Surgical treatment of the rheumatoid elbow

INTERPOSITION-ARTHROPLASTY OF THE ELBOW: SYSTEMATIC REVIEW

OBJECTIVE

To perform a systematic review of the main methods and indications of interposition arthroplasty in the rigid elbow.

METHODS

The research was carried out by three independent researchers, in the databases PubMed, Medline and Embase, according to the descriptors selected as a research strategy and filters selected in the inclusion criteria.

RESULTS

In total, 21 studies were found with the afore mentioned descriptors and which were considered adequate according to the design and relevance according to the type of study and inclusion filters. There was a very strong correlation between the searches of the three researchers (k = 0.809). At the end, 14 complete studies were presented, all of which were included.

CONCLUSION

The main finding of this study was to note that there is an evident lack of research with a high level of real effectiveness and indication for interposition arthroplasty in the rigid elbow. Most studies point to positive results when the patient is young and a total arthroplasty is not indicated. No meta-analysis or randomized clinical trial was found for this specific topic, despite being a technique applied in clinical practice for some decades and showing good results. Level of Evidence V, Systematic Review.

Solutions for the Unstable and Arthritic Elbow Joint

An unstable, arthritic elbow presents a therapeutic challenge. Patients may have painful, limited range of motion, often due to trauma or progressive joint destruction from rheumatologic disease. The options for management may be particularly challenging when treating young, active patients. While elbow arthroplasty usually provides predictable pain relief and joint range of motion, concerns exist regarding postoperative activity limitations and implant survival. Therefore, these procedures are limited to select subsets of patients, typically low-demand, elderly patients. Interposition arthroplasty is an option for the young, active patient with a painful arthritic elbow.

Long-term Outcome of Open Synovectomy with Radial Head Resection for Rheumatoid Elbow

BACKGROUND

We reviewed our surgical results of open synovectomy with radial head resection for rheumatoid elbow.

METHODS

We reviewed the 20 patients (22 elbows) underwent open synovectomy for rheumatoid elbows retrospectively. The minimum follow-up period is over 10 years, and the average was 13 years 4 months. Surgical outcomes were evaluated using the VAS pain scale, range of motion, and radiologic outcomes including Larsen's grade and carrying angle.

RESULTS

The mean VAS score was 39 (range, 10-90) at last follow-up. The only one patient underwent revision surgery. The mean flexion-extension range of elbow was -28°-112° and arc of motion was 82° before surgery. The mean flexion-extension range of elbow was -23°-114°, and arc of motion was 90° at last follow-up. Radiologic findings of nine elbows in 21 elbows worsened at last follow-up according to the Larsen-s grade. Carrying angle increased by mean 4.2°, and it increased by 10° or more in four elbows.

CONCLUSIONS

Our results show that open synovectomy with radial head resection resulted in functional motion maintenance and pain control for a long time, but often resulted in an elbow valgus deformity. Our findings suggest open synovectomy can be considered as palliative treatment for painful rheumatoid elbow.

Total elbow arthroplasty: a prospective clinical outcome study of Discovery Elbow System with a 4-year mean follow-up

BACKGROUND

Total elbow arthroplasty (TEA) is increasingly used for the treatment of advanced elbow conditions to reduce pain and improve function. However, TEA is still associated with a higher complication rate than total hip and knee arthroplasty despite advances in the design and surgical techniques. This prospective clinical study reports the outcome of the Discovery Elbow System (Biomet, Warsaw IN, USA), which has been in clinical use in the United Kingdom since 2003.

METHODS

The study included a total of 100 Discovery Elbows (April 2003 to January 2010) with a minimum 2-year follow-up, including 75 primary and 25 revisions (60% women and 40% men; mean age, 62 years). Outcome was assessed by means of the Liverpool Elbow Score, pain experience, patient satisfaction, range of motion, and radiographic imaging.

RESULTS

The mean follow-up period was 48.5 months (range, 24-108 months). The Liverpool Elbow Score improved from 3.79 to 6.36 (P < .001). The percentage of pain-free patients was substantially increased from 7% preoperatively to 64% at the final follow-up. The patient satisfaction rate was over 90%. The flexion-extension arc and pronation-supination arc increased from 72° to 93° and from 86° to 111°, respectively (P < .001). Major postoperative complications included deep infection (2%), progressive aseptic loosening requiring revision (primary, 5%; revision 12%), persistent ulnar neuropathy (3%), and periprosthetic fracture (primary, 6.8%; revision, 8%).

CONCLUSION

The Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction. Long-term results are required to assess the survivorship of this system.

