Long-term results of the lateral resurfacing elbow arthroplasty

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.

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.

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.

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.

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.

Total elbow arthroplasty in patients with rheumatoid arthritis

AIMS

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

METHODS

We searched PubMed, MEDLINE, Cochrane Reviews, and Embase from between January 2003 and March 2019. The primary aim was to determine the implant failure rate, the mode of failure, and risk factors predisposing to failure. A secondary aim was to identify the overall complication rate, associated risk factors, and clinical performance. A meta-regression analysis was completed to identify the association between each parameter with the outcome.

RESULTS

A total of 38 studies including 2,118 TEAs were included in the study. The mean follow-up was 80.9 months (8.2 to 156). The implant failure and complication rates were 16.1% (95% confidence interval (CI) 0.128 to 0.200) and 24.5% (95% CI 0.203 to 0.293), respectively. Aseptic loosening was the most common mode of failure (9.5%; 95% CI 0.071 to 0.124). The mean postoperative ranges of motion (ROMs) were: flexion 131.5° (124.2° to 138.8°), extension 29.3° (26.8° to 31.9°), pronation 74.0° (67.8° to 80.2°), and supination 72.5° (69.5° to 75.5°), and the mean postoperative Mayo Elbow Performance Score (MEPS) was 89.3 (95% CI 86.9 to 91.6). The meta-regression analysis identified that younger patients and implants with an unlinked design correlated with higher failure rates. Younger patients were associated with increased complications, while female patients and an unlinked prosthesis were associated with aseptic loosening.

CONCLUSION

TEA continues to provide satisfactory results for patients with RA. However, it is associated with a substantially higher implant failure and complication rates compared with hip and knee arthroplasties. The patient's age, sex, and whether cemented fixation and unlinked prosthesis were used can influence the outcome. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Joint J 2020;102-B(8):967-980.

Chronic complex persistent elbow instability: a consecutive and prospective case series and review of recent literature

BACKGROUND

Chronic complex persistent elbow instability (CCPEI) is a condition that even expert elbow surgeons find challenging to treat. The results of the few studies that have dealt with the treatment of this condition are conflicting. We describe the surgical results of a consecutive prospective series of patients with CCPEI and provide a review of the recent literature.

METHODS

We assessed 21 patients with previous failed surgical or conservative treatment, with a terrible-triad injury in 13, Monteggia-like lesion in 6, humeral shear fracture-dislocation in 1, and radial head fracture-dislocation in 1. Overall, 21 open débridement procedures, 15 ulnar nerve transpositions, 6 ulnar in situ neurolysis procedures, 7 total elbow arthroplasties, 8 radial head arthroplasties, 1 radial head resection with humeroradial anconeus interpositional arthroplasty, 4 coronoid graft reconstructions, 14 ligament retensioning procedures, 3 ulnar nonunion treatments, and 2 ulnar osteotomies were performed. Two dynamic external fixators were applied. The Mayo Elbow Performance Score, quick Disabilities of the Arm, Shoulder and Hand score, and modified American Shoulder and Elbow Surgeons score were used preoperatively and postoperatively.

RESULTS

The mean follow-up period was 29.4 months. A significant improvement was found between preoperative and postoperative clinical scores and range-of-motion values. The reintervention and major complication rates were 19% and 23%, respectively. Arthritic evolution was observed in 71% of the cases.

CONCLUSIONS

CCPEI is a challenging condition with an uncertain prognosis. The variability in patients' pathoanatomic conditions requires customized surgical treatment aimed at elbow stabilizer reconstruction when the ulnohumeral joint is preserved or aimed at joint replacement in case of severe articular degeneration. The time interval between the initial trauma and index surgical procedure significantly affects the feasibility of reconstructive procedures.

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

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.