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Matsuo T, Iwamoto T, Kiyota Y, Suzuki T, Matsumura N, Sato K. Accuracy of Implant Placement Based on Three-Dimensional Preoperative Planning in Total Elbow Arthroplasty. J Hand Surg Asian Pac Vol 2024; 29:397-407. [PMID: 39205520 DOI: 10.1142/s2424835524500450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Background: Accurate implant placement in the optimal position is important to obtain favourable clinical outcomes and prevent complications in total joint arthroplasty. We aimed to assess the accuracy of implant placement based on three-dimensional (3D) preoperative planning for unlinked total elbow arthroplasty (TEA) and to clarify the effect of implant placement on clinical outcomes. Methods: This study included 20 patients (22 elbows, 17 with rheumatoid arthritis and 5 with osteoarthritis, with a mean follow-up period of 47 months) who underwent TEA with an unlinked-type implant after computed tomography (CT)-based 3D preoperative planning. Implant placement was planned preoperatively and several parameters were set to reflect it intraoperatively. TEA was performed based on the plan, and postoperative CT was conducted to evaluate differences in implant placement by comparing the preoperative plan and postoperative implant placement. Furthermore, we evaluated the relationship between implant placement differences and postoperative clinical outcomes, including range of motion, Visual Analogue Scale, Mayo Elbow Performance Score 1 year after surgery and complications at the last follow-up. Results: The mean absolute translation was within 2 mm, the mean absolute tilt was within 4°, the mean absolute rotation of the humeral component was within 4° and the mean absolute rotation of the ulnar component was 10.2° ± 6.8°. In the ulnar components, 15/22 (68%) cases were externally rotated, and the mean external rotation was 7.1° ± 10.2°. We defined the absolute ulnar component's rotational difference of more than 10° as a 'malrotation' group (n = 8) and 10° or less as a 'control' group (n = 14). We compared the clinical outcomes between both groups, however, no significant differences were observed in clinical outcomes and complications. Conclusions: We observed notable malrotation in the postoperative positioning of the ulnar component. Intraoperative support devices may be necessary to accurately reproduce the preoperative plan in the surgical field. Level of Evidence: Level IV (Therapeutic).
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MESH Headings
- Humans
- Female
- Male
- Middle Aged
- Aged
- Imaging, Three-Dimensional/methods
- Arthroplasty, Replacement, Elbow/methods
- Arthroplasty, Replacement, Elbow/instrumentation
- Tomography, X-Ray Computed
- Osteoarthritis/surgery
- Osteoarthritis/diagnostic imaging
- Range of Motion, Articular
- Arthritis, Rheumatoid/surgery
- Arthritis, Rheumatoid/diagnostic imaging
- Preoperative Care/methods
- Adult
- Elbow Joint/surgery
- Elbow Joint/diagnostic imaging
- Treatment Outcome
- Retrospective Studies
- Aged, 80 and over
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Affiliation(s)
- Tomoki Matsuo
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takuji Iwamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kiyota
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taku Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
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Hamoodi Z, Sayers A, Whitehouse MR, Rangan A, Kearsley-Fleet L, Sergeant JC, Watts AC. Total elbow replacement in England: a protocol for analysis of National Joint Registry and Hospital Episode Statistics data. J Orthop Surg Res 2024; 19:526. [PMID: 39215301 PMCID: PMC11363632 DOI: 10.1186/s13018-024-04903-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 07/09/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Primary total elbow replacement (TER) services in England are being restructured with the goal of centralising care to specialised centres. It is important to monitor the impact of this service redesign. This protocol outlines an intended analysis to provide detailed descriptions of the patients who are receiving primary TER, where and by whom TER is being performed, and what the current surgical practices for TER are in England before the reconfiguration. METHODS This analysis will use the National Joint Registry (NJR) elbow dataset and link it with NHS England Hospital Episode Statistics-Admitted Patient Care (HES-APC). It will include eligible patients from the start of the NJR elbow dataset in April 2012 to December 2022. The main objective is to determine the incidence of TER in England. Age-sex standardised rates will be calculated for groups including different ethnicities, and socioeconomic backgrounds, using the mid-year population data provided by the Office for National Statistics. This planned analysis will summarise patient characteristics such as age, sex, body mass index (BMI), hand dominance, American Society of Anaesthesiologists (ASA) grade, indication for TER, socioeconomic status, and patient co-morbidities. It will also examine implant fixation type, classification, brand/type, and changes over time in implant types used in England. Additionally, it will explore the characteristics and volume of the surgeons and hospitals providing primary TER services, including the grade of the primary surgeons, funding source for surgery, and admission type. The analysis will cover the number of procedures performed by surgeons and hospitals annually in England and in each region of England. Finally, the planned analysis will summarise the elective wait time, postoperative length of stay, and any serious adverse events or re-admissions within 30 and 90 days after the TER. DISCUSSION This protocol describes the first deep dive analysis into the NJR elbow dataset to describe the incidence of TER surgery in England and the characteristics of patients who are receiving it. This analysis will summarise current primary TER practices in England before service reconfigurations. The impact of reconfiguration can be monitored by comparing future practice to the outcomes from this study. Trial registration ClinicalTrials.gov, NCT06355011. Registered 02 April 2024, https://clinicaltrials.gov/ct2/show/NCT06355011 .
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Affiliation(s)
- Zaid Hamoodi
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, UK.
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK.
| | - Adrian Sayers
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Amar Rangan
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Health Sciences and Hull York Medical School, University of York, York, UK
| | - Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, UK
| | - Jamie C Sergeant
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, UK
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
- Health Research Institute, Edge Hill University, Ormskirk, UK
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Tharakan S, Klein B, Bartlett L, Atlas A, Parada SA, Cohn RM. Do ChatGPT and Google differ in answers to commonly asked patient questions regarding total shoulder and total elbow arthroplasty? J Shoulder Elbow Surg 2024; 33:e429-e437. [PMID: 38182023 DOI: 10.1016/j.jse.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Artificial intelligence (AI) and large language models (LLMs) offer a new potential resource for patient education. The answers by Chat Generative Pre-Trained Transformer (ChatGPT), a LLM AI text bot, to frequently asked questions (FAQs) were compared to answers provided by a contemporary Google search to determine the reliability of information provided by these sources for patient education in upper extremity arthroplasty. METHODS "Total shoulder arthroplasty" (TSA) and "total elbow arthroplasty" (TEA) were entered into Google Search and ChatGPT 3.0 to determine the ten most FAQs. On Google, the FAQs were obtained through the "people also ask" section, while ChatGPT was asked to provide the ten most FAQs. Each question, answer, and reference(s) cited were recorded. A modified version of the Rothwell system was used to categorize questions into 10 subtopics: special activities, timeline of recovery, restrictions, technical details, cost, indications/management, risks and complications, pain, longevity, and evaluation of surgery. Each reference was categorized into the following groups: commercial, academic, medical practice, single surgeon personal, or social media. Questions for TSA and TEA were combined for analysis and compared between Google and ChatGPT with a 2 sample Z-test for proportions. RESULTS Overall, most questions were related to procedural indications or management (17.5%). There were no significant differences between Google and ChatGPT between question categories. The majority of references were from academic websites (65%). ChatGPT produced a greater number of academic references compared to Google (80% vs. 50%; P = .047), while Google more commonly provided medical practice references (25% vs. 0%; P = .017). CONCLUSION In conjunction with patient-physician discussions, AI LLMs may provide a reliable resource for patients. By providing information based on academic references, these tools have the potential to improve health literacy and improved shared decision making for patients searching for information about TSA and TEA. CLINICAL SIGNIFICANCE With the rising prevalence of AI programs, it is essential to understand how these applications affect patient education in medicine.
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Affiliation(s)
- Shebin Tharakan
- New York Institute of Technology - College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Brandon Klein
- Department of Orthopaedic Surgery, Northwell Health, Donald and Barbara Zucker School of Medicine, Huntington, NY, USA.
| | - Lucas Bartlett
- Department of Orthopaedic Surgery, Northwell Health, Donald and Barbara Zucker School of Medicine, Huntington, NY, USA
| | - Aaron Atlas
- Department of Orthopaedic Surgery, Northwell Health, Donald and Barbara Zucker School of Medicine, Huntington, NY, USA
| | - Stephen A Parada
- Department of Orthopaedic Surgery, Augusta University Health, Augusta, GA, USA
| | - Randy M Cohn
- Department of Orthopaedic Surgery, Northwell Health, Donald and Barbara Zucker School of Medicine, Huntington, NY, USA
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Ahmed AS, Clifton T, Subbiah K, Spasojevic M, Young A, Cass B, Marmen A, Yu R, Burton C, Smith MM, Hughes J. Midterm follow-up of the Nexel total elbow arthroplasty. J Shoulder Elbow Surg 2024; 33:1699-1708. [PMID: 38522777 DOI: 10.1016/j.jse.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/27/2024] [Accepted: 02/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at midterm follow-up. METHODS Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3-year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via the Wrightington method by 3 independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Patient-Rated Elbow Evaluation (PREE), and EuroQoL-5 Dimensions (EQ-5D). RESULTS Thirty-eight consecutive patients (22 female, 16 male) with a mean age of 67 years underwent TEA via a triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were as follows: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), and 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with 1 patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across 3 observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QuickDASH, PREE, and EQ-5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs. CONCLUSION At midterm follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preoperative to final postoperative follow-up. Although promising, these results should be interpreted with some caution as long-term data regarding this prosthesis are still lacking.
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Affiliation(s)
- Adil Shahzad Ahmed
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Thomas Clifton
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | | | - Milos Spasojevic
- Rockhampton Department of Orthopaedic Surgery, University of Queensland, Queensland, QLD, Australia
| | - Allan Young
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | - Benjamin Cass
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | | | - Raymond Yu
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | - Codey Burton
- Department of Orthopaedic Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | | | - Jeffery Hughes
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
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Krane F, Heck VJ, Leyendecker J, Klug K, Klug A, Hackl M, Kircher J, Müller LP, Leschinger T. The Future of Total Elbow Arthroplasty: A Statistical Forecast Model for Germany. Healthcare (Basel) 2024; 12:1322. [PMID: 38998857 PMCID: PMC11241371 DOI: 10.3390/healthcare12131322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/25/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
This study provides a statistical forecast for the development of total elbow arthroplasties (TEAs) in Germany until 2045. The authors used an autoregressive integrated moving average (ARIMA), Error-Trend-Seasonality (ETS), and Poisson model to forecast trends in total elbow arthroplasty based on demographic information and official procedure statistics. They predict a significant increase in total elbow joint replacements, with a higher prevalence among women than men. Comprehensive national data provided by the Federal Statistical Office of Germany (Statistisches Bundesamt) were used to quantify TEA's total number and incidence rates. Poisson regression, exponential smoothing with Error-Trend-Seasonality, and autoregressive integrated moving average models (ARIMA) were used to predict developments in the total number of surgeries until 2045. Overall, the number of TEAs is projected to increase continuously from 2021 to 2045. This will result in a total number of 982 (TEAs) in 2045 of mostly elderly patients above 80 years. Notably, female patients will receive TEAs 7.5 times more often than men. This is likely influenced by demographic and societal factors such as an ageing population, changes in healthcare access and utilization, and advancements in medical technology. Our projection emphasises the necessity for continuous improvements in surgical training, implant development, and rehabilitation protocols.