Good long-term outcome of synovectomy in advanced stages of the rheumatoid elbow

BACKGROUND AND PURPOSE

Synovectomy is an effective procedure for management of the rheumatoid elbow at radiographically early stages (Larsen grades 1 and 2). However, its efficacy for advanced stages (Larsen grades 3-5) is controversial. We investigated the outcome of synovectomy for advanced stages of the rheumatoid elbow.

METHODS

Between May 1985 and September 1994, synovectomy was performed for 67 rheumatoid elbows in 59 patients (mean age 52 (26-72) years, 54 women). 3 elbows (3 patients) were lost to follow-up after mean 15 (10-23) years. Thus, 64 elbows were evaluated clinically and radiographically.

RESULTS

The mean Mayo elbow performance score (MEPS) improved from 42 (15-75) points preoperatively to 78 (45-100) points at the final follow-up examination. In cases of Larsen grade 5, the mean MEPS at final follow-up examination (69 points) was lower than those of Larsen grade 3 and 4 cases (80 and 79 points, respectively) (p < 0.01). Recurrence of synovitis was obvious in 20/67 elbows. 12 cases had a total elbow arthroplasty mean 13 years after the synovectomy. The 10-year, 15-year, and 20-year survival rates were 97%, 75%, and 70%, respectively.

INTERPRETATION

Our findings suggest that synovectomy for the rheumatoid elbow gives a good long-term outcome for radiographically judged destroyed joints of Larsen grades 3-4.

A case of rheumatoid arthritis improved from Steinbrocker classification class IV to class II after multi-joint surgery

We report the case of a patient with rheumatoid arthritis (RA) who showed a reduction in disease severity (from class IV to class II) after multi-joint surgery. The patient was a 61-year-old man with a history of RA, type-2 diabetes, chronic obstructive pulmonary disease, and nephrotic syndrome. He had been undergoing treatment for RA for the past 10 years, but his condition could not be appropriately controlled. In addition to generalized edema, marked destruction of the left elbow joint and knees was observed, and he was unable to move in bed (Steinbrocker classification: stage IV, class IV). In March 2009, he developed suppurative arthritis of the left elbow (methicillin-sensitive Staphylococcus aureus [MSSA] infection) and was referred to our institution, where the infection subsided after cleaning of the wound and administration of antibiotics. In March 2010, he underwent artificial joint replacement arthroplasty of the left elbow, followed by replacement arthroplasty of the right knee in July that year and of the left knee in November. As of December 2011, the patient showed no signs of inflammatory reactions and was able to walk using crutches (Steinbrocker classification: stage IV, class II). Recent advancements in pharmacotherapy have made it possible to control the advancement of joint destruction in RA. However, in this patient, because of the advanced stage of joint destruction, surgical methods were required to aid the patient in recovering his ability to walk.

Elbow interposition arthroplasty

End-stage elbow arthritis in young, active patients presents a challenging problem to the upper extremity surgeon. Total elbow arthroplasty is not a viable option in this population because of functional restrictions, limited implant survivorship, and the lack of an adequate salvage option. With the appropriate surgical indication, interposition arthroplasty can relieve severe pain, affording a functional elbow without severely proscribing permitted activities. In addition, bone stock is preserved, as are other reconstructive options for the future.

Total elbow arthroplasty: history, current concepts, and future

Total elbow arthroplasty (TEA) has proven to be a reliable joint replacement procedure that has a high degree of patient satisfaction. The long-term functional and implant survival scores rival those of total knee arthroplasty. Despite these favorable outcomes, few patients with disabling elbow degenerative conditions have TEA recommended to them as an alternative procedure by rheumatologists, physiatrists, or orthopedists. This article reviews the history, current concepts, and future of TEA.

Total elbow arthroplasty in patients forty years of age or less

BACKGROUND

It is generally accepted that prosthetic elbow replacement should be avoided in young patients because of an anticipated high rate of early failure. The purpose of this paper was to define the success, prosthetic survival rate, and problems encountered in patients who were treated with a semiconstrained total elbow arthroplasty when they were forty years of age or less.

METHODS

We retrospectively reviewed the records of 758 patients who had undergone primary arthroplasty with the Coonrad-Morrey total elbow prosthesis for any reason between 1982 and 2003. We identified fifty-five total elbow arthroplasties that had been performed in forty-nine patients (thirty-eight women and eleven men) who were forty years of age or less (mean, thirty-three years) at the time of the operation and that had been followed for a minimum of five years. Six patients had a bilateral procedure. The indication for the arthroplasty was inflammatory arthritis in thirty patients and posttraumatic arthritis in nineteen. Patients with hemophilia or a neoplasm were excluded. The medical record data were used to calculate the preoperative and postoperative Mayo Elbow Performance Score.

