Non-constrained elbow arthroplasty for mutilans deformity in rheumatoid arthritis: a report of six cases

A survivorship study of 838 total elbow replacements: a report from the Norwegian Arthroplasty Register 1994-2016

BACKGROUND

The aim of this study was to present the long-term survivorship (20 years) of total elbow arthroplasty (TEA) for a relatively large population and to compare different prosthesis brands and patient subgroups.

METHODS

Between 1994 and 2017, a total of 838 primary TEAs were reported to the Norwegian Arthroplasty Register. Implant survival was calculated using the Kaplan-Meier method. Risk differences were examined using Cox regression analyses and exact Cox regression for rare events. We compared the survivorship of the 8 most frequently used implant brands, the different diagnoses leading to TEA, and the influence of the fixation technique.

RESULTS

The overall 5-, 10-, 15-, and 20-year survival rates for all elbow arthroplasties were 92%, 81%, 71%, and 61%, respectively. Risk factors for revision were a diagnosis of sequelae after trauma and cementless fixation of the ulna component. There were some differences between the implant brands. The Norway prostheses had higher survival compared with the Kudo after 15 years of follow-up (78% and 66%, respectively; P < .001). Among the implants with shorter follow-up, the IBP and NES had inferior survivorship compared with the Norway. The frequently used Discovery had promising survivorship up to 5 years. The most frequent reason for revision surgery was aseptic loosening, followed by defective polyethylene, infection, and dislocation. The revision causes were to some degree implant specific.

CONCLUSION

Fairly good results in terms of prosthesis survival were obtained with TEA, although results were poorer than for knee and hip arthroplasties.

Results after 562 total elbow replacements: a report from the Norwegian Arthroplasty Register

BACKGROUND

The aim of this study was to give results of elbow arthroplasty for a relatively large population and compare different prosthesis brands and different patient subgroups.

METHODS

Between 1994 and 2006, 562 total elbow replacement operations were reported to the Norwegian Arthroplasty Register. Revisions of prostheses were shown using Kaplan-Meier failure curves, and risk of revision was calculated using Cox regression analysis.

RESULTS

The overall 5- and 10-year failure rates were 8% and 15%, respectively. There were only minor differences between the different implants. Patients who developed traumatic arthritis after fracture had the worst prognosis compared with inflammatory arthritis (P = .005). Risk of revision was also increased when the ulnar component was inserted without cement (P = .02.)

CONCLUSIONS

Good results in terms of prosthesis survival were obtained with total elbow arthroplasty, although results were worse than for knee- and hip arthroplasties. The best results were achieved in patients with inflammatory arthritis.

Long-term results with the Kudo type 3 total elbow arthroplasty

From 1992 to 1993, 17 elbows were replaced with the unlinked Kudo type 3 total elbow arthroplasty in 16 patients with arthritic joint destruction. Of these elbows, 8 were available for clinical examination after a mean of 9.5 years. Of the 17 elbow implants, 5 were revised: 2 because of loosening of the ulnar component, 1 because of dislocation, 1 because of a periprosthetic fracture, and 1 because of a late deep infection. At 9.5 years' follow-up, 67.9% of the prostheses had survived, and the mean survival of the implant was 8.7 years (95% confidence interval, 7.5-10 years). In this study, we observed high rates of progressive valgus tilting of the ulnar component. This valgus tilting is of major concern because it provides more stress to a smaller area on the polyethylene. It may, therefore, cause an increased degree of polyethylene wear and, thereby, reduce the final implant survival rate.

The GSB III elbow prosthesis in rheumatoid arthritis: a 2- to 9-year follow-up

BACKGROUND

The optimal design of an elbow prosthesis for badly damaged elbows is unkown. We evaluated 23 GSB III semi-constrained (sloppy-hinged) total elbow arthroplasties in 16 consecutive patients with rheumatoid arthritis.

PATIENTS AND METHODS

After a mean follow-up period of 5 (2-9) years, we assessed quality of the cementing technique, signs of aseptic loosening, patient satisfaction, range of movement, and determined the Hospital for Special Surgery (HSS) elbow score. 3 patients had died before follow-up; thus, 20 replacements in 16 patients were available for clinical and radiographic study. All patients had endstage rheumatoid arthritis (RA) of the elbow joint.

RESULTS

In 2 patients, humeral components were revised due to malorientation. 1 arthroplasty was revised due to aseptic loosening of the humeral component. There were 4 cases of intraoperative fracture which healed uneventfully. The total rate of complications was thus one-third. In 17 of 40 components, the cementing technique was rated as marginal or inadequate. We found no association between cementing technique and loosening. The arc of extension/flexion increased by 19 degrees (0-80), and the range of pronation/supination increased by 31 degrees (0-130). There were no cases of infection or ulnar nerve dysfunction. At the latest follow-up, the HSS elbow score was 84 (40-100) points. 11 of 20 elbows were rated as excellent, 4 elbows were rated as good, 2 elbows were rated as fair, and 3 elbows were rated as poor. 14 of 16 patients were satisfied with the result and the 2 patients who were not satisfied had persistent pain.