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Affiliation(s)
- Felix Krane
- University Hospital Cologne, Department of Orthopedics, Trauma and Plastic Surgery, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Vincent Johann Heck
- University Hospital Cologne, Department of Orthopedics, Trauma and Plastic Surgery, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jannik Leyendecker
- University Hospital Cologne, Department of Orthopedics, Trauma and Plastic Surgery, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Kristina Klug
- Department of Psychology, Goethe-University Frankfurt, Theodor-W.-Adorno Platz 6, PEG, 60629 Frankfurt am Main, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389 Frankfurt am Main, Germany
| | - Michael Hackl
- University Hospital Cologne, Department of Orthopedics, Trauma and Plastic Surgery, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jörn Kircher
- Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Admiralitätstrasse 3-4, 20459 Hamburg, Germany
- Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40255 Düsseldorf, Germany
| | - Lars Peter Müller
- University Hospital Cologne, Department of Orthopedics, Trauma and Plastic Surgery, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Tim Leschinger
- University Hospital Cologne, Department of Orthopedics, Trauma and Plastic Surgery, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Sandoval LA, Reiter CR, Wyatt PB, Satalich JR, Ernst BS, O’Neill CN, Vanderbeck JL. Total Elbow Arthroplasty Versus Open Reduction and Internal Fixation for Distal Humerus Fractures: A Propensity Score Matched Analysis of 30-Day Postoperative Complications. Geriatr Orthop Surg Rehabil 2024; 15:21514593241260097. [PMID: 38855405 PMCID: PMC11159534 DOI: 10.1177/21514593241260097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/25/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024] Open
Abstract
Introduction Open reduction and internal fixation (ORIF) is an established surgical procedure for distal humeral fractures; however, total elbow arthroplasty (TEA) has become an increasingly popular alternative for elderly patients with these injuries. Using a large sample of recent patient data, this study compares the rates of short-term complications between ORIF and TEA and evaluates complication risk factors. Methods Patients who underwent primary TEA or ORIF from 2012 to 2021 were identified by Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared. Results A total of 1539 patients were identified, with 1365 (88.7%) and 174 (11.3%) undergoing ORIF and TEA, respectively. Patients undergoing TEA were older on average (ORIF: 56.2 ± 19.8 years, TEA: 74.3 ± 11.0 years, P < .001). 348 patients were included in the matched analysis, with 174 patients in each group. TEA was associated with an increased risk for postoperative transfusion (OR = 6.808, 95% CI = 1.355 - 34.199, P = .020). There were no significant differences in any adverse event (AAE) between procedures (P = .259). A multivariate analysis indicated age was the only independent risk factor for the development of AAE across both groups (OR = 1.068, 95% CI = 1.011 - 1.128, P = .018). Conclusion The risk of short-term complications within 30-days of ORIF or TEA procedures are similar when patient characteristics are controlled. TEA, however, was found to increase the risk of postoperative transfusions. Risks associated with increasing patient age should be considered prior to either procedure. These findings suggest that long-term functional outcomes can be prioritized in the management of distal humerus fractures.
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Affiliation(s)
- Luke A. Sandoval
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Charles R. Reiter
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Phillip B. Wyatt
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - James R. Satalich
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Brady S. Ernst
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Conor N. O’Neill
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L. Vanderbeck
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
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Schiffman CJ, Baker W, Kwak D, Ramsey ML, Namdari S, Austin LS. High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience. J Shoulder Elbow Surg 2024; 33:S122-S129. [PMID: 38417731 DOI: 10.1016/j.jse.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 12/19/2023] [Accepted: 01/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. METHODS We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined. RESULTS Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179). CONCLUSION Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.
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Affiliation(s)
- Corey J Schiffman
- Department of Orthopaedic Surgery, The University of Washington, Seattle, WA, USA.
| | - William Baker
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Daniel Kwak
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Matthew L Ramsey
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Luke S Austin
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Hamoodi Z, Gehringer CK, Bull LM, Hughes T, Kearsley-Fleet L, Sergeant JC, Watts AC. Prognostic factors associated with failure of total elbow arthroplasty. Bone Joint Res 2024; 13:201-213. [PMID: 38688503 PMCID: PMC11060869 DOI: 10.1302/2046-3758.135.bjr-2023-0281.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Aims The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA). Methods Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used. Results A total of 19 studies met the inclusion criteria, investigating 28 possible prognostic factors. Most QUIPS domains (84%) were rated as moderate to high risk of bias. The quality of the evidence was low or very low for all prognostic factors. In low-quality evidence, prognostic factors with consistent associations with failure of TEA in more than one study were: the sequelae of trauma leading to TEA, either independently or combined with acute trauma, and male sex. Several other studies investigating sex reported no association. The evidence for other factors was of very low quality and mostly involved exploratory studies. Conclusion The current evidence investigating the prognostic factors associated with failure of TEA is of low or very low quality, and studies generally have a moderate to high risk of bias. Prognostic factors are subject to uncertainty, should be interpreted with caution, and are of little clinical value. Higher-quality evidence is required to determine robust prognostic factors for failure of TEA.
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Affiliation(s)
- Zaid Hamoodi
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Upper Limb Unit, Wrightington Hospital, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Celina K. Gehringer
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Tom Hughes
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
- Institute of Sport, Manchester Metropolitan University, Manchester, UK
| | - Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Jamie C. Sergeant
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Adam C. Watts
- Upper Limb Unit, Wrightington Hospital, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
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9
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Iwamoto T, Ikegami H, Tanji A, Kiyota Y, Suzuki T, Matsumura N, Sato K. Recent advances in unlinked total elbow arthroplasty in Japan. JSES Int 2024; 8:602-607. [PMID: 38707579 PMCID: PMC11064626 DOI: 10.1016/j.jseint.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background Total elbow arthroplasty (TEA) is a valuable therapeutic approach for improving function and relieving pain in severely deformed elbow joints. However, TEA is associated with a high incidence of complications. In Japan, the use of unlinked TEA has a long history, with the development of the Kudo prosthesis marking a significant milestone. Subsequently, various unlinked implant designs have been developed. Although favorable long-term clinical results have been reported, complications remain a concern. To further improve the outcome of unlinked TEA, attempts have been made in recent years to develop various surgical approaches and intraoperative support devices. This review focuses on the clinical outcomes and recent advances in unlinked TEA in Japan. Methods A comprehensive review of clinical results and advancements in unlinked TEA in Japan was conducted. The analysis included trends in the number of TEA, medium-term and long-term results for unlinked TEA, surgical approaches, or preoperative planning techniques. Results Several implant designs have been developed in Japan. Clinical studies have reported satisfactory long-term outcomes with these implants, but complications, such as infection, fractures, and dislocation, have been observed. In order to enhance the outcomes of unlinked TEA, various triceps-on approaches have been developed as alternatives to the triceps-detaching approach, which compromises the continuity between the triceps tendon and ulna, leading to inevitable complications related to the triceps tendon. Preservation or repair of the surrounding soft tissues is considered critical for preventing postoperative instability due to the absence of a radial head in the current unlinked TEA design. Computed tomography-based 3-dimensional preoperative planning has been pioneered in Japan, demonstrating its effectiveness in predicting implant size and achieving appropriate implant placement. Additionally, augmented reality-assisted surgery is being explored to accurately translate preoperative planning into the surgical procedure. Conclusion Unlinked TEA for inflammatory arthritis has exhibited promising long-term results in Japan, with ongoing efforts to improve surgical techniques and preoperative planning. Further advancements are anticipated to prevent complications such as dislocation and peri-implant fractures.
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Affiliation(s)
- Takuji Iwamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyasu Ikegami
- Department of Orthopedic Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Atsushi Tanji
- Department of Orthopedic Surgery, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Yasuhiro Kiyota
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taku Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
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10
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Nieboer M, Braig Z, Rosenow C, Marigi E, Tande A, Barlow J, Sanchez-Sotelo J, O'Driscoll S, Morrey M. Non-cefazolin antibiotic prophylaxis is associated with higher rates of elbow periprosthetic joint infection. J Shoulder Elbow Surg 2024; 33:940-947. [PMID: 38104721 DOI: 10.1016/j.jse.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a common source of failure following elbow arthroplasty. Perioperative prophylactic antibiotics are considered standard of care. However, there are no data regarding the comparative efficacy of various antibiotics in the prevention of PJI for elbow arthroplasty. Previous studies in shoulder, hip, and knee arthroplasty have demonstrated higher rates of PJI with administration of non-cefazolin antibiotics. The elbow has higher rates of PJI than other joints. Therefore, this study evaluated whether perioperative antibiotic choice affects rates of PJI in elbow arthroplasty. MATERIALS AND METHODS A single-institution, prospectively collected total joint registry database was queried to identify patients who underwent primary elbow arthroplasty between 2003 and 2021. Elbows with known infection prior to arthroplasty (25) and procedures with incomplete perioperative antibiotic data (7) were excluded, for a final sample size of 603 total elbow arthroplasties and 19 distal humerus hemiarthroplasties. Cefazolin was administered in 561 elbows (90%) and non-cefazolin antibiotics including vancomycin (32 elbows, 5%), clindamycin (27 elbows, 4%), and piperacillin/tazobactam (2 elbows, 0.3%) were administered in the remaining 61 elbows (10%). Univariate and multivariate analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Infection-free survivorship was estimated using the Kaplan-Meier method. RESULTS Deep infection occurred in 47 elbows (7.5%), and 16 elbows (2.5%) were diagnosed with superficial infections. Univariate analysis demonstrated that patients receiving non-cefazolin alternatives were at significantly higher risk for any infection (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.4-5.0; P < .01) and deep infection (HR 2.7, 95% CI 1.3-5.5; P < .01) compared with cefazolin administration. Multivariable analysis, controlling for several independent predictors of PJI (tobacco use, male sex, surgical indication other than osteoarthritis, and American Society of Anesthesiologists score), showed that non-cefazolin administration had a higher risk for any infection (HR 2.8, 95% CI 1.4-5.3; P < .01) and deep infection (HR 2.9, 95% CI 1.3-6.3; P < .01). Survivorship free of infection was significantly higher at all time points for the cefazolin cohort. DISCUSSION In primary elbow arthroplasty, cefazolin administration was associated with significantly lower rates of PJI compared to non-cefazolin antibiotics, even in patients with a greater number of prior surgeries, which is known to increase the risk of PJI. For patients with penicillin or cephalosporin allergies, preoperative allergy testing or a cefazolin test dose should be considered before administering non-cefazolin alternatives.