RESULTS

The mean duration of follow-up was ninety-one months. During this period, twelve (22%) of the elbows had undergone a subsequent surgical procedure: four because of loosening, three because of triceps weakness, three because of wear, and two because of deep infection. On the basis of the Mayo Elbow Performance Score at the last review, thirty-six results (65%) were considered to be excellent; fifteen (27%), good; three (5%), fair; and one (2%), poor.

CONCLUSIONS

Semiconstrained total elbow arthroplasty in young patients was associated with a 22% revision rate at a mean of ninety-one months, and the rate of revision was significantly higher for patients with posttraumatic arthritis. Despite this revision rate, fifty-one elbows (93%) had a good or excellent Mayo Elbow Performance Score.

Comparison of perioperative complications in patients with and without rheumatoid arthritis who receive total elbow replacement

Total elbow replacement is a well-recognized surgical treatment for patients with advanced rheumatoid arthritis (RA) of the elbow. At present, there is minimal literature outlining the perioperative complications associated with total elbow replacement. We endeavored to identify complication rates and hospital disposition differences between patients with and without RA who received a total elbow replacement. Data from the Nationwide Inpatient Sample was used to capture 3,617 patients who received a total elbow arthroplasty between 1988-2005. Of these, 888 had a primary diagnosis of RA and were compared against patients without RA. Analyses addressed perioperative complications and hospital disposition factors, such as charges and length of stay. Overall complication rates were very low with only 2 variables, respiratory complications (P = .01) and renal failure (P = .04) demonstrating significantly worse outcomes in patients without RA (P = .01). Patients without RA had also had longer lengths of stay (P < 0.01). There were 9 reported perioperative deaths. The findings suggest that the perioperative complications of a total elbow replacement for all patients studied are few and that outcomes in patients with RA are nearly equivalent to those in patients without RA.

Chronic posttraumatic elbow disorders treated with metallic radial head arthroplasty

BACKGROUND

Metallic radial head arthroplasty is a proven technique for the treatment of complex radial head fractures. The purpose of this study was to evaluate the functional outcomes of a metallic radial head arthroplasty in patients with chronic posttraumatic elbow disorders.

METHODS

The results of thirty-two metallic radial head arthroplasties in thirty-two consecutive patients were retrospectively reviewed. The indications for the radial head arthroplasty included posttraumatic nonunion and malunion of the radial head, elbow instability following previous excision of the radial head, and failure of a silicone radial head implant used to treat an acute radial head fracture. The study included thirteen male and nineteen female patients followed for a minimum of two years. The radial head arthroplasties were performed at an average of 2.4 years after the injury. Analysis included chart review, personal interview, physical examination, radiographic examination, and strength testing as well as the administration of general and region-specific questionnaires.

RESULTS

The mean duration of follow-up was eight years. The average Mayo Elbow Performance Score was 83 of 100 points, with seventeen (53%) of the thirty-two results rated as excellent; four (13%), as good; seven (22%), as fair; and four (13%), as poor. The average score for subjective patient satisfaction was 8.5 points on a 10-point scale. Patients had significantly less motion and strength in the affected elbow than in the unaffected elbow. Seventy-four percent of the patients demonstrated some degree of posttraumatic arthritis. There were no significant differences in ulnar variance and the ulnohumeral joint space between the affected and unaffected arms. Over the course of the study, no metallic radial head arthroplasties required revision.

CONCLUSIONS

Metallic radial head arthroplasty for the treatment of posttraumatic elbow disorders appears to be a safe and durable procedure that can provide a functional range of motion and pain relief for at least five to ten years. However, longer follow-up is needed to evaluate progression of lucencies adjacent to stems and osteoarthritis.

Indikationen und Alternativen der endoprothetischen Versorgung beim jüngeren Patienten

Due to the significant risk of aseptic implant loosening, the indications for endoprosthetic treatment of young adults must be assessed critically. All conservative and surgical therapy options must always be considered cautiously. Even advanced osteoarthritis of the upper extremities (shoulder, elbow and wrist joints) can often be treated with joint sparing, non-endoprosthetic therapy that leads to good clinical results and sufficient joint function. Total joint replacement is often inevitable for regaining an acceptable gait and adequate mobility in cases of advanced joint destruction of the lower extremities (hip and knee joints). Arthrodesis of the upper ankle joint in cases of isolated osteoarthritis remains a valid therapeutic option. Replacement of the upper ankle joint should be considered in cases of bilateral affliction as well as in the event of additional osteoarthritis of the adjacent joints of the lower ankle and the tarsus.

