Medium-term clinical results of a linked total elbow replacement system

Clinical and Radiographic Outcomes of Total Elbow Arthroplasty Using a Semi-constrained Prosthesis with a Triceps-preserving Approach over a Minimum Follow-up Period of 4 Years

OBJECTIVE

Complications related to triceps after total elbow arthroplasty (TEA) have become a major surgical concern. The triceps-preserving approach has the advantage of not disturbing the insertion of triceps but is disadvantaged by the reduced exposure of the elbow joint. The aim of this study was to investigate the clinical and radiological outcomes of TEA with a triceps-preserving approach and to compare the outcomes of TEA to treat arthropathy with that of TEA to treat acute distal humerus fracture.

METHODS

From January 2010 to December 2018, 23 patients undergoing primary TEAs were retrospectively reviewed with a mean follow-up time of 92.6 months (range, 52-136 months). Each TEA was performed using the triceps-preserving approach with a semi-constrained Coonrad-Morrey prosthesis. Patient demographics, range of motion (ROM), pain visual analogue scale (VAS), and triceps strength (Medical Research Council [MRC] scale) were compared before and after surgery. The Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiographic outcome, and complications were evaluated at follow-up.

RESULTS

In total, seven males and 16 females were included in this study, with a mean age of 66.1 years (range:46-85 years). By the last follow-up, pain had been significantly relieved in all patients. The average MEPS in the arthropathy group and fracture group were 90.8 ± 10.3 points (range: 68-98 points) and 91.7 ± 0.4 (range: 76-100 points), respectively. The average DASH of the arthropathy group and fracture group was 37.3 ± 18.8 points (range: 18-52 points) and 38.4 ± 20.1 (range: 16-60 points). At the last follow-up after surgery, the mean flexion arcs in the arthropathy group and fracture group were 100.4° ± 24.1° and 97.8° ± 28.1°, respectively. The mean pro-supination arcs in the arthropathy group and fracture group were 142.4° ± 15.2° and 139.2° ± 17.5°, respectively. There were no significant differences in clinical outcomes between the two groups (P ≥ 0.05). Triceps strength was normal (MRC grade V) in 15 elbows and good in eight elbows. None of the cases experienced weakness of the triceps strength, infection, periprosthetic fractures, or prosthesis breakage.

CONCLUSIONS

The clinical and radiographical outcomes of TEA with the triceps-preserving approach were satisfactory in patients with distal humerus fracture, osteoarthritis and rheumatoid arthritis.

Triceps Insufficiency After Total Elbow Arthroplasty: A Systematic Review

BACKGROUND

The incidence of triceps insufficiency after total elbow arthroplasty (TEA) varies in the literature, and a consensus on treatment strategy is lacking. We review the incidence, the risk factors, the clinical presentation, and the diagnosis and treatment of triceps insufficiency after TEA. Based on this information, we have formulated recommendations for clinical practice.

METHODS

We performed a systematic review of the literature from January 2003 to April 2020 to identify studies that investigated triceps function following TEA by searching the PubMed, Cochrane, and Embase databases. Eligible studies (1) reported on triceps function following primary or revision TEA for every indication, regardless of technique (e.g., bone grafts), (2) included ≥6 adult patients, (3) had the full-text article available, and (4) had a minimum follow-up of 1 year.

RESULTS

Eighty studies with a total of 4,825 TEAs were included. The quality was low in 15 studies, moderate in 64 studies, and high in 1 study. The mean incidence of triceps insufficiency was 4.5%. The rates were highest in patients after revision TEA (22%), in those with posttraumatic arthritis as an indication for surgery (10.2%), and after a triceps-reflecting approach (4.9%). Most studies used the Medical Research Council scale to score triceps function, although cutoff points and the definition of triceps insufficiency differed among studies. Surgical treatment showed favorable results with anconeus tendon transfer and Achilles allograft repair when compared with direct repair.

