors associated with subchondral bone parameters, including age, sex, osteophyte location, and carrying angle.

RESULTS

Radial versus ulna subchondral bone density (SBD ratio ) was modestly higher in patients with advanced OA (118% ± 17%) than in patients with early OA (109% ± 17%, mean difference 9% [95% CI 2.3% to 15.3%]; p = 0.01). With increasing radial deviation in subchondral bone density, cubitus valgus had a modest association (β = 0.46 ± 0.23; p = 0.04) and severe osteophytes at the radiocapitellar joint had a large association (β = 9.51 ± 3.06; p = 0.002).

CONCLUSION

According to subchondral bone density distribution, stress concentration was more radially deviated in patients with the advanced stages of elbow OA than in those with the early stages. We also found that an increase in carrying angle is associated with radial deviation of stress. A future study that examines longitudinal changes in the subchondral bone density might be required to confirm changes in stress concentration with OA progression.

CLINICAL RELEVANCE

This study gives us insight into the potential pathophysiology of elbow OA in relation to elbow alignment. Although debridement of osteophytes in the ulnotrochlear joint is the most frequently performed procedure in patients with advanced elbow OA, our finding suggests that some patients with an increased carrying angle might benefit from management of the radiocapitellar joint as well, or from being informed of the future development of OA in the radiocapitellar joint, because stress at this site can be increased with the advancement of OA.

Articular fracture of the distal humerus classified Dubberley 2b: Case report of two patients and review of the literature

Articular fractures of the distal humerus are rare, and even rarer are fractures involving the trochlea and capitellum in a single fragment, with no associated comminution. These fractures are classified as 2a according to the Dubberley classification and are rarely described in the literature. Two cases of Dubberley 2a fractures were treated at our hospital. The first case, involving a 68-year-old patient, was treated with a medial and a lateral approach, combined with posteroanterior fixation using 3 Herbert screws. In the 2nd case, a 16-year-old male was treated with a single lateral approach, permitting fixation with two Herbert screws. One of the two screws is inserted into the bone at the edge of the cartilage, with an anteroposterior trajectory that leaves the cartilage intact. We opted mainly for posteroanterior screw fixation in subchondral bone, which is less damaging to articular cartilage and soft tissues and has already demonstrated its reliability. No associated lesions were found, and no complications were encountered. Results were excellent, with Mayo Elbow Performance Index (MEPI) scores of 95 and 100 respectively. Herbert screw fixation therefore appears to be an option of choice for these fractures, although comparative studies are needed to evaluate the different treatments available.

The Clinical Outcomes of Radiocapitellar Reconstruction With Radiocapitellar Arthroplasty: A Systematic Review and Meta-Analysis

Background

Radiocapitellar arthroplasty fills a treatment void for young patients who experience isolated capitellar fractures or radiocapitellar osteoarthritis who are not candidates for total elbow arthroplasty. The outcomes of this procedure are sparsely reported. We designed a meta-analysis to determine the utility of radiocapitellar arthroplasty with respect to functional and patient reported outcomes.

Methods

The PubMed database was searched for relevant studies. Only studies published in English language that assessed patient reported outcomes following radiocapitellar arthroplasty were included in this study. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses for 2020.

Results

The initial review yielded 562 studies that met the criteria. After excluding duplications and confounding factors, eight case series were identified for review. Of the eight studies, seven were eligible for inclusion in the meta-analysis for Mayo Elbow Performance Score, flexion-extension arc, and pronation-supination arc. The pooled standard mean difference was found to be statistically significant between pre-operative and post-operative outcomes for Mayo Elbow Performance Score (SMD = 3.04, 95% CI [2.40, 3.67]), flexion-extension arc (SMD = 1.28, 95% CI [0.73, 1.83]), and pronation-supination arc (SMD = 0.81, 95% CI [0.43, 1.18]). Cochran's Q-test and I2 statistics indicated statistically significant heterogeneity for Mayo Elbow Performance Score (p = .04, I2 = 54%) and flexion-extension arc (p < .01, I2 = 67%).