GSB III total elbow replacement in rheumatoid arthritis

Between 1993 and 2002, 58 GSB III total elbow replacements were implanted in 45 patients with rheumatoid arthritis by the same surgeon. At the most recent follow-up, five patients had died (five elbows) and six (nine elbows) had been lost to follow-up, leaving 44 total elbow replacements in 34 patients available for clinical and radiological review at a mean follow-up of 74 months (25 to 143). There were 26 women and eight men with a mean age at operation of 55.7 years (24 to 77).

At the latest follow-up, 31 excellent (70%), six good (14%), three fair (7%) and four poor (9%) results were noted according to the Mayo elbow performance score. Five humeral (11%) and one ulnar (2%) component were loose according to radiological criteria (type III or type IV). Of the 44 prostheses, two (5%) had been revised, one for type-IV humeral loosening after follow-up for ten years and one for fracture of the ulnar component. Seven elbows had post-operative dysfunction of the ulnar nerve, which was transient in five and permanent in two.

Despite an increased incidence of loosening with time, the GSB III prosthesis has given favourable mid-term results in patients with rheumatoid arthritis.

Total elbow replacement with the Souter-Strathclyde prosthesis in rheumatoid arthritis

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.

Interposition elbow arthroplasty

Pain and loss of motion associated with elbow arthritis is poorly tolerated and constitutes a major functional impairment. While total elbow arthroplasty reliably alleviates pain and improves motion, durability issues mandate restricted indications and light use. Interposition arthroplasty, combined with hinged external fixation, is an alternative and may be preferred in younger, more active patients anticipating heavier use.

Primary Souter-Strathclyde total elbow prosthesis in rheumatoid arthritis

BACKGROUND

Total elbow arthroplasty is a well-established treatment for the painful elbow joint in patients with rheumatoid arthritis. We present the results of what we believe to be the first prospective study of the Souter-Strathclyde total elbow prosthesis.

METHODS

Between June 1982 and December 2000, 204 primary total elbow prostheses were inserted in 166 patients who had rheumatoid arthritis. No patient was lost to follow-up. The mean duration of follow-up was 6.4 years. All patients were examined preoperatively, at one and two years postoperatively, and at regular intervals thereafter.

RESULTS

Six of the 204 elbows had pain at rest at the time of the latest follow-up. Ten patients (ten elbows) without previous neurological symptoms had development of paresthesias in the distribution of the ulnar nerve postoperatively. Patients who had pain at rest or at night and those who had ulnar nerve symptoms preoperatively were found to have a significant chance of having the same complaints postoperatively. Pain at rest or at night and a decrease in function during the follow-up period were associated with humeral loosening. Twenty-four elbows had revision of the total elbow prosthesis because of loosening of the humeral component (ten), loosening after fracture (six), dislocation (four), infection (two), restricted range of motion (one), or fracture of the middle part of the humeral shaft, proximal to the prosthesis (one). One prosthesis was removed because of humeral loosening, and eight were removed because of deep infection. Another five prostheses were radiographically loose at the time of the latest follow-up. The rate of implant survival, according to the method of Kaplan-Meier, was 77.4% after ten years and 65.2% after eighteen years.

CONCLUSIONS

Total elbow replacement is associated with a high complication rate and therefore may be warranted only for seriously disabled patients. Currently, the results associated with the Souter-Strathclyde total elbow prosthesis are comparable with the results associated with other prostheses, but loosening of the humeral component remains a concern.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Elbow synovectomy on patients with juvenile rheumatoid arthritis

Twenty-four primary elbow synovectomies were done between 1991 and 1998 at the authors' institution on 19 patients (15 females, four males) with juvenile rheumatoid arthritis. Five bilateral and 14 unilateral procedures were done. The mean age of the patients was 29 years (range, 11-64 years) at the time of surgery and the mean disease duration was 19 years (range, 2-51 years). Preoperatively radiographic destruction of Larsen Grade 1 was detected in 21% of elbows, Grade 2 in 54%, and Grade 3 in 4%. In 21% of elbows no radiographic destruction was present (Grade 0). The cumulative survival rate of elbow synovectomy was 84% (95% confidence interval, 68-98) at 5 years. Four resynovectomies and two elbow replacement arthroplasties were done during the followup period. Complete pain relief was documented in 44% of patients and subjective outcome was excellent or good in 72% of patients. No significant improvement was observed in functional ability or range of motion in extension and flexion or pronation and supination. The results of the current study (mean followup, 5 years; range, 2-9 years) are slightly worse compared with the short-term results of elbow synovectomy in patients with adult-onset rheumatoid arthritis.