CONCLUSIONS

The incidence of triceps insufficiency varies greatly, probably due to a lack of consensus on the definition of the term. Therefore, we recommend the guidelines for clinical practice that are presented in this article. These guidelines assist clinicians in providing the best possible treatment strategy for their patients and help researchers optimize their future study designs in order to compare outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mid- to long-term survivorship of the cemented, semiconstrained Discovery total elbow arthroplasty

BACKGROUND

The incidence of total elbow arthroplasty (TEA) is increasing, and an improved understanding of elbow kinematics and biomaterials has driven advances in implant design. In modern practice, cemented, semiconstrained devices are most frequently used. The Discovery TEA has demonstrated promising early results, although there are a paucity of follow-up studies and no dedicated mid- to long-term series. We therefore present the longest, most complete such study to date.

METHODS

A prospectively maintained local joint registry was interrogated to yield a consecutive series of Discovery TEAs performed at a single non-design center. The minimum follow-up period was set at 5 years. Revision procedures and TEAs performed for acute trauma were excluded. The primary outcome was survivorship of the implant. The secondary outcomes included clinical, radiographic, and patient-reported outcomes.

RESULTS

We identified 67 TEAs in 58 patients for inclusion at a mean of 98.5 ± 20.4 months from surgery. Four cases (6%) were lost to follow-up, and implant survival was censored accordingly. The implant was revised in 14 cases (20.9%). The Kaplan-Meier method showed an implant survivorship rate of 76.8% at 119 months. A significant difference in survival was found between dominant and nondominant elbows (P = .012, Breslow test), with elbow dominance conferring a 4.5-fold increased risk of revision (relative risk, 4.5; 95% confidence interval, 1.1-18.5). Pooled clinical outcomes (70.9% follow-up at minimum of 60 months and median of 77.8 months) were also determined.

CONCLUSIONS

We present the longest-term and most complete single-center follow-up study of the Discovery TEA to date. Further long-term survival studies are required to elucidate the performance of this implant compared with more established designs. We have also demonstrated differences in implant survivorship owing to hand dominance for the first time.

Prospective cohort study comparing a triceps-sparing and triceps-detaching approach in total elbow arthroplasty: a protocol

BACKGROUND

New surgical approaches have been developed to optimise elbow function after total elbow arthroplasty (TEA). Currently, there is no consensus on the best surgical approach. This study aims to investigate the functional outcomes, prosthetic component position and complication rates after a triceps-sparing and a triceps-detaching approach in TEA.

METHODS AND ANALYSIS

A multicentre prospective comparative cohort study will be conducted. All patients with an indication for primary TEA will enrol in either the triceps-sparing or the triceps-detaching cohort. Primary outcome measure is elbow function, specified as fixed flexion deformity. Secondary outcome parameters are self-reported and objectively measured physical functioning, including triceps force, prosthetic component position in standard radiographs and complications.

DISCUSSION

The successful completion of this study will clarify which surgical approach yields better functional outcomes, better prosthetic component position and lower complication rates in patients with a TEA.

ETHICS AND DISSEMINATION

The Medical Ethics Review Board of University Medical Center Groningen reviewed the study and concluded that it is not clinical research with human subjects as meant in the Medical Research Involving Human Subjects Act (WMO), therefore WMO approval is not needed (METc2019/544).

TRIAL REGISTRATION NUMBER

NTR NL8488.

Discovery® elbow system arthroplasty: results of 10-year follow-up

BACKGROUND

The semi-constrained Discovery® Elbow System (LimaCorporate, San Daniele del Friuli, Italy) allows varus-valgus laxity of 7° [8]. It has been reported to provide good pain relief and increased range of motion [5, 9] on mid-term follow-up. The aim of the study was to evaluate long-term outcomes of total elbow arthroplasty using the Discovery® Elbow System (LimaCorporate, San Daniele del Friuli, Italy).

MATERIALS AND METHODS

The Mayo Elbow Performance Score (MEPS) and elbow range of motion (ROM) were assessed. Plain radiographs were obtained to assess radiolucency in the humerus and ulna. The data were extracted from electronic patient records.