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Affiliation(s)
- Micah Nieboer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Zachary Braig
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Erick Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Aaron Tande
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Shawn O'Driscoll
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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11
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Duijn RGA, Meijering D, Vegter RJK, Albers F, Boerboom AL, Eygendaal D, van den Bekerom MPJ, Stevens M, Schelhaas R, Lamoth CJC, Murgia A. Elbow joint loads during simulated activities of daily living: implications for formulating recommendations after total elbow arthroplasty. J Shoulder Elbow Surg 2024; 33:145-155. [PMID: 37689102 DOI: 10.1016/j.jse.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Overloading of the elbow joint prosthesis following total elbow arthroplasty can lead to implant failure. Joint moments during daily activities are not well contextualized for a prosthesis's failure limits, and the effect of the current postoperative instruction on elbow joint loading is unclear. This study investigates the difference in elbow joint moments between simulated daily tasks and between flexion-extension, pronation-supination, and varus-valgus movement directions. Additionally, the effect of the current postoperative instruction on elbow joint load is examined. METHODS Nine healthy participants (age 45.8 ± 17 years, 3 males) performed 8 tasks; driving a car, opening a door, rising from a chair, lifting, sliding, combing hair, drinking, emptying cup, without and with the instruction "not lifting more than 1 kg." Upper limb kinematics and hand contact forces were measured. Elbow joint angles and net moments were analyzed using inverse dynamic analysis, where the net moments are estimated from movement data and external forces. RESULTS Peak elbow joint moments differed significantly between tasks (P < .01) and movement directions (P < .01). The most and least demanding tasks were, rising from a chair (13.4 Nm extension, 5.0 Nm supination, and 15.2 Nm valgus) and sliding (4.3 Nm flexion, 1.7 Nm supination, and 2.6 Nm varus). Net moments were significantly reduced after instruction only in the chair task (P < .01). CONCLUSION This study analyzed elbow joint moments in different directions during daily tasks. The outcomes question whether postoperative instruction can lead to decreasing elbow loads. Future research might focus on reducing elbow loads in the flexion-extension and varus-valgus directions.
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Affiliation(s)
- Roos G A Duijn
- Department of Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Daniëlle Meijering
- Department of Orthopedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Riemer J K Vegter
- Department of Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Friederike Albers
- Department of Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alexander L Boerboom
- Department of Orthopedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michel P J van den Bekerom
- Department of Orthopedic Surgery, OLVG Hospital, Amsterdam, the Netherlands; Amsterdam Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Martin Stevens
- Department of Orthopedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Reslin Schelhaas
- Department of Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Claudine J C Lamoth
- Department of Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alessio Murgia
- Department of Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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12
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Ahiarakwe U, Zachary Pearson, Ochuba A, Kim W, Pressman Z, Haft M, Srikumaran U, Best MJ. Trends in total elbow arthroplasty in patients with rheumatoid arthritis receiving disease-modifying antirheumatic drug therapy based on payer status. J Shoulder Elbow Surg 2023; 32:2132-2139. [PMID: 37348781 DOI: 10.1016/j.jse.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/01/2023] [Accepted: 05/06/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Total elbow arthroplasty (TEA) is often used to manage advanced arthropathies of the elbow caused by inflammatory conditions such as rheumatoid arthritis (RA). Recent literature has shown that use of TEA is decreasing in patients with RA, part of which can be attributed to early medical management involving disease-modifying antirheumatic drugs (DMARDs). However, there is a significant economic barrier to accessing DMARD therapy. The purpose of this study was to compare the use of TEA between patients with and without DMARD therapy from 2010 to 2020. METHODS A retrospective cohort analysis was performed using a national insurance claim database to investigate the trends of patients with RA undergoing TEA from 2010-2020. Patients who underwent TEA and had a diagnosis of RA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 and ICD-10 codes between 2010 and 2020. These patients were then stratified into 2 cohorts: those with DMARD prescription claims and those without. A linear regression, compound annual growth rate (CAGR) analysis, and χ2 analysis were conducted to compare trends and demographic variables, including insurance type, between cohorts. Additionally, a multivariable logistic regression was subsequently performed to observe odds ratios (ORs) and 95% confidence intervals. RESULTS From 2010 to 2020, there has been no significant change in the incidence of TEA in RA patients without DMARD prescriptions, whereas there has been a statistically significantly decreasing rate of TEA observed in RA patients with DMARD prescription claims. The analysis showed that there was a CAGR of -4%. For patients with a diagnosis of RA and DMARD prescription claims, the highest incidence of undergoing TEA was seen in the age group of 60-69 years, whereas patients with a diagnosis of RA and no DMARD prescription claims had the highest incidence of undergoing TEA in the age group of 70-79 years. CONCLUSION The incidence of patients undergoing TEA with a diagnosis of RA and DMARD prescription claims has shown a statistically significant decrease from 2010 to 2020, whereas no significant difference was observed for patients without DMARD prescription claims. There were no statistically significant differences in the insurance plans between cohorts.
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Affiliation(s)
- Uzoma Ahiarakwe
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA; Department of Orthopaedic Surgery, Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Zachary Pearson
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
| | - Arinze Ochuba
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
| | - William Kim
- Department of Orthopaedic Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Zachary Pressman
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
| | - Mark Haft
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Columbia, MD, USA
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13
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Walch A, Jensen AR, Nishikawa H, Morrey ME, Sanchez-Sotelo J, O'Driscoll SW. Intraoperative modification of total elbow arthroplasty implants. J Shoulder Elbow Surg 2023; 32:1494-1504. [PMID: 36918118 DOI: 10.1016/j.jse.2023.02.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Modification of total elbow arthroplasty (TEA) implants may be necessary in selected patients with substantial anatomic bone deformity or those undergoing revision surgery. The purpose of this study was to investigate the prevalence and consequences of implant modifications during TEA at our institution. We hypothesized that TEA implant modification would be more common in revisions than in primary replacements, and that it would not be associated with worse clinical outcomes or increased rates of radiographic or surgical complications directly related to the implant modification. METHODS Elbows that had undergone TEA by any of 3 surgeons at our institution with use of intraoperative implant modification between January 1992 and October 2019 were retrospectively reviewed for the type of modification and complications. Complications were classified as definitely related, probably related, possibly related, or nonrelated to the implant's modification according to the consensus review by the 3 senior surgeons. A survey was sent out to surgeons outside of our institution to investigate whether intraoperative modification to TEA implants is a common clinical practice. RESULTS A total of 106 implant components were modified during 94 of 731 TEA procedures (13%) in 84 of 560 patients. Implant modifications were performed in 60 of 285 revision cases (21%) compared with 34 of 446 (8%) primary cases (P < .0001). These included shortening the stem in 40 (44%), bending the stem in 16 (15%), notching the stem in 16 (15%), tapering the stem in 9 (9%), and a combination of 2 or more of these modifications in 19 implants (17%). Among the 55 index surgeries available for complication analysis, 40 complications occurred in 28 index surgeries (11 primary and 17 revisions; 25 patients), making the overall complication rate 51%. Of these 40 complications, 23 were considered independent of any implant modification. Of the remaining 17 complications, 9 were considered nonrelated to the implant modification, 6 were possibly related, and 2 were probably related to the implant modification. Therefore, the complication rate possibly related or probably related to implant modification was 15% (8 of 55). No complication was classified as definitely related to the implant modification. No implant breakage or malfunction occurred after any modification. A total of 442 survey responses were received representing 29 countries, of which 144 surgeons (39%) performed modification to implants during TEA procedures. DISCUSSION This study confirmed our hypothesis that modification of TEA implants is not uncommon at our institution, particularly in revision arthroplasty. Surgeons should keep in mind that complications possibly related or probably related to implant modification were at minimum 15% and could have been as high as 30% if the patients lost to follow-up had all had complications. Implant modification may be necessary in some cases but should be exercised with thoughtful consideration and caution.
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Affiliation(s)
- Arnaud Walch
- Chirurgie Orthopédique et Traumatologique du Membre Superieur, Hopital Edouard Herriot, Lyon, France
| | - Andrew R Jensen
- Department of Orthopaedic Surgery, University of California, Los Angeles, CA, USA
| | - Hiroki Nishikawa
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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14
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Stone A, Chan G, Sinclair L, Phadnis J. Elbow arthroplasty in trauma-current concepts review. J Orthop 2023; 35:126-133. [PMID: 36471696 PMCID: PMC9718957 DOI: 10.1016/j.jor.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Despite advancements in modern locking plate technology, distal humerus fractures in the elderly remain difficult to treat. A subset of fractures in this osteoporotic bone includes multiple, shallow articular fragments that renders fixation unreliable, precluding early motion and acceptable functional outcomes. Arthroplasty, in the form of either Total Elbow Arthroplasty (TEA) or Distal Humeral Hemiarthroplasty (DHH) are alternative treatment options in this cohort and are being increasingly used. Methods This article reviews the use of TEA or DHH for acute distal humerus fracture, including patient selection, pre-operative planning, surgical approach, implant positioning, rehabilitation, outcomes and complications. Results Arthroplasties are being increasingly used for acute distal humerus fractures, however they introduce potential complications not seen with fixation. Due care must be employed to correct implant positioning which is a function of implant rotation, implant length and implant sizing. We describe a robust technique for epicondyle repair in DHH and unlinked TEA to avoid instability. Outcomes of DHH and TEA for acute distal humerus fracture are encouraging, however further long-term outcome and comparative data regarding arthroplasty is required. Conclusions Short to medium term outcomes demonstrate that both DHH and TEA are valuable options for selected patients, although attention to technique is required to minimise potential complications.
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Affiliation(s)
- A. Stone
- Shoulder & Elbow Post-CCT Fellow, University Hospitals Sussex NHS Foundation Trust, UK
| | - G. Chan
- Specialty Registrar, University Hospitals Sussex NHS Foundation Trust, Honorary Clinical Lecturer, Brighton & Sussex Medical School, UK
| | - L. Sinclair
- Clinical Librarian, University Hospitals Sussex NHS Foundation Trust, UK
| | - J. Phadnis
- Consultant Trauma & Orthopaedic Surgeon, University Hospitals Sussex NHS Foundation Trust, Honorary Clinical Reader, Brighton & Sussex Medical School, UK
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Gambhir N, Alben MG, Shankar D, Larose G, Kwon YW, Virk MS. Comparison of 90-day complication rates and readmissions of primary total elbow arthroplasty in elective and traumatic cases: a single center experience. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03425-6. [PMID: 36346474 DOI: 10.1007/s00590-022-03425-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The purpose of this study is to compare the 90 day complication rates of primary Total Elbow Arthroplasty (TEA) performed for arthritis (primary-OA; rheumatoid arthritis-RA) versus those performed for distal humerus fractures (DHF). METHODS Patients who underwent a TEA from 2015 to 2021 were identified from our institutional database and placed into cohorts based on surgical indications (TEA-OA, TEA-RA and TEA-DHF). Chart review was conducted to analyze the prevalence of complications, emergency department (ED) visits, readmissions, and secondary procedures in the first 90 day post-operative period. Complications included but were not limited to wound complications, hematoma, infection (superficial or deep), nerve palsy, periprosthetic fracture/failure and others. RESULTS 49 patients who underwent TEA were included in this study: (DHF = 19, OA = 14, RA = 16). Six complications occurred within the first 90 days of surgery. There were two periprosthetic joint infections (PJI) in the OA group, requiring irrigation and debridement (I & D) within the first 90 days of surgery. There were three post-operative ulnar nerve palsies and one PJI requiring I & D in the TEA-RA group. Compared to the TEA-DHF and TEA-OA groups, the RA group had higher rates of all-cause complications (p = 0.03) and nerve palsy (p = 0.03). There were no significant differences between groups in readmissions (p = 0.27) or secondary interventions (p = 0.27). CONCLUSION The 90-day complication/readmission rates of TEA preformed for DHFs is lower than those preformed for OA and RA. These differences could be related to the underlying chronic inflammatory etiology and side effect of treatments (intraarticular steroid injection, and biologics) received by patients with arthritis. LEVEL OF EVIDENCE Retrospective Cohort Study, level IV.