INTERPRETATION

Despite the inherent problems of cementing in small-calibre medullary cavities, the clinical outcome of the GSB III arthroplasty was encouraging for patients with-end stage RA. The rate of overall complications compared favorably with other studies of semiconstrained elbow arthroplasty for end-stage RA. Most complications of the series were minor and did not necessitate revision.

The burden of hospitalised fractures in Sweden

The aim of this study was to characterise the hospital burden of fractures in the Swedish population by age and gender. The number of patients and number of fractures were documented according to site of fracture, age, sex and duration of hospital stay for the whole population of Sweden in 1996. Fractures were additionally classified as osteoporotic according to fracture site. In 1996 there were 54,000 admissions for fracture in men and women aged 50 years or more, accounting for 600,000 hospital-bed days. Hip fractures accounted for 63% of admissions for fracture in men and 72% in women, for 69% and 73% of hospital-bed days, respectively. Fractures considered to be osteoporotic accounted for 84% of all hospital-bed days due to fracture in men, and 93% in women. More hospital-bed days were due to osteoporotic fracture than to breast cancer and prostate cancer combined. The number of hospital-bed days due to osteoporotic fracture was between the amount due to ischaemic heart disease and the amount due to stroke.

[Differential arthroplasty and endoprosthesis indications in rheumatoid arthritis of the elbow joint]

Management of patients with rheumatoid arthritis of the elbow has changed significantly over the last several years. From a medical standpoint, the disease-modifying agents have decreased the number of patients requiring a synovectomy. When synovectomy is indicated, arthroscopic synovectomy has lessened the morbidity of this procedure, but the long-term effectiveness as a definitive reconstructive procedure has yet to be determined. Both coupled and uncoupled elbow joint replacements have emerged as reliable interventions for this diagnosis. Mayo's experience with 78 patients with rheumatoid arthritis undergoing total elbow arthroplasty has revealed a satisfactory outcome of approximately 92% at 12 years. The complication rate is approximately 15% consisting primarily of delayed avulsions or deficiency of the triceps tendon (2%), deep infection (2%), and ulnar nerve irritation (3%).

Results of elbow endoprostheses in patients with rheumatoid arthritis in correlation with previous operations

Fifty-nine patients with rheumatic destruction of the elbow received 20 St Georg, 20 GSB III, 13 Souter-Strathclyde, and 13 Kudo endoprostheses. Among the various prosthetic categories, 43.9% of the joints had had preceding rheumatoid surgery (a previous synovectomy had been performed in 10 joints at a mean of 4.1 +/- 3.7 years and a resection interposition arthroplasty had been performed in 19 cases 4.2 +/- 1.8 years before endoprosthetic replacement). We examined 51 patients with 54 prostheses after a mean follow-up of 5.7 +/- 4.1 years using the Inglis score and analyzing all radiographs. Complications occurred in 20% of the St Georg prostheses, 25% of the GSB III prostheses, and 23% of the Souter-Strathclyde prostheses. Of the St Georg prostheses, 6 (30%) had to be exchanged, as well as 4 (20%) of the GSB III prostheses and 4 (30.7%) of the Souter-Strathclyde prostheses. Of the primarily implanted joints, the St Georg prostheses measured 77.7 +/- 7.7 on the Inglis score, GSB III 89.6 +/- 7.2, Souter-Strathclyde 88.4 +/- 6.5, and Kudo 89.7 +/- 4.4. Radiolucent lines greater than 1 mm were observed in 26% of the St Georg prostheses, 23% of the GSB III prostheses, 27% of the Souter-Strathclyde prostheses, and 9% of the Kudo prostheses. In contrast to the clinical results, the intraoperative and postoperative complications, as well as the rate of failure and radiolucent lines, showed a statistically significant relationship to previous operations of the joints, especially with the resection interposition arthroplasty. We conclude that resection interposition arthroplasty seems to be associated with complications and failures when a subsequent endoprosthesis is used.

Kudo total elbow arthroplasty in patients with rheumatoid arthritis: a long-term follow-up study

BACKGROUND

Improvements in the design of total elbow prostheses over the last two decades have led to better and more consistent results. The type-3 Kudo total elbow prosthesis was developed in 1980. The long-term results of use of this implant have not been reported. Because it is an unlinked prosthesis, it is not known whether preservation of the anterior oblique component of the ulnar collateral ligament at the time of implantation is important.

METHODS

A type-3 Kudo total elbow arthroplasty with cement was performed in forty-seven patients (fifty elbows) with rheumatoid arthritis. Revision rates, clinical symptoms, postoperative complications, and radiographic changes were assessed eleven to sixteen years (mean, thirteen years) postoperatively.