RESULTS

During the follow-up period of 105.4 (range 24.6-179.9) months, 132 patients (153 elbows) underwent surgery. The cause of surgery was rheumatoid arthritis in 105 (71%) cases, posttraumatic or primary arthritis in 17 (13%) and fracture in 10 (6%) patients. The total MEPS increased on average by 35.0 points. Elbow extension deteriorated by 5.0°. Respectively, flexion improved by 10.0° and pronation by 5.0°. The difference in supination was 0.0°. Pain severity improved by 2.5 points in motion and by 5.5 points at rest. During follow-up, 24 (16%) patients needed revision surgery. The most common cause for revision was periprosthetic fracture. Radiolucent lines were seen in all zones in both the ulna and the humerus. The Kaplan-Meier survival at 5 years was 88% and 79% at 10-14 years.

CONCLUSION

The Discovery® Elbow System provides good results in ROM and pain relief of the elbow. The revision rate was relatively high (16% of patients).

LEVEL OF EVIDENCE

IV.

Indications and outcome in total elbow arthroplasty: A systematic review

BACKGROUND

Total elbow arthroplasty (TEA) is the established treatment for end-stage rheumatoid arthritis but improved surgical techniques have resulted in expanded indications. The aim of this study is to review the literature to evaluate the evolution of surgical indications for TEA.

METHODS

A systematic review of PubMed and EMBASE databases was conducted. Case series and comparative studies reporting results after three types of primary TEA were eligible for inclusion.

RESULTS

Forty-nine eligible studies were identified (n = 1995). The number of TEA cases published annually increased from 6 cases in 1980 to 135 cases in 2008. The commonest indication for TEA throughout the review period was rheumatoid arthritis but its annual proportion reduced from 77% to 50%. The mean Mayo Elbow Performance Score significantly improved for all indications. Three comparative studies reported statistically improved functional outcomes in rheumatoid arthritis over the trauma sequelae group. Complication and revision rates varied; rheumatoid arthritis 5.2-30.9% and 11-13%, acute fracture 0-50% and 10-11%, trauma sequelae 14.2-50% and 0-30%, osteoarthritis 50% and 11%, respectively.

DISCUSSION

TEA can provide functional improvements in inflammatory arthritis, acute fractures, trauma sequelae and miscellaneous indications. Long-term TEA survivorship appears satisfactory in rheumatoid arthritis and fracture cases; however, further research into alternative surgical indications is still required.

The Influence of Obesity on Total Elbow Arthroplasty

Total elbow arthroplasty (TEA) has undergone a significant evolution in indications and outcomes in the past decade. Although rheumatoid patients once had the overwhelming number of TEAs, now TEAs for the sequelae of trauma predominate. Furthermore, as obesity has mirrored the increase in the posttraumatic population, TEA complications have increased whereas the durability of implants under these loads has decreased. Solutions are urgently needed to address the complications and revision burden related to posttraumatic deformity and obesity.

Early results of Latitude primary total elbow replacement with a minimum follow-up of 2 years

BACKGROUND

The aim of this study was to present outcomes of primary Latitude total elbow replacement (TER) with a minimum follow-up of 2 years.

METHODS

A retrospective cohort study was undertaken with prospective outcome data collection for the latest outcome. Included were 63 consecutive primary Latitude TERs in 58 patients performed during a period of 5 years at a specialist orthopedic hospital.

RESULTS

The mean age of the patients was 62 years (33-85 years). Five primary TERs (4 patients) were lost to follow-up. The primary diagnosis was rheumatoid arthritis in 49, osteoarthritis in 8, and trauma in 6 elbows. The mean flexion-extension arc was 75° preoperatively and 97° postoperatively. Mean postoperative Elbex pain score was 19/100, and function score was 37/100. Mean postoperative scores were 42/100 for the Quick Disabilities of the Arm, Shoulder, and Hand and 38/50 for the elbow-specific American Shoulder and Elbow Surgeons assessment. Four patients died of unrelated causes, and 8 of 63 underwent further surgical intervention, including explantation and conversion from unlinked to linked implant. On radiographic review of 41 surviving TERs, aseptic radiologic loosening was observed of the humeral component in 4 elbows and of the ulnar component in 9. Seven elbows had no radial component, and of the remaining 34 elbows, 16 (47%) had signs of loosening of the radial implant. Complications included 1 heterotopic ossification, 1 olecranon fracture, and 3 further procedures for ulnar nerve entrapment.

