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

Long-term outcomes of Kudo type-5 unlinked surface-replacing total elbow arthroplasty for rheumatoid arthritis: a 15-year average follow-up study

BACKGROUND

Total elbow arthroplasty (TEA) has been used for various conditions including rheumatoid arthritis (RA). While the Kudo TEA has been associated with favorable short-term outcomes, there is limited information on the longer term outcomes of this device. The aim of this study was to investigate the average 15-year outcome of Kudo type-5 TEA in patients with RA.

METHODS

For this retrospective cohort study, we reviewed 29 elbows in 28 patients (Larsen grade III, n = 8; IV, n = 19; V, n = 2) with RA who underwent Kudo type-5 TEA between 1999 and 2010. The patients were followed up for a mean of 15 (range: 10-21) years. We investigated the survival with setting revision/removal as the endpoints. The risk factors for revision/loosening were assessed.

RESULTS

There was a significant improvement in elbow flexion after Kudo TEA. Preoperative and postoperative Mayo Elbow Performance Score improved significantly from 60.3 to 94.7. Complications included intraoperative medial humeral epicondyle fracture (n = 2), postoperative dislocations (n = 4), deep infections (n = 1), and persistent ulnar nerve neuropathy (n = 1). Aseptic loosening was observed in 7 elbows (24.1%; humerus, n = 3; ulna, n = 3; both sides, n = 1). The causes of the 5 revisions were postoperative dislocation (n = 1), deep infection (n = 1), aseptic loosening of the humerus (n = 2), and aseptic loosening of the ulna (n = 1). All 5 elbows underwent revision of the ulnar component (n = 2) or the linked TEA (n = 3). The survival rate was 81% at 15 years after surgery with setting revision/removal as the endpoints. A deviation of ulnar component insertion angle of over 5° in any plane was associated with more revision compared to those with accurately placed implants.

CONCLUSION

The Kudo type-5 elbow showed good results for up to 15 years of follow-up. However, excessive deviation of insertion angle of the ulnar component (over 5°) was associated with more revision. Due to the small sample size, robust statistical analysis of risk factors for postoperative complications or revision could not be performed, and further research is warranted to resolve this limitation.

Outcome of unlinked total elbow arthroplasty for rheumatoid arthritis in patients younger than 50 years old

AIMS

There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA).

METHODS

We retrospectively reviewed the records of 26 elbows of 21 patients with RA who were aged less than 50 years who underwent primary TEA with an unlinked elbow prosthesis. The mean patient age was 46 years (35 to 49), and the mean follow-up period was 13.6 years (6 to 27). Outcome measures included pain, range of motion, Mayo Elbow Performance Score (MEPS), radiological evaluation for radiolucent line and loosening, complications, and revision surgery with or without implant removal.

RESULTS

The mean MEPS significantly improved from 47 (15 to 70) points preoperatively to 95 (70 to 100) points at final follow-up (p < 0.001). Complications were noted in six elbows (23%) in six patients, and of these, four with an ulnar neuropathy and one elbow with postoperative traumatic fracture required additional surgeries. There was no revision with implant removal, and there was no radiological evidence of loosening around the components. With any revision surgery as the endpoint, the survival rates up to 25 years were 78.1% (95% confidence interval 52.8 to 90.6) as determined by Kaplan-Meier analysis.

CONCLUSION

The clinical outcome of primary unlinked TEA for young patients with RA was satisfactory and comparable with that for elderly patients. A favourable survival rate without implant removal might support the use of unlinked devices for young patients with this disease entity, with a caution of a relatively high complication rate regarding ulnar neuropathy.Level of Evidence: Therapeutic Level IVCite this article: Bone Jt Open 2023;4(1):19-26.

Clinical outcome of Niigata-Senami-Kyocera modular unconstrained total elbow arthroplasty for destructive elbow in patients with rheumatoid arthritis

BACKGROUND

Total elbow arthroplasty (TEA) is a treatment option for destructive and painful unstable elbows in rheumatoid arthritis (RA). We evaluated the clinical outcomes of unconstrained TEA (Niigata-Senami-Kyocera modular system).

METHODS

Seventy-five unconstrained TEAs were performed in patients with RA (mean age, 64 years; age range, 41-79 years; follow-up rate, 97%). Outcome measures included the Japanese Orthopaedic Association (JOA) functional evaluation score for the elbow joint (JOA score), range of motion, and arc. Bone ingrowth of the humeral component, the incidence of stress shielding around the humeral component, the incidence of loosening of the ulnar component, complications, and the survival rate were investigated.

RESULTS

The mean follow-up period was 5.2 years (range, 2-11.3 years). The JOA elbow score improved from 42 points preoperatively to 87 points postoperatively (P < .0001). Each specified item improved (P < .0001). Flexion improved from 109° to 134°; the flexion-plus-extension arc improved from 70° to 108° (P < .0001). Bone ingrowth of the humeral implant was achieved in all elbows. Stress shielding of the humeral component was detected in 11 elbows (14%); it was significantly higher in 10- and 9-mm-diameter humeral stems than in 8-mm-diameter humeral stems (P = .008). The ulnar component showed no loosening except in 1 elbow owing to infection. Complications were detected in 9 patients (9 elbows, 12%): periprosthetic infection (3), fracture (4), and dislocation (2). The survival rates were 97% at 5 years and 93% at 10 years postoperatively.

DISCUSSION

The Niigata-Senami-Kyocera modular system for patients with RA showed good outcomes. Stress shielding can be avoided by using an 8-mm-diameter humeral stem.

Heterotopic ossification after total elbow arthroplasty: a systematic review

BACKGROUND

Heterotopic ossification (HO) is a known complication that can arise after total elbow arthroplasty (TEA). In most cases, it is asymptomatic; however, in some patients, it can limit range of motion and lead to poor outcomes. The objective of this review was to assess and report the incidence, risk factors, prophylaxis, and management of HO after TEA.

METHODS

A systematic search was conducted using MEDLINE, Embase, and PubMed to retrieve all relevant studies evaluating the occurrence of HO after TEA. The search was performed in duplicate, and a quality assessment of all included studies was performed.