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Affiliation(s)
- Neil Gambhir
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Matthew G Alben
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Dhruv Shankar
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Gabriel Larose
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Young W Kwon
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA
| | - Mandeep S Virk
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital -NYU Langone Health, 333 East 38Th Street, New York, NY, 10016, USA.
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Wickman JR, Chopra A, Goltz DE, Levin JM, Pereira G, Pidgeon T, Richard M, Ruch D, Anakwenze O, Klifto CS. Influence of medical comorbidity and surgical indication on total elbow arthroplasty cost of care. J Shoulder Elbow Surg 2022; 31:1884-1889. [PMID: 35429632 DOI: 10.1016/j.jse.2022.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/17/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Movement toward providing value-based musculoskeletal care requires understanding the cost associated with surgical care as well as the drivers of these costs. The aim of this study was to investigate the effect of common medical comorbidities and specific total elbow arthroplasty (TEA) indications on reimbursement costs throughout the 90-day TEA episode of care. The secondary aim was to identify the drivers of these costs. METHODS Administrative health claims for patients who underwent orthopedic intervention between 2010 and 2020 were queried using specific disease classification and procedural terminology codes from a commercially available national database of 53 million patients. Patients with commercial insurance were divided into various cohorts determined by different surgical indications and medical comorbidities. The reimbursement costs of the surgical encounter, 89-day postoperative period, and total 90-day period in each cohort were evaluated. The cost drivers for the 89-day postoperative period were also determined. Analyses were performed using descriptive statistics and the Kruskal-Wallis test for comparison. RESULTS A total of 378 patients who underwent TEA were identified. The mean reimbursement cost of the surgical encounter ($13,393 ± $8314) did not differ significantly based on patient factors. The mean reimbursement cost of the 89-day postoperative period ($4232 ± $2343) differed significantly when stratified by surgical indication (P < .0001) or by medical comorbidity (P < .0001). The indication of rheumatoid arthritis ($4864 ± $1136) and the comorbidity of chronic kidney disease ($5873 ± $1165) had the most expensive postoperative period. In addition, the total 90-day reimbursement cost ($16,982 ± $4132) differed significantly when stratified by surgical indication (P = .00083) or by medical comorbidity (P < .0001), with the indication of acute fracture ($18,870 ± $3971) and the comorbidity of chronic pulmonary disease ($19,194 ± $3829) showing the highest total 90-day cost. Inpatient costs related to readmissions represented 38% of the total reimbursement cost. The overall readmission rate was 5.0%, and the mean readmission cost was $16,296. CONCLUSION TEA reimbursements are significantly influenced by surgical indications and medical comorbidities during the postoperative period and the total 90-day episode of care. As the United States transitions to delivering value-based health care, the need for surgeons and policy makers to understand treatment costs associated with different patient-level factors will expand.
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Affiliation(s)
- John R Wickman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Aman Chopra
- Georgetown University School of Medicine, Washington, DC, USA
| | - Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Gregory Pereira
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Tyler Pidgeon
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Marc Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - David Ruch
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Factors Associated with 30-Day Adverse Events After Brachial Plexus Neurolysis. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:332-336. [DOI: 10.1016/j.jhsg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
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Unexpected High Early Failure Rate of the Nexel Total Elbow Arthroplasty. JSES Int 2022; 6:690-695. [PMID: 35813147 PMCID: PMC9264017 DOI: 10.1016/j.jseint.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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19
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Farías-Cisneros E, Martínez-Peniche JL, Olguín-Delgado LC, Castillo-Vázquez FG, Romo-Rodríguez R, Torres-Gómez A. Total Elbow Arthroplasty and Antegrade Posterior Interosseous Flap for Infected Posttraumatic Arthritis with an Active Fistula. A Rationale for Comprehensive Treatment. Case Report. J Shoulder Elb Arthroplast 2022; 6:24715492221090745. [PMID: 35669624 PMCID: PMC9163731 DOI: 10.1177/24715492221090745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/16/2022] [Accepted: 03/12/2022] [Indexed: 11/17/2022] Open
Abstract
The indication for total elbow arthroplasty (TEA) for primary and posttraumatic elbow arthritis has increased, however, its indication after infection remains elusive. Wound closure about the elbow increases the challenge of treating a previously infected elbow, often necessitating soft tissue coverage with local or regional flaps. We present a 75-year-old male patient with an elbow infection following a failed complex intraarticular fracture open reduction and internal fixation of the distal humerus. Initially, he presented with severe functional impairment and pain, also with an active fistula with serous exudate, whose culture was positive for Cutinebacterium acnes. Septic hardware loosening, and septic nonunion with intraarticular involvement of the left elbow was diagnosed. The patient underwent hardware removal, fistulectomy, serial irrigation and debridement and a pedicled antegrade posterior interosseous artery (PIA) flap on staged surgical treatment. Finally, after ruling out infection persistence, a TEA was performed. We aim to report the outcome of a patient treated with a TEA in the context of a previously infected elbow with soft tissue coverage with an antegrade PIA flap. Comprehensive treatment must be done in an appropriate manner, to obtain an expedited and desirable outcome.
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Affiliation(s)
- Efraín Farías-Cisneros
- Hand, Peripheral Nerve and Upper Extremity Surgeon. Orthopedic Surgery Department. Centro Médico ABC
| | | | | | | | - Ranulfo Romo-Rodríguez
- Hand, Peripheral Nerve and Upper Extremity Surgeon. Orthopedic Surgery Department. Centro Médico ABC
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Bendall S, Halliwell P, Goldberg A, Robinson A. Ankle Arthritis Networking: Getting the right treatment to the right patient first time. Foot Ankle Surg 2022; 28:153-158. [PMID: 33757730 DOI: 10.1016/j.fas.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/07/2021] [Accepted: 03/08/2021] [Indexed: 02/04/2023]
Abstract
End stage ankle joint arthritis is a debilitating condition. Surgical treatment, most commonly ankle arthrodesis or fusion, can be highly effective. The authors outline the nature and prevalence of ankle arthritis and show that the frequency of each type of procedure varies geographically. They present data supporting the hypothesis that units performing ankle replacement more frequently tend to have better outcomes, both clinically and financially. Adoption of country-wide Ankle Arthritis Networks is proposed, ensuring that every patient seeing a foot and ankle orthopaedic surgeon has potential access to all treatment options whether their surgeon chooses to perform replacement or not. The case is made that establishment of Ankle Arthritis Networks will avoid the need for units to perform a low number of replacements per year, homogenise treatment availability across the country and enables the right patient to receive the right treatment first time. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Stephen Bendall
- Sussex Orthopaedic Treatment Centre, Brighton and Sussex University Hospitals, Lewes Road, RH16 4EX, United Kingdom.
| | - Paul Halliwell
- Royal Surrey Hospital, Egerton Road Guildford, GU2 7XX, United Kingdom.
| | - Andrew Goldberg
- UCL Institute of Orthopaedics, Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, United Kingdom.
| | - Andrew Robinson
- Cambridge University Hospitals, NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom.
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Poff C, Kunkle B, Li X, Friedman RJ, Eichinger JK. Assessing the hospital volume-outcome relationship in total elbow arthroplasty. J Shoulder Elbow Surg 2022; 31:367-374. [PMID: 34592413 DOI: 10.1016/j.jse.2021.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty (TEA) is an effective intervention for multiple elbow disorders including complex fracture in elderly patients, post-traumatic arthropathy, inflammatory arthropathy, and distal humeral nonunion. Given its known therapeutic value and low utilization rate, an investigation into the thresholds for TEA institutional volume-outcome relationships is warranted. The purpose of this study was to identify TEA volume thresholds that serve as predictors of institutional outcomes including complications, readmissions, revisions, cost of care, length of stay (LOS), and non-home discharge. We hypothesized that increased institutional volume would be associated with decreased 90-day adverse outcomes and resource utilization. METHODS The Nationwide Readmission Database was queried from 2010 to 2017 to identify all cases of TEA. Hospital volume was calculated using a unique hospital identifier and divided into quartiles. Outcomes such as complications, readmissions, revisions, cost of care, LOS, and non-home discharge were then analyzed by quartile. The same outcomes were assessed via stratum-specific likelihood ratio (SSLR) analysis to define volume strata among institutions. RESULTS SSLR analysis defined statistically significant hospital volume categories for each 90-day outcome. The volume category with the lowest complication rate was ≥21 TEAs per year (5.6%). The volume categories with the lowest readmission rates were 1-3 TEAs per year (4.7%) and ≥18 TEAs per year (9.2%). Revision rates were lowest in the volume categories of 1-5 TEAs per year (0.1%) and ≥18 TEAs per year (0.1%). Hospitals with ≥21 TEAs per year had the lowest cost of care and the highest rate of extended LOS (>2 days). SSLR analysis showed that non-home discharges decreased in a stepwise manner as volume increased. The lowest non-home discharge rate was associated with the volume category of ≥22 TEAs per year (20.3%). CONCLUSION This study defines TEA volume strata for institutional outcomes. The highest TEA volume strata were associated with the lowest rates of 90-day complications, revisions, and non-home discharges and the lowest cost of care. This trend is likely attributable to the benefits of high-volume institutional experience and standardized patient-care processes.
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Affiliation(s)
- Charles Poff
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Bryce Kunkle
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Richard J Friedman
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Josef K Eichinger
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA.
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22
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Tanji A, Nagura T, Iwamoto T, Matsumura N, Nakamura M, Matsumoto M, Sato K. Total elbow arthroplasty using an augmented reality-assisted surgical technique. J Shoulder Elbow Surg 2022; 31:175-184. [PMID: 34175467 DOI: 10.1016/j.jse.2021.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Precision placement of implants in total elbow arthroplasty (TEA) using conventional surgical techniques can be difficult and riddled with errors. Modern technologies such as augmented reality (AR) and 3-dimensional (3D) printing have already found useful applications in many fields of medicine. We proposed a cutting-edge surgical technique, augmented reality total elbow arthroplasty (ARTEA), that uses AR and 3D printing to provide 3D information for intuitive preoperative planning. The purpose of this study was to evaluate the accuracy of humeral and ulnar component placement using ARTEA. METHODS Twelve upper extremities from human frozen cadavers were used for experiments performed in this study. We scanned the extremities via computed tomography prior to performing TEA to plan placement sites using computer simulations. The ARTEA technique was used to perform TEA surgery on 6 of the extremities, whereas conventional (non-ARTEA) techniques were used on the other 6 extremities. Computed tomography scanning was repeated after TEA completion, and the error between the planned and actual placements of humeral and ulnar components was calculated and compared. RESULTS For humeral component placement, the mean positional error ± standard deviation of ARTEA vs. non-ARTEA was 1.4° ± 0.6° vs. 4.4° ± 0.9° in total rotation (P = .002) and 1.5 ± 0.6 mm vs. 8.6 ± 1.3 mm in total translation (P = .002). For ulnar component placement, the mean positional error ± standard deviation of ARTEA vs. non-ARTEA was 5.5° ± 3.1° vs. 19.5° ± 9.8° in total rotation (P = .004) and 1.5 ± 0.4 mm vs. 6.9 ± 1.6 mm in total translation (P = .002). Both rotational accuracy and translational accuracy were greater for joint components replaced using the ARTEA technique compared with the non-ARTEA technique (P < .05). CONCLUSION Compared with conventional surgical techniques, ARTEA had greater accuracy in prosthetic implant placement when used to perform TEA.