CONCLUSION

The results indicate that the early outcome of Latitude TER is comparable to that of other prostheses. There is concern about early radiologic loosening of the radial component.

Why does total elbow arthroplasty fail today? A systematic review of recent literature

BACKGROUND

Total elbow arthroplasty is a relatively uncommon type of arthroplasty, which has undergone several design changes in the past four decades. However, research on improvement requires knowledge of failure mechanisms that can be addressed. Therefore, we conducted a systematic review on modes of failure of total elbow arthroplasty.

METHODS

We conducted searches on PubMed/Medline, Embase and Cochrane databases to identify studies describing modes of failure of primary total elbow arthroplasties. The results were coupled per type of total elbow arthroplasty and individual arthroplasty models.

RESULTS

A total of 70 articles were included in this systematic review. 9308 individual total elbow arthroplasties were identified with 1253 revisions (13.5%). Aseptic loosening was the most prevalent reason for revision (38%), followed by deep infection (19%) and periprosthetic fractures (12%).

CONCLUSION

Revision rates have been found similar to a systematic review published in 2003. The revision percentage of total elbow arthroplasty for rheumatoid arthritis is significantly higher than for trauma and post-traumatic osteoarthritis. Aseptic loosening was seen less in linked implants. Infections and periprosthetic fractures did not differ between linkage design groups. Aseptic loosening remains the most frequent cause for revision of primary total elbow arthroplasty. Therefore, more research on the occurrence, progression and risk factors of aseptic loosening should be performed and lead to higher implant survival.

Discovery Elbow System: clinical and radiological results after 2- to 10-year follow-up

BACKGROUND

Discovery Elbow System (DES) is a semi-constrained prosthesis, mainly used for patients with rheumatoid arthritis (RA).

METHODS

Records from 79 patients with RA (90 DES arthroplasties) were reviewed; 47 patients with 55 DES elbows were re-examined. Range of motion (ROM) of both elbows, upper limb function, and quality of life (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Elbow Performance Score [MEPS], and the RAND 36-Item Health Survey [RAND-36]) were assessed. Cementing quality was assessed, and radiolucent lines measured from plain radiographs. Mean follow-up was 64 (range 24-123) months.

RESULTS

Pre-operatively to post-operatively, mean elbow flexion improved from 120° to 146° (p < 0.001) and mean extension lag improved from 29° to 24° (p = 0.02), respectively. At follow-up, mean supination was 66°, mean pronation was 69°, and mean grip strength was 14 kg. Grip strength and ROM (except supination) were similar between the DES elbow and contralateral un-operated elbow. Mean post-operative MEPS was 93 points (excellent, n = 38; good, n = 14; fair, n = 2; and poor, n = 1). Mean DASH score was 43 points. The RAND-36 showed that physical functioning, physical role functioning, bodily pain, and general health were lower than the Finnish reference values. Primary cementing was challenging, and radiolucent lines appeared during follow-up. Four prostheses were revised because of aseptic loosening (n = 3) and periprosthetic fracture (n = 1).

CONCLUSION

DES provides significant improvement in patient's flexion-extension arc. Cementing of the elbow prosthesis was challenging; radiolucent lines appeared during the 5-year follow-up, but their clinical relevance remains unclear. First-generation locking screws may loosen over time.

LEVEL OF EVIDENCE

Level IV.

The long-term outcome of the Gschwend-Scheier-Bähler III elbow replacement

BACKGROUND

The Gschwend-Scheier-Bähler III (GSBIII) is a semiconstrained, sloppy-hinge total elbow replacement. We report the long-term functional and radiological outcome of a cohort of patients more than 10 years after surgery.