RESULTS

A total of 1907 studies were retrieved, of which 45 were included involving 2256 TEA patients. HO was radiographically present in 10% of patients and was symptomatic in 3%. Fewer than 1% of patients went on to undergo surgical excision of HO, with outcomes after surgery reported as good or excellent as assessed by range of motion and the Mayo Elbow Performance Score. HO appears more likely to develop in patients undergoing TEA because of ankylosis, primary osteoarthritis, and distal humeral fractures. Surgical intervention is more likely to be required in patients in whom HO develops after TEA performed for ankylosis and post-traumatic osteoarthritis.

CONCLUSION

HO is an uncommon complication after TEA, with most patients in whom HO develops being asymptomatic and requiring no surgical management. Routine HO prophylaxis for TEA is not supported by the literature. The effectiveness of prophylaxis in high-risk patients is uncertain, and future studies are required to clarify its usefulness.

Outcomes after revision total elbow arthroplasty: a systematic review

BACKGROUND

Although revision arthroplasty surgery is a frequently used treatment for failed total elbow arthroplasty (TEA), published results are conflicting. The aim of this systematic review was to provide an overview of the outcomes of revision TEA surgery.

METHODS

A systematic literature search was performed in major databases to find articles relating to outcomes after revision of TEA. Two reviewers independently screened the articles for inclusion, and a third reviewer screened them before final inclusion.

RESULTS

Twenty-one articles containing 532 cases were included. The mean age at revision was 61 years. The mean interval between primary and revision arthroplasty was 77 months, and the average follow-up period was 65 months. Different types of prostheses were included, with 69% of the revision prostheses having linked designs and 31% having unlinked designs. The visual analog scale score, Mayo Elbow Performance Score, Oxford Elbow Score, and range of motion improved significantly after revision surgery. Complications were reported in 232 of 532 cases (44%), leading to reoperations in 22%. After revision with linked prostheses, the Mayo Elbow Performance Score, range of flexion-extension, and pronation improved significantly more than with unlinked designs.

CONCLUSION

Improved functional outcomes can be expected after revision TEA, but the complication rate remains high. Revision TEA should still be considered a salvage procedure for failed TEA. Linked designs for revision TEA result in better outcomes than unlinked designs in the midterm follow-up.

Mid-term results of alumina ceramic unlinked total elbow arthroplasty with cement fixation for patients with rheumatoid arthritis

Aims

The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA).

Patients and Methods

We retrospectively reviewed 87 elbows, in 75 patients with RA, which was replaced using a cemented JACE total elbow arthroplasty (TEA) between August 2003 and December 2012, with a follow-up of 96%. There were 72 women and three men, with a mean age of 62 years (35 to 79). The mean follow-up was nine years (2 to 14). The clinical condition of each elbow before and after surgery was assessed using the Mayo Elbow Performance Index (MEPI, 0 to 100 points). Radiographic loosening was defined as a progressive radiolucent line of >1 mm that was completely circumferential around the prosthesis.

Results

The mean MEPI scores significantly improved from 40 (10 to 75) points preoperatively to 95 (30 to 100) points at final follow-up (p < 0.0001). Complications were noted in ten elbows (ten patients; 11%). Two had an intraoperative humeral fracture which was treated by fixation and united. One had a postoperative fracture of the olecranon which united with conservative treatment and one had a radial neuropathy which resolved. Further surgery was required for one with a dislocation, three with an ulnar neuropathy and one with a postoperative humeral fracture. Revision with removal of the components was performed in one elbow due to deep infection. There was no radiographic evidence of loosening around the components.With any revision surgery or revision with implant removal as the endpoint, the rates of survival up to 14 years were 93% (95% confidence interval (CI), 83.9 to 96.6) and 99% (95% CI 91.9 to 99.8), respectively, as determined by Kaplan-Meier analysis.

Conclusion

With the appropriate indications, the mid-term clinical performance of the cemented JACE TEA is reliable and comparable to other established TEAs in the management of the elbow in patients with RA.

Cite this article: Bone Joint J 2018;100-B:1066–73.

Macroscopic investigation of failed Kudo type 5 total elbow arthroplasty

BACKGROUND

On the basis of the intra-articular findings during Kudo type 5 elbow prosthesis revision surgery, we infer the mechanisms leading to implant failure.

MATERIALS AND METHODS

We performed primary Kudo type 5 total elbow arthroplasty on 60 rheumatoid elbows in 45 patients between 1994 and 2003. Revision surgery was performed in 8 patients (9 elbows) because of implant failure. We radiographically assessed their status before this surgical procedure and then assessed the surgical intra-articular findings based on surgery records and photographs.

RESULTS

In all cases, revision surgery was necessitated by failure of the ulnar component. There were 2 types of implant failure: fracture of the ulnar component neck (n = 3) and loosening of the ulnar component (n = 6). In the latter group, 2 elbows exhibited valgus deformity of the retrieved ulnar component. There were no cases of metallosis or wear of the articular surface.

CONCLUSION

This study describes the types of implant failure in unlinked Kudo type 5 total elbow arthroplasties with all-polyethylene ulnar components based on the intra-articular findings. Failure of the all-polyethylene ulnar component could have been caused by ulnar neck distortion that occurred prior to polyethylene wear on the joint surface. In addition, valgus stress on the elbow joint may have contributed to these implant failures.

The History and Future of Unlinked Total Elbow Arthroplasty

Unlinked total elbow arthroplasty (TEA), which has no mechanical connection between the humeral and ulnar components, has theoretical advantages based on its near-normal elbow kinematics and the preservation of bone stock. Unlinked TEA is appropriate only for patients who have limited bone loss or limited deformity and good ligamentous function. This is because postoperative instability has been a major complication of unlinked prostheses. The concept and goal of unlinked TEA is to share the loading stress on the bone implant interface with the surrounding tissues. Although the loosening rate of unlinked prostheses theoretically should be lower than that of linked prostheses (which have a mechanical connection between the humeral and ulnar components), there is no clear evidence that unlinked TEAs are superior to linked TEAs in this respect. However, we believe that primary TEA should be performed using an unlinked TEA, especially for younger patients, because revision surgery for unlinked TEA results in longer prosthesis survival than revision surgery for linked TEA. Improvement of the design of unlinked prostheses and the introduction of less invasive surgical techniques are required to reduce postoperative instability.

Linked semiconstrained and unlinked total elbow replacement in juvenile idiopathic arthritis: a case comparison series with mean 11.7-year follow-up

BACKGROUND

Few series report the results of total elbow replacement (TER) in patients with juvenile idiopathic arthritis (JIA). Most report the use of a linked implant. There are theoretical benefits to using an unlinked prosthesis, and thus we report our experience of the clinical benefit and survivorship of both this implant and a linked semiconstrained prosthesis.