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Affiliation(s)
- Atsushi Tanji
- Department of Orthopedic Surgery, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan; Department of Orthopedic Surgery, Keio University, Tokyo, Japan.
| | - Takeo Nagura
- Department of Orthopedic Surgery, Keio University, Tokyo, Japan
| | - Takuji Iwamoto
- Department of Orthopedic Surgery, Keio University, Tokyo, Japan
| | | | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University, Tokyo, Japan
| | - Kazuki Sato
- Department of Orthopedic Surgery, Keio University, Tokyo, Japan
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23
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Green CK, Scanaliato JP, Polmear MM, Narimissaei DS, Fitzpatrick KV, Parnes N, Dunn JC. Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures. J Shoulder Elbow Surg 2021; 30:2543-2548. [PMID: 33930557 DOI: 10.1016/j.jse.2021.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/02/2021] [Accepted: 04/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity. METHODS Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly. RESULTS There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07. CONCLUSION Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.
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Affiliation(s)
- Clare K Green
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA.
| | | | | | | | | | | | - John C Dunn
- William Beaumont Army Medical Center, El Paso, TX, USA
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24
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Kwon BT, Lee SH, Baik JS, Lee YC, Kim JW. Reconstruction With Achilles Tendon Allograft Using the Keyhole Technique for Chronic Triceps Insufficiency After Total Elbow Arthroplasty. Orthopedics 2021; 44:e498-e502. [PMID: 34292832 DOI: 10.3928/01477447-20210618-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Total elbow arthroplasty (TEA) is associated with a relatively high incidence of chronic triceps insufficiency, but there is difficulty in treatment. This case series describes reconstruction with Achilles allografts using the keyhole technique in patients with postoperative chronic triceps insufficiency. Fourteen patients who underwent reconstruction for triceps insufficiency after TEA were included in the study. During this procedure, a keyhole-shaped osteotomy was performed on the proximal olecranon, and a fragment of the calcaneal allograft was shaped into a bone plug to fit the olecranon. The clinical outcomes were assessed in all patients 12 months after reconstruction and at last follow-up (range, 13-54 months). After 12 months, patients had a mean Mayo Elbow Performance Score of 84.3 (range, 75-100), and all achieved a marked improvement compared with before reconstruction (mean, 42.7; range, 20-75). Seven, 4, and 3 patients achieved excellent, good, and fair outcomes, respectively. The mean extension peak torque of the operated-on arm was 34.91 Nm (range, 16.3-63.9 Nm), and the percentage of extension peak torque of the operated-on arm to the opposite arm was from 14.5% preoperative to 76.2% 12 months postoperative. This case series suggests that triceps reconstruction with an Achilles tendon using the keyhole technique is a useful treatment option for triceps insufficiency after TEA. [Orthopedics. 2021;44(4):e498-e502.].
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25
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Abstract
Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.
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Affiliation(s)
- Naoko Onizuka
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Julie Switzer
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455, USA; Department of Orthopaedic Surgery, Methodist Hospital, 6500 Excelsior Boulevard, Saint Louis Park, MN 55426, USA
| | - Chad Myeroff
- TRIA Orthopedic Center, 155 Radio Drive, Woodbury, MN 55125, USA.
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26
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Michielsen M, Masson M, van Haver A, Vanhees M, van Riet R. A quantitative analysis of two cementing techniques in total elbow replacement: A cadaveric study. Shoulder Elbow 2021; 13:552-556. [PMID: 34659490 PMCID: PMC8512976 DOI: 10.1177/1758573220987853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022]
Abstract
One of the reasons for failure of total elbow replacement is loosening of the ulnar component. Cementing techniques are often outdated. A special small nozzle is needed for the ulnar component, when a cement gun is used. This may not always be available, or surgeons may prefer to use a syringe. We postulated that the use of a cement gun and smaller nozzle would result in improved filling of the ulnar canal. A cadaveric study was performed in which the ulnas of paired specimens were cemented with a cement gun or with a syringe. A 3D printed ulnar component was inserted and computed tomography scanning was performed on all specimens. Filling of the ulnar intramedullary canal was analysed using 3D reconstructions of the specimens. A greater degree of filling was seen by the use of the cement gun in 85.7%. Filling was 52.7% in the syringe group (25.1-78.7%), compared to 63.3% for the cement gun group (p < 0.05). The use of a small nozzle cement gun provided a significantly higher filling degree of the ulnar canal. We recommend to always use a cement gun with a specific small nozzle to cement the ulnar component in total elbow arthroplasty.
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Affiliation(s)
- Maartje Michielsen
- Department of Orthopedic Surgery, AZ Monica Hospital, Antwerp, Belgium,Department of Orthopedic Surgery, University
Hospital Antwerp, Antwerp, Belgium
| | | | - Annemieke van Haver
- Department of Orthopedic Surgery, AZ Monica Hospital, Antwerp, Belgium,Monica Orthopedic Research Institute (MoRe),
Antwerp, Belgium
| | - Matthias Vanhees
- Department of Orthopedic Surgery, AZ Monica Hospital, Antwerp, Belgium,Department of Orthopedic Surgery, University
Hospital Antwerp, Antwerp, Belgium
| | - Roger van Riet
- Department of Orthopedic Surgery, AZ Monica Hospital, Antwerp, Belgium,Department of Orthopedic Surgery, University
Hospital Antwerp, Antwerp, Belgium,Monica Orthopedic Research Institute (MoRe),
Antwerp, Belgium,Roger van Riet, Department of Orthopedic Surgery, AZ
Monica Hospital, Stevenslei 20, Antwerp 2100, Belgium.
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27
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Gerow DE, Tan EH, Bamberger HB. Cue Ball Arthroplasty With Humeroradial Total Elbow Arthroplasty (TEA) Revision: An Approach to Managing Infection and Severe Ulnar Bone Loss in TEA. J Shoulder Elb Arthroplast 2021; 4:2471549220961592. [PMID: 34497965 PMCID: PMC8282159 DOI: 10.1177/2471549220961592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/29/2022] Open
Abstract
Total elbow arthroplasties (TEA) have become more prevalent as indications expand. However, TEA complications remain a treatment conundrum. One such complication, periprosthetic joint infections (PJIs) have been reported to occur in up to 12% of all TEA procedures. Irrigation and debridement with retention of hardware and antibiotic suppression has a high failure rate. Two stage revisions of TEA, while more morbid, is an effective approach with previous studies showing a 79% eradication rate. These cases are often associated with periprosthetic bone loss, adding to the surgical complexity. In our case report, we present the case of a 59 year old diabetic male with a primary TEA secondary to a distal humerus fracture who developed a deep infection and was successfully treated with explantation, cue ball antibiotic cement arthroplasty, and humeroradial revision. This case report will discuss the cue ball antibiotic spacer technique and humeroradial revision as a salvage procedure in TEA revisions in the setting of extensive ulnar bone loss.
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Affiliation(s)
- Daniel E Gerow
- Metro Health-University of Michigan Health, Wyoming, Michigan
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28
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Zeltser DW, Prentice HA, Navarro RA, Mirzayan R, Dillon MT, Foroohar A. Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System. J Hand Surg Am 2021; 46:552-559. [PMID: 33896647 DOI: 10.1016/j.jhsa.2021.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 01/11/2021] [Accepted: 03/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system. METHODS All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated. RESULTS A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively. CONCLUSIONS This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- David W Zeltser
- Department of Orthopedic Surgery, The Permanente Medical Group, South San Francisco, CA.
| | | | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Harbor City, CA
| | - Raffy Mirzayan
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Baldwin Park, CA
| | - Mark T Dillon
- Department of Orthopedic Surgery, The Permanente Medical Group, Sacramento, CA
| | - Abtin Foroohar
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Harbor City, CA
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Long-term outcomes of total elbow arthroplasty: a systematic review of studies at 10-year follow-up. J Shoulder Elbow Surg 2021; 30:1423-1430. [PMID: 33418089 DOI: 10.1016/j.jse.2020.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to systematically review the literature to evaluate the functional outcomes, dislocation, and revision rates following total elbow arthroplasty (TEA) at a minimum 10 years' mean follow-up. MATERIALS AND METHODS Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and Cochrane Library databases. Studies were only included if they focused on outcomes post-TEA at a minimum 10 years' mean follow-up. RESULTS Our search found 23 studies including 1429 elbows (60.4% linked TEA) that met our inclusion criteria. There were 1276 patients (79.0% female), with an average age of 64.7 years (19-93) and a mean follow-up of 137.2 months (120-216). At final follow-up, the mean Mayo Elbow Performance Score, Oxford Elbow Score, and Quick Disabilities of the Arm, Shoulder, and Hand scores were 89.1 (35-100), 64.4 (16-48), and 39.2 (3-93), respectively, and 63.3% of patients reported having no pain. The rates of aseptic loosening, infection, implant dislocation, and nerve injury were 12.9%, 3.3%, 4.2%, and 2.1%, respectively. The overall complication and revision rates were 16.3% and 14.6%, respectively. DISCUSSION AND CONCLUSION Our systematic review established that TEA offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term.
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Augmented Total Elbow Arthroplasty with Femoral Strut Allograft for Revision of Prosthetic Joint Infection with Distal Humerus Bone Loss and Incomplete Union of Periprosthetic Humeral Shaft Fracture. Case Rep Orthop 2021; 2021:6661870. [PMID: 33968457 PMCID: PMC8084658 DOI: 10.1155/2021/6661870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 03/02/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022] Open
Abstract
Total elbow arthroplasty (TEA) prosthetic joint infection (PJI) in the setting of distal humerus bone loss poses a challenge for restoration of function. This can be complicated by a periprosthetic humeral fracture. Revision surgery in the setting of these pathologies possesses a significant challenge, especially when two or, in this case, all three problems are treated simultaneously. We present the clinical course, operative findings, and definitive treatment with the use of an augmented total elbow arthroplasty and femoral strut allograft reinforcement in detail. A review of the literature regarding the identification and management of infected TEA with augmented prosthesis and bone allograft augmentation of humerus fractures will be outlined in this case report.
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Complex fractures of the distal humerus in the elderly: primary total elbow arthroplasty or open reduction and internal fixation? Mid-term follow-up. INTERNATIONAL ORTHOPAEDICS 2021; 45:2103-2110. [PMID: 33846847 DOI: 10.1007/s00264-021-05027-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare the mid-term outcomes in intra-articular distal humerus fracture (AO/OTA type C) treated with either open reduction-internal fixation (ORIF) or total elbow arthroplasty (TEA) in patients older than 75 years and with more than five years of follow-up. METHODS Retrospective study including 24 patients (11 TEA vs. 13 ORIF) with a mean age of 82 years and being all females. Results assessed included (1) radiographic measures; (2) functional results: range of motion, Mayo Elbow Performance Score (MEPS), quick-DASH; and (3) complications. RESULTS TEA group vs. ORIF group achieved a mean flexion of 117° ± 9.6° vs. 106° ± 14°, extension loss of 38° ± 17° vs. 30.8° ± 16°, pronation 75° ± 5° vs. 85° ± 7° and supination 75° ± 4° vs. 70° ± 5°. Mean MEPS score was 71.6 vs. 83.6 (p = .183) and mean quick-DASH was 44.8 vs. 42.6 (p = .789). All 13 patients in the ORIF group demonstrated radiographic signs of bone union and none underwent conversion to TEA. Sixty-three percent of the patients in the TEA group underwent re-operation at an average of 72 months (62.4-75.2 months), including three for periprosthetic fracture and four for implant loosening. Whereas in the ORIF group, 23% of the patients were re-operated upon excluding olecranon osteotomy hardware, two for stiffness, and one for an olecranon tension band wire failure. CONCLUSIONS Although there were no differences in mid-term functional outcomes between either treatment, our results suggest that the recent trend towards the use of TEA instead of ORIF in the elderly should be re-examined due to the high rate of complications beyond five years of follow-up with TEA.