Conclusions

Patients undergoing radiocapitellar arthroplasty showed statistically significant improvements in flexion-extension arc, pronation-supination arc, and Mayo Elbow Performance Scores compared to pre-operative measures.

Reconstruction of the Distal Humerus in a Post-traumatic Arthritic Elbow with a Frozen Osteochondral Allograft Using CT-based Preoperative 3D Planning: A Case Report

CASE

We present a young patient with malunion of the Type IV distal humeral coronal shear fracture and post-traumatic arthritis of the elbow joint. He was treated with a frozen osteochondral allograft transplant using CT-based preoperative 3D planning. At 64 months after surgery, both the clinical and radiological results were satisfactory and no complications had been reported.

CONCLUSION

The precision of computer-aided surgical planning could assist in preoperative designing and preparation of a personalized elbow osteochondral allograft. Even in a chronic situation, a personalized treatment approach can allow for osseointegration and satisfactory clinical results.

Morphometric analysis of the lateral column of the distal humerus with an interest on radio-capitellar arthroplasty design. A computed tomography anatomical study on 50 elbows

PURPOSE

To perform a morphometric analysis of the distal humerus lateral column medullary canal (LCMC).

METHODS

Fifty computed tomography(CTs) from 24 males and 26 females were examined. Two observers measured: (1) the capitellum sagittal (R_S) and axial (R_T) radii of curvature; (2) the sagittal(Sd) and coronal(Cd) diameters of the LCMC in 5 different disto-proximal sites spaced 4 mm apart; (3) the capitellum and LCMC axis offsets on the sagittal (capSO,axSO) and coronal (capCO,axCO) planes; (4) the sagittal (Si) and coronal (Ci) inclination of the LCMC axis.

RESULTS

The mean R_S and R_T were 1.07 cm (SD, 0.11) and 1.30 cm (SD, 0.11), respectively. The mean Sd and Cd values were 1.17 cm (SD, 0.17) and 1.58 cm (SD, 0.24), respectively, with a disto-proximal decrease on both planes. The capSO, capCO, axSO and axCO mean values were 0.76 (SD, 0.21), 1.60 (SD, 0.27), - 0.16 (SD, 0.30) and 0.79 cm (SD, 0.30), respectively. Si and Ci were 70° and 72°, respectively. A strong correlation (r = 0.78) was found between R_S and R_T and between adjacent levels of Sd and Cd. AxSO and axCO yielded a strong inverse correlation. Male patients showed higher values than female ones in all variables (p < 0.03). The intra-class correlation coefficient (ICC) was always > 0.9.

CONCLUSION

The dimensions of the LCMC decrease disto-proximally, with the coronal diameters being greater than the sagittal diameters, resembling a portion of an elliptic torus with an antero-medial concavity. The articular surface of the humeral capitellum is non-spherical, with two strongly correlated radii of curvature. The results of this study may be relevant to the stem design of radiocapitellar arthroplasty.

Avoiding Articular Breakthrough in Screw Fixation of Radial Head Fractures

Background

Methods

Results

Conclusion

Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes

Fractures of the capitellum and trochlea are uncommon fractures of the elbow and can be challenging to treat due to their size, location, and articular nature. Because of their intra-articular nature and predilection toward displacement, these fractures are typically treated operatively. Furthermore, capitellum fractures have high rates of associated injuries, including radial head fractures or lateral collateral ligament injury in ~30% to 60% of patients. In addition to open reduction internal fixation, operative options include fragment excision, arthroscopic assisted reduction and fixation, and elbow arthroplasty. In this article, we undertake a comprehensive literature review of capitellum fractures of the distal humerus, in an attempt to summarize the existing body of evidence and propose areas of future study.