METHODS

There were 21 elbows replaced in 14 JIA patients (12 women and 2 men; 14 unlinked, 7 linked). Mean age at surgery was 39.5 years (range, 26-52 years). Mean clinical follow-up was 11.7 years (range, 5.4-17.6 years).

RESULTS

Reoperation, including implant revision, was required in 9 elbows (42.9%). Using revision as an end point, survivorship was 95% (95% confidence interval [CI], 74%-99%) at 5 years and 68% (95% CI, 45%-86%) at 10 years. The 10-year survival was 70% (95% CI, 40%-89%) for the unlinked group and 69% (95% CI, 28%-94%) for the linked group. The need for bilateral TER was found to be a risk factor for revision within 10 years of primary surgery (6/11 vs. 0/7 elbows; P = .037). The rate of aseptic loosening seen on radiographs was high in the unlinked group (12/14, 85.7%), but many of these patients continue to function well without need for revision.

CONCLUSION

Both the unlinked Kudo 5 and linked Coonrad-Morrey prostheses for TER can provide benefits in the long-term for most patients with JIA. The need for bilateral TER in this group is associated with higher rate of revision at 10 years.

The anconeus-triceps lateral flap approach for total elbow arthroplasty in rheumatoid arthritis

BACKGROUND

The posterior approaches to the elbow are considered as to allow an excellent joint exposure for total elbow arthroplasty. One complication that is well recognized is the insufficiency of the extensor mechanism in particular with the patients with poor tendon quality as in the rheumatoid diseases. The purpose of this paper is to present a new triceps-splitting exposure for total elbow arthroplasty used in rheumatoid patients with their preliminary results.

METHODS

Fifteen consecutive patients with rheumatoid disease at grades III to V of the Larsen grading scale underwent total elbow replacement using the new triceps-splitting exposure called anconeus-triceps lateral flap and it preserves the integrity of the medial proper triceps tendon. The assessments were performed with a minimum follow-up of 2 years.

RESULTS

The mean Mayo Elbow Performance Score increased from 24 points to 95 points at a mean follow-up of 38 months. The pain was calculated using the visual analogue score, it had a mean pre-operative value of 8.9 points and it became 0.5 points. Although elbow motion in flexion-extension and pronosupination was allowed from the day after surgery, we did not observe any insufficiency or secondary detachments of the triceps tendon reporting grade 4 to 5 according to the Medical Research Council scale.

CONCLUSIONS

These preliminary outcomes suggest that the decision to preserve the medial proper triceps tendon insertion allows to start an earlier active unrestricted rehabilitation programme. This new triceps management improves the surgical exposure of the olecranon surface.

LEVEL OF EVIDENCE

Level IV.

Recognizing the elbow prosthesis on conventional radiographs

The objective of this study was to make an overview that can be useful in determining which type and brand of prosthesis a patient has when visiting the emergency department or outpatient clinic with a periprosthetic fracture, dislocation, or implant failure. The commonly used prostheses in Europe are opted for this list. The radiographs used for this list are obtained either from the company or from our own patients. This list contains the Coonrad/Morrey total elbow prosthesis, the Nexel total elbow prosthesis, the GSB III Elbow Prosthesis, the iBP Total Elbow System, the Discovery Elbow System, the NESimplavit Elbow System, the Latitude Elbow prosthesis, the Solar Elbow, and the Souter-Strathclyde total elbow. The characteristics of each prosthesis are described.

Kudo Total Elbow Arthroplasty in Rheumatoid Arthritis. Clinical and Radiological Results

We have analysed the results of 28 total elbow replacements in 27 patients. The replacements were made using the Kudo unconstrained, unlinked, total elbow prosthesis. The elbows were all affected by rheumatoid arthritis. The follow-up time was from 3 to 7 years, with a mean follow-up of 58 months. Our results with this prosthesis in rheumatoid arthritis appear promising and only few complications were noticed. In one case, a radiological loosening of the ulnar component was observed at the 5-year visit but without any clinical symptoms and no operations were needed. In two other cases, an open reduction was performed within the first 3 months to correct a subluxation. A triceps tendon was re-inserted for a fourth patient 55 months postoperatively. In general, the range of motion became statistically significantly better with the prosthesis and there was also a high rate of relief of pain in patients in whom the elbow was severely affected by rheumatoid arthritis.

Short-term clinical results of revision elbow arthroplasty using the Latitude total elbow arthroplasty

Aims

Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA.

Patients and Methods

Between 2006 and 2010 we used the Latitude TEA for revision in 18 consecutive elbows (17 patients); mean age 53 years (28 to 80); 14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde TEA in three. Stability, range of movement (ROM), visual analogue score (VAS) for pain and functional scores, Elbow Functional Assessment Scale (EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM) and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed pre-operatively and at each post-operative follow-up visit (six, 12 months and biennially thereafter). Radiographs were analysed for loosening, fractures and dislocation. The mean follow-up was 59 months (26 to 89).

Results

The ROM of the elbow did not improve significantly. The mean EFAS and MAESS scores improved significantly six months post-operatively (18.6 points, standard deviation (sd) 7.7; p = 0.03 and 28.8 points, sd 8.6; p = 0.006, respectively) and continued to improve slightly or reached a plateau. The mean pain scores at rest (Z = -3.2, p = 0.001) and during activity (Z = -3.2, p = 0.001), and stability (Z = -3.0, p = 0.003) improved significantly six months post-operatively. Thereafter scores continued to improve slightly or a plateau was reached. There were no signs of loosening.

Conclusion

Revision surgery using the Latitude TEA results in improvement of functionality, reduced pain and better stability of the elbow. Improvement of ROM of the elbow should not be expected. Cite this article: Bone Joint J 2016;98-B:1086–92.

The effect of using a cement gun with a narrow nozzle on cement penetration for total elbow arthroplasty: a cadaveric study

PURPOSE

To compare the cement mantle characteristics associated with use of a narrow nozzle cement gun versus the use of a 60-mL catheter tip syringe.