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Cutler HS, Collett G, Farahani F, Ahn J, Nakonezny P, Koehler D, Khazzam M. Thirty-day readmissions and reoperations after total elbow arthroplasty: a national database study. J Shoulder Elbow Surg 2021; 30:e41-e49. [PMID: 32663565 DOI: 10.1016/j.jse.2020.06.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to determine the rate of short-term complications after total elbow arthroplasty (TEA) and identify predictors of readmission and reoperation. We hypothesized that TEA performed for acute elbow trauma would have higher rates of 30-day readmission and reoperation than TEA performed for osteoarthritis (OA). METHODS Using the National Surgical Quality Improvement Program for the years 2011-2017, we identified patients undergoing TEA for fracture, OA, or inflammatory arthritis. Patient demographic characteristics, comorbidities, reoperations, and readmissions within 30 days of surgery were analyzed. Potential predictors of reoperation and readmission in the model included age, sex, race, body mass index (BMI), diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, smoking, bleeding disorders, American Society of Anesthesiologists classification, wound classification, operative time, and indication for surgery. RESULTS A total of 414 patients underwent TEA from 2011-2017. Of these patients, 40.6% underwent TEA for fracture; 37.0%, for OA; and 22.7%, for inflammatory arthritis. The overall rate of unplanned readmissions was 5.1% (21 patients). The rate of unplanned reoperations was 2.4% (10 patients). Infection was the most common reason for both unplanned readmissions and reoperations. The rates of reoperations and readmissions were not significantly associated with any of the 3 operative indications: fracture, OA, or inflammatory arthritis. Multiple logistic regression analysis found increased BMI to be associated with lower odds of an unplanned readmission (odds ratio [OR], 0.883; 95% confidence interval [CI], 0.798-0.963; P = .0035) and found wound classification ≥ 3 to be associated with increased odds of an unplanned reoperation (OR, 16.531; 95% CI, 1.300-167.960; P = .0144) and total local complications (OR, 17.587; 95% CI, 2.207-132.019; P = .0057). Patients who were not functionally independent were more likely to experience local complications (OR, 4.181; 95% CI, 0.983-15.664; P = .0309) than were functionally independent patients. CONCLUSIONS The 30-day unplanned reoperation rate after TEA was 2.4%, and the unplanned readmission rate was 5.1%. Low BMI was predictive of readmission. Wounds classified as contaminated or dirty were predictive of reoperation. Dependent functional status and contaminated wounds were predictive of local complications. The indication for TEA (fracture vs. OA vs. inflammatory arthritis) was not found to be a risk factor for reoperation or readmission after TEA.
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Affiliation(s)
- Holt S Cutler
- Department of Orthopaedic Surgery, Shoulder Service, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Garen Collett
- Department of Orthopaedic Surgery, Shoulder Service, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Farzam Farahani
- Department of Orthopaedic Surgery, Shoulder Service, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Juhno Ahn
- Department of Orthopaedic Surgery, Shoulder Service, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul Nakonezny
- Division of Biostatistics, Department of Clinical Sciences, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Daniel Koehler
- Department of Orthopaedic Surgery, Shoulder Service, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael Khazzam
- Department of Orthopaedic Surgery, Shoulder Service, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Claxton MR, Shirley MB, Nauert RF, Morrey ME, Sanchez-Sotelo J, Houdek MT. Humeral amputation following total elbow arthroplasty. INTERNATIONAL ORTHOPAEDICS 2021; 45:1281-1286. [PMID: 33447873 DOI: 10.1007/s00264-020-04906-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Total elbow arthroplasty (TEA) is associated with a relatively high complication rate, and exceptionally catastrophic complications might lead to amputation. The purpose of this study was to determine the incidence and aetiology of amputation performed at our institution in upper extremity limbs with a prior TEA. METHODS Between 1973 and 2018, 1906 consecutive TEAs were performed at our institution. Upper extremity amputation was performed in seven (0.36%) elbows with five transhumeral amputations and two shoulder disarticulations. The group consisted of five females and two males with a mean age of 64 years (range, 37-80). The index TEA had been performed for rheumatoid arthritis (n = 2), rheumatoid arthritis with acute fracture (n = 2), radiation associated nonunion (n = 2), and metastatic cancer (n = 1). Mean follow-up after amputation was three years (range, 3 months-5 years). RESULTS Mean time between amputation and TEA was 5 years (range, 2 months-13 years). The indications for amputation included uncontrolled deep infection in six (86%) elbows and tumor recurrence in one (14%) elbow. Only one elbow (14%) was fitted with a prosthesis. Six (86%) patients died at a mean of three years (range, 3 months-5 years) after amputation. CONCLUSION The results of this study highlight a low incidence of amputation after TEA. Most amputations were the direct result of TEA complications, with infection being the most common cause of amputation. Outcomes after amputation are concerning, with poor overall survival and few patients being fit for a prosthesis.
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Affiliation(s)
- Matthew R Claxton
- Mayo Clinic Alix School of Medicine, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Matthew B Shirley
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Richard F Nauert
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Joaquin Sanchez-Sotelo
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA.
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Differences in 30-day outcomes between inpatient and outpatient total elbow arthroplasty (TEA). J Shoulder Elbow Surg 2020; 29:2640-2645. [PMID: 32619659 DOI: 10.1016/j.jse.2020.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND As the health care system in the United States shifts toward value-based care, there has been increased interest in performing total joint arthroplasty in the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings. METHODS The American College of Surgeons National Quality Improvement Program database was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables-age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities-between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups. RESULTS Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P = .01), surgical complications (7.6% vs. 2.6%, P = .04), and medical complications (3.6% vs. 0.0%, P = .04). CONCLUSION Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA.
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Quantitative ultrahigh-molecular-weight polyethylene wear in total elbow retrievals. J Shoulder Elbow Surg 2020; 29:2364-2374. [PMID: 32666923 DOI: 10.1016/j.jse.2020.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 03/20/2020] [Accepted: 03/26/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate ultrahigh-molecular-weight polyethylene (UHMWPE) wear and damage from retrieved total elbow arthroplasty components and compare in vivo wear with wear produced in vitro. METHODS Explanted total elbow components were collected at revision surgery. UHMWPE damage was characterized visually, whereas penetration and wear were quantified using micro-computed tomography and gas pycnometry. Volumetric wear rates were compared with historical hip data, and wear data were compared with reported in vitro wear test data. RESULTS Humeral bushing damage primarily occurred in the form of burnishing, scratching, and pitting at the articular face in the region of contact with the ulnar component. Wear of the ulnar bushings was concentrated on the edge of the component at the point of contact with the axis pin. Pitting and embedded debris were dominant damage modes, in addition to burnishing and delamination. Backside wear was negligible. The median linear penetration rates of the lateral, medial, and ulnar bushings were 0.14 mm/yr (range, 0.01-0.78 mm/yr), 0.12 mm/yr (range, 0.03-0.55 mm/yr), and 0.11 mm/yr (range, 0.01-0.69 mm/yr), respectively. The volumetric wear rates of the lateral, medial, and ulnar bushings were 5.5 mm3/yr (range, 0.7-37.2 mm3/yr), 5.9 mm3/yr (range, 0.6-25.5 mm3/yr), and 5.5 mm3/yr (range, 1.2-51.2 mm3/yr), respectively. CONCLUSIONS The observed wear rates were similar to those reported in well-functioning total hip replacement patients with conventional UHMWPE bearings. We found limitations in reported in vitro testing resulting in wear that was not consistent with our retrieval data. We recommend further investigation to clinically validate in vitro simulation to provide appropriate loading protocols for elbow wear simulation.
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Triceps-Sparing Total Elbow Arthroplasty for Distal Humerus Fracture: The Lateral Paraolecranon Approach. J Orthop Trauma 2020; 34 Suppl 2:S9-S10. [PMID: 32639338 DOI: 10.1097/bot.0000000000001830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Distal humerus fractures in the elderly are a difficult problem to treat. Open reduction internal fixation has a high rate of complications, particularly because osteopenia compromises what is already tenuous fixation in a metaphyseal fracture. Total elbow arthroplasty is a more predictable outcome and easier recovery for these patients. However, most surgeons perform a low volume of total elbow arthroplasty. In addition, traditional exposure requires detachment of the triceps tendon. The lateral paraolecranon approach maintains the central tendon attachment to the olecranon while still facilitating relative ease of the procedure. Patients are allowed full active use of the triceps postoperatively, which is very helpful for polytrauma patients and those who are already dependent on assistive devices for ambulation.
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Viswanath AI, Frampton CM, Poon PC. A review of the New Zealand National Joint Registry to compare the outcomes of Coonrad-Morrey and Latitude total elbow arthroplasty. J Shoulder Elbow Surg 2020; 29:838-844. [PMID: 32197768 DOI: 10.1016/j.jse.2019.12.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty has traditionally been used in the treatment of inflammatory arthropathy patients. More and more, however, its use is expanding to include acute trauma and sequelae of trauma. In New Zealand, the most commonly used prosthesis is the Coonrad-Morrey prosthesis, but the Latitude prosthesis has gained in popularity, with a 3-fold increase in implantation over the past 5 years. METHODS Prospectively collected national joint registry data were used to compare the survival rates of these prostheses. Underlying diagnoses, reasons for revision, and patient-reported outcome measures, as well as patient age and exact implants used, were all recorded. Statistical analysis involved survival analysis using Kaplan-Meier curves and the paired Student t test. RESULTS Over the 18-year study interval, the Coonrad-Morrey prosthesis has shown consistently lower revision rates than the Latitude prosthesis. This was true for both the linked and unlinked Latitude prostheses and was not affected by radial head replacement or underlying diagnosis. In all cases, the risk of revision for the Coonrad-Morrey prosthesis was reduced by at least 65% compared with the Latitude prosthesis. CONCLUSION This study using New Zealand Joint Registry data shows a lower failure rate of the Coonrad-Morrey elbow prosthesis compared with the Latitude prosthesis. The hazard ratio for a revision procedure for the Coonrad-Morrey prosthesis compared with the Latitude prosthesis was 0.28 (95% confidence interval, 0.14-0.55). This lower rate was evident irrespective of linkage and radial head replacement. The reason for the lower rate of revision with the Coonrad-Morrey prosthesis is likely multifactorial, but perhaps when used by lower-volume surgeons, the Coonrad-Morrey prosthesis may confer better implant longevity.