Surgical management for primary osteoarthritis of the elbow

The objective of this review is to summarize the surgical options for primary osteoarthritis of the elbow, reported clinical outcomes, and suggested indications in previous literatures. The surgical management of primary elbow arthritis has evolved because of an improved understanding of pathologic mechanisms and manifestations as well as the development of novel surgical techniques and devices. Osteocapsular arthroplasty (OCA), elbow debridement, distraction arthroplasty, and total elbow arthroplasty (TEA) have been employed for managing elbow osteoarthritis. Elbow debridement and OCA can be helpful in most cases of symptomatic elbow arthritis. TEA is usually recommended for end-stage arthritis in elderly patients after prosthetic implants have been in place for long periods or after complications. Distraction arthroplasty might find a place in the treatment of younger, active patients with end-stage arthritis.

Radiocapitellar arthroplasty

This article sets out the evidence demonstrating that the clinical need for a prosthetic arthroplasty designed specifically for the radiocapitellar joint has been underestimated. The prevalence of radiocapitellar degenerative change requiring treatment is discussed and the relationship between 'isolated' radiocapitellar joint arthritis and more generalised elbow arthritis is explained. Current literature now supports our view that radiocapitellar joint arthroplasty is not only an effective long-term solution for patients with localised radiocapitellar arthritis but also for those patients with more severe degenerative changes involving the elbow joint irrespective of their cause. We consider that is important to avoid resection of the radial head and therefore that resurfacing implants rather than joint replacement implants are more likely to provide a good longterm outcome for patients with elbow arthritis.

Post-traumatic elbow osteoarthritis after radial head arthroplasty: Prevalence and risk factors

BACKGROUND

One of the treatment options for comminuted radial head fractures is radial head arthroplasty (RHA), especially when the elbow is also dislocated. While the clinical outcomes of RHA have been well documented, the incidence of post-traumatic osteoarthritis after RHA and its risk factors are not well known.

OBJECTIVE

To determine the incidence of post-traumatic elbow osteoarthritis (humeroulnar and humeroradial joints) after RHA and identify its risk factors.

METHODS

All patients who underwent RHA at our hospital between 2008 and 2016 were included retrospectively. The inclusion criteria were primary RHA, recent radial head fracture (isolated or associated with elbow dislocation), minimum 1 year of follow-up, clinical and radiographic examination at final assessment. The exclusion criteria were pre-existing elbow osteoarthritis, RHA revision, multiple fractures of the ipsilateral upper limb or polytrauma. The final assessment consisted of a clinical examination [joint range of motion (ROM) and Mayo Elbow Performance Score (MEPS)] and standard radiographs. The correlation between the incidence and severity of osteoarthritis and various risk factors was determined.

RESULTS

Seventy-three patients were included in the analysis with a mean age of 56 years (21-85). The injuries consisted of 41 terrible triad, 15 isolated radial head fractures, 11 Monteggia fractures and 6 transolecranon fracture-dislocations. The mean follow-up was 3.4 years (1-10.9). At the final assessment, osteoarthritis was visible in the humeroulnar compartment in 56% of cases and in the humeroradial compartment in 72% of cases. There was a statistical correlation between the presence of humeroulnar osteoarthritis at the final assessment and ROM in flexion-extension (p=0.003), MEPS (p<0.001), duration of immobilization (p=0.03) and presence of posterior subluxation on immediate postoperative radiographs (p=0.012). The correlation between humeroradial osteoarthritis at the final assessment and ROM in flexion-extension (p=0.0054), RHA implant position (p<0.01), and unipolar configuration (p=0.027) was statistically significant.

CONCLUSION

In our study, elbow osteoarthritis incidence after RHA was 56% in the humeroulnar joint and 72% in the humeroradial joint. RHA implant placement, posterior subluxation immediately postoperative and the duration of immobilization were significantly corelated with osteoarthritis.

LEVEL OF EVIDENCE

IV; case series without control group.

The Essex-Lopresti Injury:: Evaluation and Treatment Considerations

This article describes evaluation and treatment considerations for Essex-Lopresti injuries. Specific information about pattern recognition and treatment options is provided.