METHODS

Twelve cadaveric distal humeri were cemented with either a cement gun or a syringe without canal occlusion. The humeri were sectioned and photographed. The corticocancellous junction and the outer margin of the cement mantle were analyzed digitally. The corticocancellous junction defined the available area for cement penetration. The outline of the cement mantle defined the actual area of penetration. The ratio of penetration to the available area was recorded for each slice. The mean ratio for each humerus was multiplied by the number of slices in that sample containing cement to calculate a cement index.

RESULTS

The cement penetration ratios observed in cross-sections at the same level and the cement index were significantly greater with the use of the cement gun than with the use of the syringe. There was no difference in the number of slices that contained cement.

CONCLUSIONS

The use of a cement gun with a narrow nozzle improved cement mantle characteristics compared with the use of a syringe when measured in a cadaveric model in the absence of canal occlusion.

CLINICAL RELEVANCE

Improving cement mantle characteristics may decrease the incidence of aseptic loosening after total elbow arythroplasty.

What design and material factors impact the wear and corrosion performance in total elbow arthroplasties?

The survivorship of total elbow arthroplasties is lower than surgeons and patients would like it to be, especially in patients with posttraumatic arthritis of the elbow. To improve durability, it is important to understand the failure modes of existing implants. Total elbow arthroplasties were designed primarily for low-demand rheumatoid patients. As surgical indications have extended to more active patient populations, the mechanical performance of current designs must meet an increased mechanical burden. Evaluating the degree to which they do this will guide conclusions about which contemporary devices might still meet the need and, as importantly, what design and material changes might be needed to improve performance. WHERE ARE WE NOW?: The reasons for failures of total elbow arthroplasties include infection, loosening, polyethylene wear, locking mechanism failure, periprosthetic fracture, implant fracture, and instability. Implant design factors that have influenced wear include implant constraint, material, coatings, and metal backing. Surgical factors associated with increased wear and subsequent total elbow arthroplasty failure include soft tissue balancing and restoration of alignment and implant positioning. WHERE DO WE NEED TO GO?: A clear need exists for improving the performance of total elbow arthroplasty. Many of the failures that have limited the survivorship of elbow arthroplasties thus far are mechanical in nature with wear-related problems a dominating influence. Much of what we know about the results of total elbow arthroplasty is from small studies frequently involving the designer of the implant. The establishment of total elbow arthroplasty registries coupled with the increasing regulatory burden of postmarket surveillance would lead to a better understanding of the complications and survivorship of elbow arthroplasties. Another primary goal must be to achieve a better understanding of the biomechanics of the normal elbow and how the mechanics are altered after the insertion of elbow arthroplasty components. HOW DO WE GET THERE?: Improving the performance and survivorship of total elbow arthroplasty will require the integration of clinical and implant performance data gained through the establishment of registries with a concerted basic science effort to better understand the functional loads across the joint and to incorporate these loads into experimental and computational models to allow assessment of design and material changes intended to improve durability.

A 5-22-year follow-up study of stemmed alumina ceramic total elbow arthroplasties with cement fixation for patients with rheumatoid arthritis

BACKGROUND

We determined mid to long-term results of total elbow arthroplasty (TEA) by use of unlinked elbow prostheses with solid alumina ceramic trochleae, and ceramic ulnar stems (stemmed Kyocera type I; SKC-I) for patients with rheumatoid arthritis.

PATIENTS AND METHODS

Fifty-four elbows of 39 patients were available for detailed clinical and radiographic review after a follow-up period of at least 5 years. The mean follow-up period was 12.6 years (range 5-22 years). Clinical condition before and after surgery was assessed by use of a modified version of the Mayo Elbow Performance Score (MEPS; 0-100 points) and a Japan Orthopaedic Association Elbow score (JOA score; 0-100 points). The radiographs were reviewed and loosening was defined as a progressive radiolucent line >1 mm wide that was completely circumferential around the prosthesis. Clinical records of post-operative events affecting the elbows were used for survival analysis of the prostheses using the Kaplan-Meier method.

RESULTS

The average modified MEPS and JOA scores improved significantly from 39.7 ± 14.3 to 44.7 ± 9.4, respectively, pre-operatively, to 89.7 ± 15.4 and 83.1 ± 12.8, respectively, post-operatively (P < 0.0001). The functional assessment score also improved from 4.9 ± 2.8 to 8.5 ± 3.3 points (P < 0.0001). With loosening or implant revision defined as end points, the likelihood of survival of the prosthesis for up to 20 years was 92.6% (95% confidence interval (CI), 85.6-100.0) or 86.3 % (95 % CI 75.0-97.6), respectively.

CONCLUSION

Satisfactory clinical results were obtained after TEA using SKC-I prostheses, which provided excellent pain relief and functional range of motion. The results of our study reveal the high reliability over a long period of the cemented SKC-I prosthesis with an alumina ceramic component.

Long-term outcome of elbow resurfacing

BACKGROUND

The purpose of this study is to review the long term results the Kudo and instrumented Bone Preserving elbow prostheses. The instrumented Bone Preserving prosthesis is the successor of the Kudo prosthesis, and both of these are nonconstrained elbow resurfacing prostheses.

METHODS

Fifty-five nonconstrained elbow prosthesis were implanted in 51 patients. Patients were evaluated with the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm Shoulder and Hand score. Revision or the necessity of revision was regarded as failure of the prosthesis.

RESULTS

Twenty-one prostheses (of which 3 instrumented Bone Preserving prostheses) were revised or needed revision, yielding a revision rate of 15.1% after 5 years and 36.5% after 10. The major reasons for revision were loosening in 10 cases and instability in 5. Eleven of the nonrevised patients died of unrelated causes, having little or no subjective problems until the time of death. There was no statistical difference between Kudo and instrument Bone Preserving implant survival. Most nonrevised patients were satisfied, according to the Visual Analog Scale for satisfaction. The median MEPS indicated fair to good results.

CONCLUSION

When comparing our results to those of other elbow prosthesis we must conclude that our revision rate is high, however, the outcome of the nonrevised patients is good. This study shows that the results of the Kudo prosthesis, which have been reported twice before by our department, have clearly deteriorated after an average follow-up of 174 months (the last study had an average follow-up of 58 months).