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Affiliation(s)
- Aparna I Viswanath
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand.
| | | | - Peter C Poon
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
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Kim DH, Kim BS, Baek CS, Cho CH. Primary Total Elbow Replacement for Treatment of Complex Distal Humerus Fracture: Outcomes of Short-term Follow-up. Clin Shoulder Elb 2020; 23:20-26. [PMID: 33330229 PMCID: PMC7714326 DOI: 10.5397/cise.2020.00045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/10/2020] [Indexed: 11/25/2022] Open
Abstract
Background High complication rate after open reduction and internal fixation can lead to use of primary total elbow replacement (TER) in treatment of complex distal humerus fractures in elderly patients. The purpose of this study was to investigate the short-term outcomes and complications after primary TER in patients with complex distal humerus fracture. Methods Nine patients with acute complex distal humerus fracture were treated by primary TER using the semiconstrained Coonrad-Morrey prosthesis. The mean age of patients was 72.7 years (range, 63–85 years). Clinical and radiographic outcomes were evaluated over a mean follow-up of 29.0 months (range, 12–65 months) using visual analog scale (VAS) score for pain; Mayo elbow performance score (MEPS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; and serial plain radiographs. Complications were also evaluated. Results At the final follow-up, mean VAS, MEPS, and Quick-DASH scores were 1.2, 80.5, and 20, respectively. The mean range of motion was 127.7º of flexion, 13.8º of extension, 73.3º of pronation, and 74.4º of supination. There was no evidence of bushing wear or high-grade implant loosening on serial plain radiographs. Three complications (33.3%) comprising two periprosthetic fractures and one ulnar neuropathy were observed. Conclusions Primary TER for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes. However, surgeons should consider the high complication rate after primary TER.
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Affiliation(s)
- Du-Han Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chung-Sin Baek
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Total Elbow Arthroplasty for Distal Humerus Fractures Provided Similar Outcomes When Performed as a Primary Procedure or After Failed Internal Fixation. J Orthop Trauma 2020; 34:95-101. [PMID: 31490269 DOI: 10.1097/bot.0000000000001631] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare clinical and functional outcomes of total elbow arthroplasty (TEA) for distal humerus fractures (DHF) performed either as a primary procedure or after internal fixation. DESIGN Retrospective, observational study. SETTING Mayo Clinic, Rochester, MN (1998 through 2016). PATIENTS/PARTICIPANTS Twenty-two TEA for acute DHF and 66 TEA after previous internal fixation. MAIN OUTCOME MEASUREMENTS Primary outcome measures included the Mayo Elbow Performance Score and motion. Reoperation rates and complications were also compared. RESULTS The mean time between internal fixation and arthroplasty was 7.3 years, and the main indications for conversion to TEA were nonunion (36%) and posttraumatic osteoarthritis (32%). There were female predominance (70%) and significant differences in age (74 years vs. 60 years, P < 0.0001) and tobacco use (0 vs. 23%; P = 0.02) between the primary and the salvage cohorts, respectively. Cohort demographics were otherwise comparable. TEA provided similar outcomes in both cohorts in terms of the Mayo Elbow Performance Score (acute 85, salvage 81, P = 0.32) and motion (acute 95/82/75 degrees, salvage 112/81/72 degrees in ulnohumeral/pronation/supination, P = 0.07/P = 0.85/P = 0.65). Reoperation rates were also similar (36% acute vs. 39% salvage, P = 1.00). Aseptic loosening (2 acute, 8 salvage) and deep infection (2 acute, 7 salvage) were the most common complications. CONCLUSIONS The clinical outcomes and reoperation rates of TEA for DHF seem to be similar when performed as a primary procedure or as salvage after previous internal fixation. The benefit of avoiding elbow arthroplasty in the acute setting needs to be balanced with the potential for 2 surgical procedures if internal fixation was to be unsuccessful. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Kim DM, Han M, Jeon IH, Shin MJ, Koh KH. Range-of-motion improvement and complication rate in open and arthroscopic osteocapsular arthroplasty for primary osteoarthritis of the elbow: a systematic review. INTERNATIONAL ORTHOPAEDICS 2020; 44:329-339. [PMID: 31834444 DOI: 10.1007/s00264-019-04458-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 11/27/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE To analyze ROM changes by using a Bayesian method, to compare complication and re-operation rates between open osteocapsular arthroplasty (OPEN) and arthroscopic osteocapsular arthroplasty (ARTHRO) for primary osteoarthritis of the elbow, and find evidence-based tendencies. METHODS The PubMed, Cochrane Library, and Embase databases were searched. We performed descriptive analysis to compare ARTHRO and OPEN, a Bayesian analysis of ROM changes, and methodological assessment to determine the tendencies of OPEN and ARTHRO. RESULTS Eighteen articles (625 patients, 634 elbows) were analyzed. There were 11 articles on OPEN and 8 articles on ARTHRO (1 article was a comparative study between OPEN and ARTHRO). According to the Bayesian method, flexion and total arc of flexion-extension increased more with OPEN than with ARTHRO. Further, ARTHRO showed a narrower width in the ROM graph than OPEN. The number of complications was 17 (5.1%) and five (2.0%), and the number of re-operations was 32 (9.5%) and 14 (5.6%) for OPEN and ARTHRO, respectively. By analyzing six high-quality articles, we found three tendencies: OPEN and ARTHRO were both effective for improving pain score, flexion-extension arc, and functional outcome; OPEN did not improve the pronation-supination arc; and there was a weak tendency that OPEN was more effective than ARTHRO for improving the flexion arc. CONCLUSION Both OPEN and ARTHRO improved ROM and clinical scores. The Bayesian method indicated that although OPEN increased the flexion and flexion-extension arc more than ARTHRO, ARTHRO resulted in a relatively consistent surgical outcome. Additionally, OPEN caused relatively higher complication and re-operation rates than ARTHRO.
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Affiliation(s)
- Dong Min Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05535, South Korea
| | - Minkyu Han
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05535, South Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05535, South Korea
| | - Myung Jin Shin
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05535, South Korea
| | - Kyoung-Hwan Koh
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05535, South Korea.
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DeBernardis DA, Horneff JG, Davis DE, Ramsey ML, Pontes MC, Austin LS. Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions. J Shoulder Elbow Surg 2020; 29:321-328. [PMID: 31843239 DOI: 10.1016/j.jse.2019.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/03/2019] [Accepted: 10/20/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. METHODS We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. RESULTS A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. CONCLUSION Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.
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Affiliation(s)
| | - John G Horneff
- Rothman Institute at Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Institute at Jefferson University, Philadelphia, PA, USA
| | - Matthew L Ramsey
- Rothman Institute at Jefferson University, Philadelphia, PA, USA
| | | | - Luke S Austin
- Rothman Institute at Jefferson University, Philadelphia, PA, USA
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Cordtz R, Hawley S, Prieto-Alhambra D, Højgaard P, Zobbe K, Kristensen LE, Overgaard S, Odgaard A, Soussi BG, Dreyer L. Reduction in Upper Limb Joint Surgery Among Rheumatoid Arthritis Patients: An Interrupted Time-Series Analysis Using Danish Health Care Registers. Arthritis Care Res (Hoboken) 2020; 72:274-282. [PMID: 30680930 DOI: 10.1002/acr.23835] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/15/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Joint replacement surgery is a proxy of severe joint damage in rheumatoid arthritis (RA). The aim of this study was to assess the impact of the introduction of biologic disease-modifying antirheumatic drugs (bDMARDs) on the incidence rate (IR) of upper limb joint replacements among newly diagnosed RA patients. METHODS Using the Danish National Patient Register, patients with incident RA from 1996-2012 were identified. Each patient was matched on age, sex, and municipality, with up to 10 general population controls. The age- and sex-standardized 5-year IR per 1,000 person-years of a composite outcome of any first joint replacement of the finger, wrist, elbow, or shoulder was calculated, and an interrupted time-series analysis was undertaken to investigate trends and changes of the IR in the pre-bDMARD (1996-2001) and the bDMARD eras (2003-2012), with a 1-year lag period in 2002. RESULTS In total, 18,654 incident patients with RA were identified (mean age 57.6 years, 70.5% women). The IR of joint replacements among patients with RA was stable at 2.46 per 1,000 person-years (95% confidence interval [95% CI] 1.96, 2.96) from 1996 to 2001 but started to decrease from 2003 onwards (-0.08 per 1,000 person-years annually [95% CI -0.20, 0.02]). Compared with patients with RA, the IR among controls in 1996 was 1/17 and increased continuously throughout the study period. CONCLUSION The IR of upper limb joint replacements started to decrease among patients with RA from 2002 onwards, whereas it increased among controls. Our results suggest an association between the introduction of bDMARDs and a lower need of joint replacements among patients with RA.
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Affiliation(s)
- René Cordtz
- Rigshospitalet-Gentofte, Copenhagen, Denmark, The Parker Institute, Bispebjerg, Denmark, and Frederiksberg Hospital, Frederiksberg, Denmark
| | | | - Daniel Prieto-Alhambra
- University of Oxford, Oxford, UK, and Idiap Jordi Gol, Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable, Universitat Autònoma de Barcelona, and Instituto de Salud Carlos III, Barcelona, Spain
| | - Pil Højgaard
- Rigshospitalet-Gentofte, Copenhagen, Denmark, The Parker Institute, Bispebjerg, Denmark, and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Kristian Zobbe
- Rigshospitalet-Gentofte, Copenhagen, Denmark, The Parker Institute, Bispebjerg, Denmark, and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Lars Erik Kristensen
- The Parker Institute, Bispebjerg, Denmark, and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Søren Overgaard
- Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Anders Odgaard
- Copenhagen University Hospital, Herlev-Gentofte, Copenhagen, Denmark
| | | | - Lene Dreyer
- Aalborg University and Aalborg University Hospital, Aalborg, Denmark, Rigshospitalet-Gentofte, Copenhagen, Denmark, The Parker Institute, Bispebjerg, Denmark, and Frederiksberg Hospital, Frederiksberg, Denmark
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Multiple Cultures and Extended Incubation for Upper Extremity Revision Arthroplasty Affect Clinical Care: A Cohort Study. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:JAAOSGlobal-D-19-00150. [PMID: 31875193 PMCID: PMC6903814 DOI: 10.5435/jaaosglobal-d-19-00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Skin flora organisms (SFOs) isolated from 1 to 2 tissue samples during shoulder and elbow revision arthroplasty are difficult to distinguish as contamination or infection. We examined the change in clinical care after implementation of an Arthroplasty Infection Protocol by increasing the number of intraoperative samples held for 10-day incubation to a minimum of 5. Methods Infection was defined as ≥3 cultures growing the same SFO or any one culture growing any other virulent organism. SFOs growing in 1 to 2 samples were defined as skin flora contaminant. All cases were compared with pre-Arthroplasty Infection Protocol institution standard to determine changes in microbiological diagnosis and resultant antibiotic treatment. Results Forty cases fulfilled the inclusion criteria: 50% of these were culture negative, and 35% grew Propionibacteria. When compared with the standard of obtaining one sample, this protocol altered the microbiological diagnosis and subsequent antibiotic treatment in 45% of cases (95% confidence interval 29% to 62%). This protocol had a predictive value of joint sterility in 95% of culture-negative cases (95% confidence interval 74% to 99%). Discussion The addition of 5 or more samples held for 10-day incubation reliably differentiated between joint infection, contamination, and sterility, which changed the course of care in 45% of surgical cases.