RESULTS

The overall survival rate of the prosthesis was 90% at sixteen years. The mean Mayo elbow performance scores were all poor (mean overall score, 43 points) initially. The overall score was substantially improved at both the intermediate follow-up examination (four to six years after the operation) and the late follow-up examination (eleven to sixteen years after the operation), to 81 and 77 points, respectively. The overall rate of radiolucency about the humeral component was 45% at the intermediate follow-up examination and 100% at the long-term follow-up examination. The rate of radiolucency about the ulnar component at the intermediate and late follow-up examinations was 4.3% and 8.9%, respectively. No great differences in results were found with preservation of the anterior oblique component of the ulnar collateral ligament.

CONCLUSIONS

This long-term follow-up study showed acceptable results of the type-3 Kudo total elbow arthroplasty in patients with rheumatoid arthritis. Preservation of the ulnar collateral ligament does not seem to be necessary when performing this procedure.

Treatment of instability after total elbow arthroplasty

Instability after total elbow arthroplasty can be due to incorrect component selection or position, inadequacy of the medial or lateral ligaments or triceps tendon, polyethylene wear, limb malalignment, or trauma. Patients with significant loss of bone structure, ligament deficiency, and tendon deficiency around the elbow are at increased risk of instability following total elbow arthroplasty.

Semiconstrained total elbow arthroplasty for ankylosed and stiff elbows

BACKGROUND

Total elbow arthroplasty can be a valuable option for the treatment of ankylosed or very stiff elbows.

METHODS

A semiconstrained total elbow arthroplasty was performed in thirteen patients (fourteen elbows) with a preoperative range of elbow motion of 30 degrees or less. Nine elbows were fused or ankylosed preoperatively. The mean age at the time of the surgery was fifty years (range, twenty-four to seventy-nine years). The etiology of the stiffness was trauma for eleven elbows, juvenile rheumatoid arthritis for two, and rheumatoid arthritis for one.

RESULTS

After a mean duration of follow-up of sixty-three months, the result was excellent for four elbows, good for four, fair for one, and poor for five, according to the Mayo elbow performance score. The mean arc of flexion improved from 7 degrees (range, 0 to 30 degrees) preoperatively to 67 degrees (range, 10 to 115 degrees) after the surgery. The most important factor that influenced the final result was the presence of ectopic bone surrounding the elbow joint. There were seven complications. Infection developed in five elbows. Three elbows had a superficial infection, which did not compromise the final result in two and which was treated with a myocutaneous flap in one with skin necrosis, with an excellent result. Deep infection developed in two other elbows. Both had an unsatisfactory result, one after implant removal and one after several debridements and retention of the prosthesis. Two patients sustained a fracture because of a loose component, and the prosthesis was revised. Four patients who lost motion within the first month following the surgery had a manipulation under anesthesia.

CONCLUSIONS

Semiconstrained total elbow arthroplasty is a useful option for patients with an ankylosed or a very stiff elbow and results in a considerable improvement of motion. Because of the nature of the underlying pathology, complications, including reoperation, are frequent, but the risk can be lessened by careful preoperative planning and surgical technique. Replacement is the preferred option in patients who are more than sixty years of age, but it is also a good choice in younger patients if there is no other viable option.

Total elbow arthroplasty with use of a nonconstrained humeral component inserted without cement in patients who have rheumatoid arthritis

BACKGROUND

Most total elbow prostheses that are currently in use require cement for fixation of each component. We developed a new (type-5) prosthesis that does not need cement for fixation.

METHODS

The humeral component is made of cobalt-chromium alloy, and its stem is porous-coated with a plasma spray of titanium alloy. There are two options for the ulnar component: an all-polyethylene type and a metal-backed type with a porous-coated stem. Forty-three elbows in thirty-seven patients who had rheumatoid arthritis were treated with total elbow replacement arthroplasty with use of the type-5 prosthesis. The humeral component was implanted without cement in all elbows, whereas the ulnar component was implanted without cement in eleven elbows and was fixed with cement in the remaining thirty-two. The elbows were followed for an average of three years and ten months (range, two years and six months to five years and six months).

RESULTS

The clinical results were assessed according to a modification of the Mayo Clinic Performance Index. At the time of the latest follow-up, the overall result was excellent for six elbows, good for thirty-one, and fair for six. All elbows had been rated as poor before the operation. There was almost complete relief of pain in twenty-nine elbows and mild or occasional pain in the remaining fourteen. Flexion increased markedly, from an average of 104 degrees preoperatively to an average of 133 degrees postoperatively; this difference was highly significant (p < 0.001, Student t test). In contrast, extension (flexion contracture) worsened slightly, from an average of 38 degrees preoperatively to an average of 42 degrees postoperatively; this difference was significant (p < 0.05). There was one postoperative dislocation of the elbow, and ectopic bone formed in another, with recurrence of ankylosis. Both elbows had a reoperation, and a good result eventually was obtained. There were no instances of postoperative infection or neuropathy of the ulnar nerve. Radiographically, there were no radiolucent lines at the bone-metal interface of any of the humeral or ulnar stems that had been implanted without cement, suggesting solid fixation by osseointegration.

CONCLUSIONS

The results of total elbow arthroplasty with use of this prosthesis appear promising. There was a high rate of relief of pain as well as of restoration of adequate function in patients in whom the elbow was severely affected by rheumatoid arthritis.