[Elbow replacement]

Elbow replacement or arthroplasty is a good therapeutic option for a large percentage of patients with significant joint destruction. However, many orthopaedic surgeons are no familiar with the surgical approaches or techniques associated with elbow replacement implants. Furthermore, the incidence of complications is higher than in other joint replacements, the most important being infections, mechanical failure, cubital neuropathy, and problems with the triceps. For these reasons, the use of bone arthroplasty in Spain may be less than ideal. Although, inflammatory arthritic diseases, such as rheumatoid arthritis, are the most frequent indication for this operation, distal humerus fractures and post-traumatic disease are a growing indication. This work attempts to summarise the most important current concepts associated with elbow replacement.

Current concepts of elbow-joint disorders and their treatment

BACKGROUND

Recently, many studies have emphasized the importance of the comprehension of detailed functional anatomy and biomechanics of the elbow and its significant contribution in facilitating good functional outcomes of conservative and surgical treatment in the field of elbow disorders.

METHODS

The most common disease of elbow disorders and their treatment was reviewed.

RESULTS

Lateral epicondylitis of the elbow, is defined as a microscopic tear of extensor carpi radialis brevis tendon, and microscopic findings show immature reparative tissue (angiofibroblastic hyperplasia). The patient needs coordinated rehabilitation, range-of motion-exercise, stretching, and bracing in the second phase. Ninety-five percent of patients with lateral epicondylitis heal spontaneously or conservatively. The medial collateral ligament injury of the elbow is most common in the overhead-throwing athlete. Jobe's procedure, the original reconstruction technique, and its modifications in bone-tunnel creation, allow a tendon graft to be wound in a figure-eight configuration through the tunnels. Further modification of Jobe's procedure in bone-tunnel configuration reduced the total number of tunnels and facilitates easier graft tensioning. Outcomes with these reconstruction techniques have proven effective in returning high-level throwing athletes back to their sport. Arthroscopic surgery for the elbow in the throwing athlete has evolved and has proven successful results. Arthroscopic treatment includes debridement of posteromedial synovitis, loose-body removal, and excision of the olecranon spur. Posteromedial elbow impingement is also a source of disability in the overhead-throwing athlete. Twenty-five percent of these patients require a medial collateral ligament reconstruction after removal of a posteromedial bony spur. Linked and unlinked total elbow arthroplasty are successful treatment procedures for patients with rheumatoid arthritis, posttraumatic osteoarthritis, and elderly patients with comminuted distal humeral fractures and the salvage of distal humeral nonunion. Proper selection and implantation of prostheses are also important to achieve good functional outcome and longevity.

CONCLUSION

The success of treatment of elbow disorders depends greatly on surgical design and technique, both of which require comprehensive knowledge of detailed anatomy and biomechanics of the elbow.

Unlinked and convertible total elbow arthroplasty

Total elbow arthroplasty (TEA) is still in its infancy if we compare it with other arthroplasties such as knee or hip. TEA designs have been evolving with experience; however, long-term outcome data remain limited. The designs of total elbow prostheses can be subdivided into 3 general categories: unlinked, linked, and convertible devices. This article focuses on unlinked and convertible prostheses.

Total elbow arthroplasty

Total elbow arthroplasty has continued to evolve over time. Elbow implants may be linked or unlinked. Unlinked implants are attractive for patients with relatively well preserved bone stock and ligaments, but many favor linked implants, since they prevent instability and allow replacement for a wider spectrum of indications. Inflammatory arthropathies such as rheumatoid arthritis represent the classic indication for elbow arthroplasty. Indications have been expanded to include posttraumatic osteoarthritis, acute distal humerus fractures, distal humerus nonunions and reconstruction after tumor resection. Elbow arthroplasty is very successful in terms of pain relief, motion and function. However, its complication rate remains higher than arthroplasty of other joints. The overall success rate is best for patients with inflammatory arthritis and elderly patients with acute distal humerus fractures, worse for patients with posttraumatic osteoarthritis. The most common complications of elbow arthroplasty include infection, loosening, wear, triceps weakness and ulnar neuropathy. When revision surgery becomes necessary, bone augmentation techniques provide a reasonable outcome.

The Kudo 5 total elbow replacement in the treatment of the rheumatoid elbow

Between September 1993 and September 1996, we performed 34 Kudo 5 total elbow replacements in 31 rheumatoid patients. All 22 surviving patients were reviewed at a mean of 11.9 years (10 to 14). Their mean age was 56 years (37 to 78) at the time of operation. All had Larsen grade IV or V rheumatoid changes on X-ray. Nine (three bilateral replacements and six unilateral) had died from unrelated causes. One who had died before ten years underwent revision for dislocation.

Of the 22 total elbow replacements reviewed six had required revision, four for aseptic loosening (one humeral and three ulnar) and two for infection. Post-operatively, one patient had neuropraxia of the ulnar nerve and one of the radial nerve. Two patients had valgus tilting of the ulnar component.

With revision as the endpoint, the mean survival time for the prosthesis was 11.3 years (95% confidence interval (10 to 13) and the estimated survival of the prosthesis at 12 years according to Kaplan-Meier survival analysis was 74% (95% confidence interval 0.53 to 0.91).

Of the 16 surviving implants, ten were free from pain, four had mild pain and two moderate. The mean arc of flexion/extension of the elbow was 106° (65° to 130°) with pronation/supination of 90° (30° to 150°) with the joint at 90° of flexion. The mean Mayo elbow performance score was 82 (60 to 100) with five excellent, ten good and one fair result.

Good long-term results can be expected using the Kudo 5 total elbow replacement in patients with rheumatoid disease, with a low incidence of loosening of the components.

Instrumented Bone Preserving elbow prosthesis in rheumatoid arthritis: 2-8 year follow-up

BACKGROUND

The aim of this study was to analyze the clinical and radiological results of elbow arthroplasty using the instrumented Bone Preserving (iBP) elbow prosthesis, which is the 6(th) iteration of the Kudo prosthesis, in patients with rheumatoid arthritis.

METHODS

From December 1999 to August 2006, 20 total elbow replacements in 19 patients with rheumatoid arthritis were performed by 2 surgeons using the iBP. The humeral component is uncemented and the ulnar component cemented. There were 14 women and 5 men. The period of follow-up was 2-8 years, with a mean of 49 months. The mean age at time of operation was 62 years (range, 32-80). The Larsen grade and The Mayo Elbow Performance Score were used. Possible radiolucent lines or displacement of the components were evaluated yearly.