METHODS

All GSBIII prostheses implanted from September 1996 to June 2004 were identified from our surgical database. Functional and radiological assessments were performed at routine patient clinic visits, using the Oxford Elbow Score, the 11-item version of the Disabilities of Arm, Shoulder and Hand score (QuickDASH), and plain radiographs.

RESULTS

From 1996 to 2004, 52 elbows in 40 patients were implanted; of these, 18 patients (23 elbows) had died, leaving 22 patients with 29 elbows available for follow-up. Three patients (3 elbows) could not be contacted. Functional and radiological data were available for 19 patients with 26 elbows (90%). Overall survival was a mean of 13.1 years (range, 10.6-16.4 years). Mean age at operation was 63.0 years (range, 49.5-80.6 years). There were 5 male elbows and 21 female elbows. Five total elbow replacements were performed for osteoarthritis and 24 for rheumatoid arthritis. The mean Oxford Elbow Score was 26.9 (range, 18-48). The mean QuickDASH score was 42.6 (range, 2.5-93.2). Of the 52 elbows in 40 patients, 4 elbows (7.7%) required further surgery, 2 (3.8%) of which were revisions. In addition, there was 1 intraoperative complication and 2 postoperative complications not requiring further surgery. Kaplan-Meier 10-year survival shows a 95.9% implant survival with revision as the end point.

CONCLUSIONS

The GSBIII elbow replacement provides good long-term function with a low revision rate and few complications.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Obesity is associated with increased postoperative complications after operative management of tibial shaft fractures

OBJECTIVES

To assess the association of obesity and postoperative complications after operative management of tibial shaft fractures.

METHODS

Patients who underwent operative management of a tibial shaft fracture were identified in a national database by Current Procedural Terminology (CPT) codes for: (1) open reduction and internal fixation (ORIF) and (2) intramedullary nailing (IMN) procedures in the setting of International Classification of Diseases, Ninth Revision (ICD-9) codes for tibial shaft fracture. These groups were then divided into non-obese, obese, and morbidly obese cohorts using ICD-9 codes. Each cohort was then assessed for grouped complications within 90 days, removal of implants within 6 months, and nonunion within 9 months postoperatively. Odds ratios and 95% confidence intervals were calculated.

RESULTS

From 2005 to 2012, 14,638 patients who underwent operative management of tibial shaft fractures were identified, including 4425 (30.2%) ORIF and 10,213 (69.8%) IMN. Overall, 1091 patients (7.4%) were coded as obese and 820 (5.6%) morbidly obese. In each operative group, obesity and morbid obesity was associated with a substantial increase in the rate of major and minor medical complications, venous thromboembolism, infection, procedures for implant removal, and nonunion.

CONCLUSIONS

In patients who undergo either ORIF or IMN for tibial shaft fractures, obesity and its related medical comorbidities are associated with significantly increased rates of postoperative medical complications, infection, nonunion, and implant removal compared to non-obese patients.

Mid-term clinical results of a modern convertible total elbow arthroplasty

Unlinked, linked and convertible total elbow arthroplasties (TEAs) are currently available. This study is the first to report the clinical results of the convertible Latitude TEA. This was a retrospective study of a consecutive cohort of 63 patients (69 primary TEAs) with a mean age of 60 years (23 to 87). Between 2006 and 2008 a total of 19 men and 50 women underwent surgery. The mean follow-up was 43 months (8 to 84). The range of movement, function and pain all improved six months post-operatively and either continued to improve slightly or reached a plateau thereafter. The complication rate is similar to that reported for other TEA systems. No loosening was seen. Remarkable is the disengagement of the radial head component in 13 TEAs (31%) with a radial head component implanted.

Implantation of both the linked and the unlinked versions of the Latitude TEA results in improvement of function and decreased pain, and shows high patient satisfaction at mid-term follow-up.

Cite this article: Bone Joint J 2015; 97-B:681–8.