Why does radial head arthroplasty fail today? A systematic review of recent literature

Since the introduction of the radial head prosthesis (RHP) in 1941, many designs have been introduced. It is not clear whether prosthesis design parameters are related to early failure. The aim of this systematic review is to report on failure modes and to explore the association between implant design and early failure.A search was conducted to identify studies reporting on failed primary RHP. The results are clustered per type of RHP based on: material, fixation technique, modularity, and polarity. Chi-square tests are used to compare reasons for failure between the groups.Thirty-four articles are included involving 152 failed radial head arthroplasties (RHAs) in 152 patients. Eighteen different types of RHPs have been used.The most frequent reasons for revision surgery after RHA are (aseptic) loosening (30%), elbow stiffness (20%) and/or persisting pain (17%). Failure occurs after an average of 34 months (range, 0-348 months; median, 14 months).Press-fit prostheses fail at a higher ratio because of symptomatic loosening than intentionally loose-fit prostheses and prostheses that are fixed with an expandable stem (p < 0.01).Because of the many different types of RHP used to date and the limited numbers and evidence on early failure of RHA, the current data provide no evidence for a specific RHP design. Cite this article: EFORT Open Rev 2019;4:659-667. DOI: 10.1302/2058-5241.4.180099.

Midterm results of radiocapitellar arthroplasty of the elbow

Aims

The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up.

Patients and Methods

A total of 31 patients with a mean age of 54 years (27 to 73) were analyzed; nine had primary osteoarthritis (OA) and 17 had post-traumatic OA, three had capitellar osteonecrosis, and two had a fracture. Overall, 17 Lateral Resurfacing Elbow (LRE) and 14 Uni-Elbow Radio-Capitellum Implant (UNI-E) arthroplasties were performed. Pre- and postoperative assessment involved the Mayo Elbow Performance Score (MEPS), the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the modified American Shoulder Elbow Surgeons (m-ASES) score.

Results

The mean follow-up was 6.8 years (3.8 to 11.5). The mean MEPS, m-ASES, and Q-DASH scores improved significantly by 50 (p < 0.001), 55 (p < 0.001), and 54 points (p < 0.001), respectively, with no differences being detected between the implants. Preoperative pronation and supination were worse in patients in whom the UNI-E was used. Two patients with the UNI-E implant had asymptomatic evidence of gross loosening.

Conclusion

Radiocapitellar arthroplasty yielded a significant improvement in elbow function at a mean follow-up of 6.8 years, with a high implant survival rate when the LRE was used in patients with primary or post-traumatic OA, without radial head deformity, and when the UNI-E was used in patients in whom radial head excision was indicated. Cite this article: Bone Joint J 2019;101-B:1362–1369

Radiocapitellar arthroplasty: a consecutive case series with 2 to 6 years' follow-up

BACKGROUND

The aim of this study was to analyze indications, outcomes, and complications in patients treated with radiocapitellar arthroplasty.

METHODS

This prospective analysis of clinical and radiographic results included 16 elbows in 15 patients.

RESULTS

This study included 4 men and 11 women (mean age, 51.9 years; age range, 32-65 years). The mean follow-up period was 3.4 years (range, 2-6 years). The indications were post-traumatic (n = 10) and primary radiohumeral osteoarthritis (n = 6). A mean of 2 surgical procedures (range, 0-4) had been performed before radiocapitellar arthroplasty. The mean Mayo Elbow Performance Score significantly improved from 46 points to 85 points (P < .01). The arc of motion improved from 106° to 117° (P = .27). Radiographic ulnohumeral degeneration progressed in 40% of cases but was not symptomatic in any. Subsequent surgery was required in 5 elbows (31%). Revision of the radial head component was necessary in 4 patients (25%). In 3 patients this was a result of loosening of the stem. The radial component was subsequently removed because of persistent pain in 1. Radiographic loosening not requiring revision was found in 2 patients.

CONCLUSION

The overall Mayo Elbow Performance Score was good to excellent after radiocapitellar arthroplasty. Both the revision and reoperation rates were high, and one should consider this before performing this procedure. Loosening of the radial head component was a problem. An improved fixation technique or an adaptation of the design is needed before this type of surgery can be recommended as a standard procedure.