RESULTS

The preoperative radiographs showed that all of the involved elbows were in grade 3-5 with an average of 4.1. All patients had a poor elbow before operation. Two elbows were moderately unstable. Three complications occurred: 1 intraoperative fracture of the medial condyl, 1 postoperative dislocation, and 1 persistent sensory ulnar neuropathy. After surgery, at the last follow-up, 3 patients had fair results, 5 good, and 12 excellent. In 6 cases, radiographic loosening of the ulnar component was observed without any clinical symptoms; none around the humeral component.

CONCLUSION

The iBP elbow prosthesis in patients with rheumatoid arthritis shows good to excellent clinical results, despite radiolucency around the cemented ulnar component in some cases.

Postoperative results and complications of total elbow arthroplasty in patients with rheumatoid arthritis: three types of nonconstrained arthroplasty

Postoperative results and complications of total elbow arthroplasty (TEA) conducted for rheumatoid arthritis (RA) patients at our institute were studied. Primary TEAs were performed in 72 patients. The mean follow-up period was 3.5 years. Three types of prostheses were implanted: JACE prosthesis in 34 elbows, STABLE prosthesis in 13 elbows, and KUDO prosthesis (type 5) in 32 elbows. The outcome was evaluated by the change in the range of motion and the Japanese Orthopaedic Association functional evaluation score for the elbow joint (JOA score). The arc of motion and the JOA score at discharge and at final examination significantly improved in patients with the three types of prosthesis. The loosening rates for the JACE, STABLE and KUDO prostheses were 15, 23, and 0%, respectively, although the follow-up periods were different. The loosening rate decreased to 2.5% when the humeral component was fixed with cement. Intraoperative fractures occurred in eight (10.1%) elbows and ulnar nerve palsy in six. Deep infection developed in three (4.8%) elbows and was treated by removing the prosthesis. Although there were considerable complications, the marked improvements in pain and function favor TEA in patients with rheumatoid elbow.

Unlinked elbow arthroplasty as primary treatment for fractures of the distal humerus

This study reviews our experience with primary total elbow arthroplasty in the management of acute distal humeral fractures by use of the iBP unlinked elbow prosthesis. We followed up 9 elbows in 9 patients (including 2 with rheumatoid arthritis), with a mean age of 73 years, for a mean of 3.5 years. Functional outcome was assessed with the Mayo Elbow Performance Score and the recently developed Liverpool Elbow Score. Clinical examination and radiologic assessment were performed by an independent surgeon. All elbows were stable at the latest follow-up examination, all patients were able to perform daily activities, and pain relief was satisfactory. The median value for the Mayo Elbow Performance Score was 95 (range, 65-100). This is the first report of the use of an unlinked prosthesis for the treatment of distal humeral fractures. Our results show that this method of treatment provides a reliable and effective way of dealing with these very difficult fractures when internal fixation is not a viable option.

Luxation nach Ellenbogentotalendoprothese

BACKGROUND

Instabilities and dislocations after elbow arthroplasty, in particular in surface or unlinked prostheses, may cause functional impairments occasionally with the need for surgical revision. We provide a review of the literature about the frequency and causes of these complications and present some of our results obtained with the GSB III prosthesis.

PATIENTS AND METHODS

We examined the trigger mechanisms and frequency of joint instabilities as well as treatment strategies by studying five internationally used types of prostheses on the basis of published results. We evaluated 160 GSB III prostheses regarding the above complications and determined the causes for uncoupling.

RESULTS

Unlinked prostheses dislocate in 0-15% of cases, accounting for about 25% of the total complication rate described. All surface prosthesis models, including GSB III, were affected with variable frequency. For 160 GSB III prostheses, the dislocation rate was 7.4%. Frequent causes were errors of rotation of parts of the prostheses and displacements of the centre of rotation.

CONCLUSION

Elbow arthroplasty requires demanding surgery, which is still associated with a comparatively high rate of complications. With correct indication, adequate choice of the type of prosthesis used and sufficient experience gained in surgery techniques, it is possible to considerably lower the rate of disassembling.

Morphologic analysis of the distal humerus with special interest in elbow implant sizing and alignment

This study determined the relationship between the medullary canal axis and the flexion-extension axis of the distal humerus as they relate to implant selection and design for elbow arthroplasty. Computed tomography scans of 40 fresh-frozen cadaveric specimens were analyzed with computer-aided design software. The anterior offset and cubital angle were measured between the 2 axes, and the cross-sectional area and diameter were measured for the medullary canal at various intervals. The anterior offset of the flexion-extension axis from the medullary canal axis was proportional to the length of canal used to determine the stem axis. No correlation was established among the width of the articular surface, anterior-posterior canal curvature, and cubital angle. These findings suggest that modular implants that allow for the variability in the natural anterior bow and articular offset of the distal humerus may enhance proper restoration of the flexion-extension axis of the elbow.

Failure mechanisms in uncemented Kudo type 5 elbow prosthesis in patients with rheumatoid arthritis: 7 of 49 ulnar components revised because of loosening after 2-10 years

BACKGROUND

Both components of the Kudo type 5 elbow prosthesis can be inserted with or without the use of cement. There have been no reports on the use of this prosthesis with all components uncemented in patients with rheumatoid arthritis.

PATIENTS AND METHODS

We reviewed 49 primary uncemented Kudo type 5 elbow prostheses, inserted in 36 patients with rheumatoid arthritis, after mean 6 (2-10) years. Patients were assessed clinically both pre- and postoperatively (pain, instability, motion, ulnar neuropathy) and radiographically. Furthermore, at the time of follow-up clinical outcome was assessed using the Elbow Function Assessment Scale.

RESULTS

At review, 7 of 49 elbows had undergone revision because of symptomatic loosening of the ulnar component. In 42 unrevised elbows, clinical outcome was excellent in 29, good in 7, fair in 5, and poor in one. 31 of 42 elbows had no pain; 11 were painful at rest (VAS 1-2) and/or as a result of activity (VAS 1-8). With revision as endpoint, survival was 86% at 6 years. Intraoperative malpositioning of the ulnar component with a valgus or varus alignment of < 5 degrees was associated with worse survival.

INTERPRETATION

We found an unexpectedly high rate of loosening of the ulnar component, which was associated with intraoperative malpositioning of the prosthesis. The ulnar component of this prosthesis should not be inserted without cement in patients with rheumatoid arthritis.

Survivorship of the KUDO total elbow prosthesis--comparative study of cemented and uncemented ulnar components: 89 cases followed for an average of 6 years

BACKGROUND

The Kudo total elbow prosthesis (TEP) is a well-established implant with good mid-term results. The ulnar component can be placed with or without cement, and the humeral component is normally placed without cement.

METHODS

89 Kudo type-5 total elbow prostheses were evaluated after a mean follow-up of 6 (1.7-11) years. The indication for joint replacement was rheumatoid arthritis in all cases. 49 prostheses were placed without cement. In 40 cases, the ulnar component was cemented and the humeral component was uncemented.

RESULTS

In the uncemented group, 7 revisions had taken place. 3 of these ulnar components were shortstemmed and 4 were long-stemmed. No revisions had been performed in the hybrid group. In the uncemented group another 7 patients showed progressive radiolucencies, while 3 patients in the hybrid group showed progressive radiolucencies.

INTERPRETATION

In this group of RA patients, the survivorship of the cemented ulnar component was better than that of the uncemented ulnar component.

Midterm results of revision total elbow arthroplasty in patients with rheumatoid arthritis

We retrospectively reviewed the clinical and radiographic results of 30 revision total elbow arthroplasties in patients with rheumatoid arthritis using original surface prostheses developed in our institution. We asked whether a surface prosthesis is a suitable option for reconstructing a failed surface total elbow arthroplasty in terms of reproducing clinical performance compared with other devices such as semiconstrained prostheses. All 30 failed total elbow arthroplasties were performed with various surface prostheses and revised with Dogo Onsen Hospital surface prostheses. The mean age of the patients at the time of surgery was 64.9 years (range, 44-83 years), and the minimum followup was 3 years (mean 6.7 years; range, 3-11 years). The Mayo elbow performance index improved from 42.3 preoperatively to 76.3 at last followup. Pain, stability, and function scores improved after revision surgery, but range of motion scores were unchanged. Our data indicate a surface prosthesis is a reasonable option for reconstructing failed surface total elbow arthroplasties in patients with rheumatoid 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.

Kudo type-5 total elbow arthroplasty in mutilating rheumatoid arthritis

We studied 11 patients (14 elbows) with gross rheumatoid deformity of the elbow, treated by total arthroplasty using the Kudo type-5 unlinked prosthesis, and who were evaluated between five and 11 years after operation. Massive bone defects were augmented by autogenous bone grafts. There were no major complications such as infection, subluxation or loosening. In most elbows relief from pain and stability were achieved. The results, according to the Mayo Elbow Performance Score, were excellent in eight, good in five and fair in one. In most elbows there was minimal or no resorption of the grafted bone. There were no radiolucent lines around the stems of the cementless components. This study shows that even highly unstable rheumatoid elbows can be replaced successfully using an unlinked prosthesis, with augmentation by grafting for major defects of bone.

Comparison of two types of ulnar component in type-5 Kudo total elbow arthroplasty in patients with rheumatoid arthritis

The purpose of this study was to assess the long-term results (more than ten years) of two types of cemented ulnar component with type-5 Kudo total elbow arthroplasty in a consecutive series of 56 patients (60 elbows) with rheumatoid arthritis, and to compare the results in elbows above and below a Larsen grade IV.

There was no radiolucency around the humeral component. Patients in whom a metal-backed ulnar component and a porous-coated stem were used had better clinical results and significantly less progression of radiolucent line formation around the ulnar component. They also had a significantly better long-term survival than patients with an all-polyethylene ulnar component. The clinical results of arthroplasty using all-polyethylene ulnar components were inferior, regardless of the degree of joint destruction.

We conclude that the type-5 Kudo total elbow arthroplasty with cementless fixation of the porous-coated humeral component and cemented fixation of a metal-backed ulnar component is acceptable and well-tolerated by rheumatoid patients.

Vergleich des rheumatischen und posttraumatischen Ellenbogengelenks nach Totalprothese

BACKGROUND

Patients with elbow destruction due to rheumatoid arthritis (RA) or trauma (PT) were compared to population-based normative data and to each other after total elbow arthroplasty.

PATIENTS AND METHODS

Pain, function, and biopsychosocial health were multidimensionally assessed by the generic Short Form 36 (SF-36), the condition-specific Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and the Patient Related Elbow Evaluation form (PREE) instrument and analyzed by uni- and multivariate methods.

RESULTS

Compared to normative values, the examined 59 RA patients were significantly affected in the function scales of the SF-36 and in all DASH scales. The 20 PT patients were worse than the norm only in the DASH function. Function was lower in RA than in PT in the SF-36 scales and in the DASH (RA: 44.4, PT: 70.3, p<0.001). This difference was less distinct in the PREE.

CONCLUSION

Total elbow arthroplasty led to a pain-free outcome and normal quality of life, but failed to restore complete function. Functional deficits were larger in the RA patients and could also be measured by the SF-36, possibly due to polyarticular affection.

One-stage arthroplasty of the ipsilateral shoulder and elbow

Twenty 1-stage ipsilateral shoulder and elbow joint replacements were performed in 17 patients from 1988 to 1998 in the Nottingham Shoulder and Elbow Unit, Nottingham, England. There were 12 women and 5 men with a mean age at operation of 57 years. All 17 patients had rheumatoid arthritis. The indication for performing the 2 joint replacements in 1 stage was severe symptomatic involvement of both joints. The shoulder was replaced first, with the patient being repositioned and redraped for the elbow replacement. The follow-up averaged 5 years 2 months (range, 23 months to 13 years 8 months). All patients had significant pain relief and improvement in function, and 12 of the 15 patients reviewed would have been prepared to have the same procedure on the other side, if it became necessary (in 3, this had been done). The procedure offers major advantages because the number of anesthetics is reduced, it is more cost-effective, and it facilitates functional rehabilitation.

Revision of unstable capitellocondylar (unlinked) total elbow replacement

BACKGROUND

Instability is a recognized complication associated with unlinked total elbow implants. The best form of treatment of this problem is uncertain as very little has been written about it.

METHODS

Twelve patients underwent operative treatment of instability at the site of a capitellocondylar unlinked total elbow replacement, and the results were reviewed retrospectively. The study group included ten women and two men with an average age of fifty-eight years. Ten patients had rheumatoid arthritis. Three elbows underwent conversion to a semi-constrained hinged prosthesis. In the other nine elbows, an attempt was made to continue with an unlinked prosthesis: three had reconstruction of one or both collateral ligaments, four had component revision, and two had both ligament reconstruction and component revision.

RESULTS

After an average duration of follow-up of six years (range, two to fifteen years) only three patients had retained a functioning unlinked prosthesis. Of the remaining nine patients, three had had a conversion to a semi-constrained arthroplasty at the time of the index procedure, four had had a conversion to a semi-constrained prosthesis at the time of a salvage procedure, one had had a resection arthroplasty, and one had a painfully dislocated elbow and had declined revision. Thus, seven elbows eventually underwent conversion to a semi-constrained prosthesis; these conversion procedures were technically difficult, with perforation of the humerus occurring in six patients and perforation of the ulna occurring in four. After all procedures, the average elbow flexion was 132 degrees and the average flexion contracture was 25 degrees. According to the Mayo Elbow Performance Index, there were four excellent results, three good results, three fair results, and one poor result.

CONCLUSIONS

Revision of an unlinked total elbow prosthesis to a linked total elbow prosthesis is difficult, but it restores elbow function. Although the present series documents the unpredictability of attempts to salvage an unstable unlinked prosthesis, it seems reasonable to attempt at least one soft-tissue procedure before converting to a linked prosthesis.

Stable fixation of the ulnar component in the Kudo elbow prosthesis. A radiostereometric (RSA) study of 13 prostheses with 2-year follow-up

BACKGROUND

Concern has been expressed about the large number of radiolucent lines around the ulnar component of the Kudo elbow prosthesis in medium-term follow-up.

PATIENTS AND METHODS

We studied the metal-backed cemented ulnar component in 13 Kudo elbow prostheses (type 5) using radiostereometric analysis (RSA). All patients had rheumatoid arthritis. There were 2 men and 9 women with a mean age of 55 years. 2 were operated bilaterally. The metal-backed ulnar component was marked with three 0.8 mm tantalum spheres and the proximal ulna with 5 spheres of 0.8 or 1.0 mm diameter. The initial RSA examination was performed during the first week after the operation. Further examinations were done at 4, 12 and 24 months. Conventional radiographs were taken during the first week postoperatively, and at 12 and 24 months.

RESULTS

Translations (medial/lateral, antero/posterior and proximal/distal) were less than 0.5 mm in all but 1 patient who had a maximal translation of 3.4 mm distally. The mean rotations around all three axes were less than 0.4 degrees. The patient who had a translation of 3.4 mm also had varus angulation exceeding 4 degrees. This patient also had progressive circumferential radiolucent lines on conventional radiographs. The Mayo elbow score increased from 40 (25-65) before surgery to 92 (45-100) at 2 years.

INTERPRETATION

The fixation of the metal-backed ulnar component of the Kudo elbow prosthesis at 2 years is good.

The Kudo total elbow arthroplasty in patients with rheumatoid arthritis

A Kudo total elbow arthroplasty (TEA) was performed in 36 elbows in 35 patients with rheumatoid arthritis. Of those 35, 4 died, 6 prostheses were revised, and 2 were lost to follow-up. Twenty-four elbows with a mean follow-up of 58 months were radiologically and clinically reviewed. Sixteen were scored as excellent by use of the Mayo score and Hospital for Special Surgery 2 score. The mean increase in active motion was 25 degrees. Two humeral and four ulnar radiologic loosenings were noted. Two early dislocations were successfully treated with closed reduction and cast immobilization, two patients used an elbow brace after the closed reduction, and one patient underwent a resection arthroplasty for instability and deep wound infection. Four aseptic loosenings, of which three had an intraoperative fracture at the index operation and one had instability, were revised. Despite initially excellent results, longer follow-up of TEA in rheumatoid patients demonstrated deterioration of the outcome and increased loosening.

Proximal ulnar reconstruction with strut allograft in revision total elbow arthroplasty

BACKGROUND

The growing frequency of joint arthroplasty has led to increasing numbers of patients requiring revision surgery. In the treatment of a failed total elbow arthroplasty not associated with infection, one of the main issues is poor or absent proximal ulnar bone stock due to osteolysis. We report our experience with the use of strut allograft reconstruction of the proximal part of the ulna as an adjunct to revision total elbow arthroplasty with a noncustom implant. Our aim was to better define the indications, outcomes, and complications of this technique in a population of patients with a failed total elbow arthroplasty.

METHODS

We reviewed the cases of patients with aseptic failure of a total elbow replacement and proximal ulnar bone deficiency who were treated with allograft bone struts. The patients had had an average of 2.5 (range, one to four) prior open osseous operations addressing the elbow joint. In addition to revision of the prosthetic components, the deficient bone stock was treated with allograft strut grafts in one of four ways: (1) discrete cortical defects were contained, (2) periprosthetic fractures were splinted, (3) deficient triceps attachments were reconstructed, and (4) expanded segments were augmented with struts and filled with impaction graft. Twenty-one patients (twenty-two elbows) were followed for an average of four years (range, two to eleven years).

RESULTS

The mean Mayo Elbow Performance Score improved from 34 points preoperatively to 79 points at the time of the latest follow-up. The scores for pain, stability, and activities of daily living improved most; there was little change in motion. Complications, consisting of four soft-tissue and four osseous problems, occurred in eight patients. Three patients had incorporation of 26% to 50% of the graft; five, 51% to 75%; and fourteen, 76% to 100%.

CONCLUSIONS

Most deficiencies of proximal ulnar bone stock and fractures complicating revision total elbow surgery can be treated with allograft strut grafting. Although the complication rate is high, this technique is suitable for discrete cortical lesions, periprosthetic fractures, and an expanded proximal part of the ulna, which also requires augmentation with impaction grafting. The technique has been unreliable, however, in restoring deficient olecranon bone stock.

Total elbow arthroplasty with the Kudo prosthesis

Between 1990 and 1997 we undertook 57 Kudo type-4 total elbow replacements in 45 patients with rheumatoid arthritis. A total of 34 patients (44 elbows) were evaluated at an average of 7 (4.4-11.2) years using the Mayo Clinic Performance Index. At review 29 elbows were excellent or good and four were fair or poor. The main complications were intraoperative fractures and ulnar neuropathy. No luxations were seen. Loosening of the ulnar component and breakage of the humeral component were most frequent indications for revision. Preoperative radiographic joint destruction was not correlated with revision rate.