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Wang JH, Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. Outcomes following total elbow arthroplasty for rheumatoid arthritis versus post-traumatic conditions: a systematic review and meta-analysis. Bone Joint J 2019; 101-B:1489-1497. [PMID: 31786989 PMCID: PMC6896228 DOI: 10.1302/0301-620x.101b12.bjj-2019-0799.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. MATERIALS AND METHODS We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). RESULTS This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. CONCLUSION The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489-1497.
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Affiliation(s)
- Jou-Hua Wang
- Department of Orthopaedics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Hsuan-Hsiao Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Te-Feng A Chou
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Viveen J, van den Bekerom MPJ, Doornberg JN, Hatton A, Page R, Koenraadt KLM, Wilson C, Bain GI, Jaarsma RL, Eygendaal D. Use and outcome of 1,220 primary total elbow arthroplasties from the Australian Orthopaedic Association National Joint Arthroplasty Replacement Registry 2008-2018. Acta Orthop 2019; 90:511-516. [PMID: 31452427 PMCID: PMC6844423 DOI: 10.1080/17453674.2019.1657342] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) was analyzed to determine trends in use of primary total elbow arthroplasty (TEA), the types of prostheses used, primary diagnoses, reasons for and types of revision, and whether the primary diagnosis or prosthesis design influenced the revision rate.Patients and methods - During 2008-2018, 1,220 primary TEA procedures were reported of which 140 TEAs were revised. Kaplan-Meier estimates of survivorship were used to describe the time to first revision and hazard ratios (HR) from Cox proportional hazard models, adjusted for age and sex, were used to compare revision rates.Results - The annual number of TEAs performed remained constant. The 3 most common diagnoses for primary TEA were fracture/dislocation (trauma) (36%), osteoarthritis (OA) (34%), and rheumatoid arthritis (RA) (26%). The cumulative percentage revision for all TEAs undertaken for any reason was 10%, 15%, and 19% at 3, 6, and 9 years. TEAs undertaken for OA had a higher revision rate compared with TEAs for trauma (HR = 1.8, 95% CI 1.1-3.0) and RA (HR = 2.0, CI 1.3-3.1). The Coonrad-Morrey (50%), Latitude (30%), Nexel (10%), and Discovery (9%) were the most used prosthesis designs. There was no difference in revision rates when these 4 designs were compared. The most common reasons for revision were infection (35%) and aseptic loosening (34%).Interpretation - The indications for primary and revision TEA in Australia are similar to those reported for other registries. Revision for trauma is lower than previously reported.
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Affiliation(s)
- Jetske Viveen
- Department of Orthopedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia; ,Correspondence:
| | - Michel P J van den Bekerom
- Shoulder and Elbow Unit, Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands;
| | - Job N Doornberg
- Department of Orthopedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia;
| | - Alesha Hatton
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia;
| | - Richard Page
- Australian Orthopedic Association National Joint Replacement Registry (AOANJRR), Adelaide, SA, Australia; ,Barwon Centre for Orthopaedic Research and Education (B-CORE), Barwon Health, St John of God Hospital and Deakin University, Geelong, Australia;
| | - Koen L M Koenraadt
- Foundation for Orthopedic Research, Care & Education, Amphia Hospital, Breda, The Netherlands;
| | - Christopher Wilson
- Department of Orthopedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia;
| | - Gregory I Bain
- Department of Orthopedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia;
| | - Ruurd L Jaarsma
- Department of Orthopedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia;
| | - Denise Eygendaal
- Upper Limb Unit, Department of Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands; ,Department of Orthopedic Surgery, Amsterdam University Medical Centers, Amsterdam The Netherlands
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Management of rheumatoid arthritis of the elbow with a convertible total elbow arthroplasty. J Shoulder Elbow Surg 2019; 28:2205-2214. [PMID: 31630751 DOI: 10.1016/j.jse.2019.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total elbow arthroplasty (TEA) is commonly performed in patients with rheumatoid arthritis (RA). The purpose of this study was to compare outcomes and complications of unlinked and linked TEA using a convertible system in patients with RA. METHODS All patients with RA who underwent TEA at a single center with a minimum of 2 years' follow-up were reviewed. Demographic information, patient-reported outcome scores, functional outcome assessments, and radiographic parameters were evaluated at most recent follow-up. RESULTS We evaluated 82 patients (27 with unlinked TEA and 55 with linked TEA) with RA. The mean age at surgery was 61 ± 10 years, with a mean follow-up period of 6 ± 4 years. Demographic characteristics were similar between groups, with the exception of longer follow-up in the unlinked group (8 years vs. 5 years, P = .001). No differences in range of motion were noted. Elbow strength was similar other than pronation strength (74% ± 8% for unlinked vs. 100% ± 8% for linked, P = .03). The mean Mayo Elbow Performance Index was 83 ± 16; Patient Rated Elbow Evaluation score, 15 ± 18; and QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score, 34 ± 20. No differences in the rates of reoperation (17% vs. 24%, P = .4), complications (32% vs. 31%, P = .4), or revisions (13% vs. 17%, P = .3) were found between unlinked and linked devices. Four patients with instability, all with unlinked designs, underwent revision to a linked design. Four patients, all with linked designs, underwent revision for aseptic loosening of smooth short-stem ulnar components. CONCLUSION TEA using a convertible implant design provides good patient-reported outcomes at mid-term follow-up in patients with RA. Our study was unable to detect a difference in the use of either unlinked or linked implant designs; further large comparison trials are needed.
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Watts AC, Duckworth AD, Trail IA, Rees J, Thomas M, Rangan A. Scoping review: Diagnosis and management of periprosthetic joint infection in elbow arthroplasty. Shoulder Elbow 2019; 11:282-291. [PMID: 31316589 PMCID: PMC6620798 DOI: 10.1177/1758573218789341] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/26/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Total elbow arthroplasty is an effective treatment for patients with painful elbow arthritis. Infection can be a serious complication. The aim of this scoping review was to document the available evidence on periprosthetic elbow infection. METHODS A search of Medline, Embase and PubMed was performed; two authors screened results independently. Systematic reviews, randomised controlled trials, cohort studies, case-control studies and case series including periprosthetic elbow infection were eligible. RESULTS A total of 46 studies were included. The median rate of periprosthetic elbow infection reported from recent published studies is 3.3%. The most commonly identified causative organisms are Staphylococcus aureus and Staphylococcus epidermidis. Risk factors include younger age, rheumatoid arthritis, obesity, previous surgery or infection to the elbow, and postoperative wound complications. Debridement, antibiotics and implant retention results in implant survival rates of 50-90%. Two-stage revision results in improved functional outcome scores, but with recurrent infection rates of 12-28%. CONCLUSIONS Total elbow arthroplasty carries a higher risk of infection when compared to other major joint replacements. The current body of literature is limited and is almost exclusively low volume retrospective case series. The best management of periprosthetic elbow infection is difficult to determine, but two-stage revision appears to be the gold standard.
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Affiliation(s)
- AC Watts
- Wrightington Hospital, Lancashire, UK,AC Watts, Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire WN6 9EP, UK.
| | | | - IA Trail
- Wrightington Hospital, Lancashire, UK
| | - J Rees
- University of Oxford, Oxford, UK
| | - M Thomas
- Frimley Health Foundation Trust, Frimley, UK
| | - A Rangan
- James Cook University Hospital, Middlesbrough, UK
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Abdelmalek A, Donaldson O. Total Elbow Arthroplasty Survey 2015: Current Service Provision and Future Improvements (England and Wales). Shoulder Elbow 2019; 11:292-299. [PMID: 31316590 PMCID: PMC6620797 DOI: 10.1177/1758573218763126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 01/27/2018] [Accepted: 02/05/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The number of total elbow replacement (TER) procedures conducted is relatively low compared to other joint arthroplasties. We have established a survey about current service provision and possible future improvements in the UK. METHODS A British Elbow and Shoulder Society (BESS) approved online survey was circulated to its surgical members. RESULTS In total, 153 members of BESS responded. Almost 31% of respondents performed two to five TER in 2014; 28% performed none and 22.7% performed five to ten. Two-thirds of respondents did not perform any revision surgery. The main indication for TER was rheumatoid arthritis (33%), followed by acute trauma (28.5%). In addition, 67% of surgeons have an available 'network' for advice, either locally or regionally. Most primary procedures (93%) were carried out within the local units. However, 34% of complex primary or revision procedures were referred to another centre. Furthermore, 52% of respondents agree that, to be proficient in TER, a minimum number of procedures per annum should be performed: 62% stated that five procedures per annum should be considered as the minimum required. Suggestions for improvement included a hub and spoke model (48%) and a dedicated TER surgeon within the unit (45%). CONCLUSIONS The survey highlights the interest in exploring options for improving TER provision in the UK.
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Affiliation(s)
- Amir Abdelmalek
- ST5 Trauma and Orthopaedics (Severn Deanery), Yeovil District Hospital, Higher Kingston, Yeovil, UK,Amir Abdelmalek, Yeovil District Hospital NHS Foundation Trust Yeovil, Yeovil BA21 4AT, UK.
| | - Oliver Donaldson
- Consultant Trauma and Orthopaedics, Yeovil District Hospital, Higher Kingston, Yeovil, UK
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Somerson JS, Boylan MR, Hug KT, Naziri Q, Paulino CB, Huang JI. Risk factors associated with periprosthetic joint infection after total elbow arthroplasty. Shoulder Elbow 2019; 11:116-120. [PMID: 30936951 PMCID: PMC6434963 DOI: 10.1177/1758573217741318] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/10/2017] [Accepted: 10/15/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present? METHODS The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI. RESULTS Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% (n = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections. CONCLUSIONS Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis. LEVEL OF EVIDENCE Level III: prognostic study.
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Affiliation(s)
- Jeremy S. Somerson
- University of Texas Medical Branch, Galveston, TX, USA,Jeremy S. Somerson, Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
| | | | - Kevin T. Hug
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA, USA
| | - Qais Naziri
- SUNY Downstate Medical Center, Brooklyn, NY, USA
| | | | - Jerry I. Huang
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA, USA
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Timely recognition of total elbow and radial head arthroplasty adverse events: an analysis of reports to the US Food and Drug Administration. J Shoulder Elbow Surg 2019; 28:510-519. [PMID: 30466818 DOI: 10.1016/j.jse.2018.08.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/23/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent recalls of several commonly used elbow arthroplasty implants have prompted interest in the modes by which elbow implants fail and the timing of reports of these failures. METHODS We reviewed the adverse event reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database from 2012 to 2015 regarding elbow arthroplasty to determine the event date and the type of each adverse event. RESULTS Among 179 total elbow adverse event reports, the most common modes of failure were implant dissociation (23%), loosening (22%), and infection (16%). The most common modes of failure among 58 radial head replacement reports were component dissociation (19%) and linkage screw failure (19%). The percentage distribution of adverse event types differed among different arthroplasty systems and from that reported in published reviews of elbow arthroplasty. Three implant recalls were implemented 2, 5, and 9 years after the first adverse event report in the MAUDE database. For 2 of the recalls, the first reports of the device failures were published 2 and 5 years after the first MAUDE reports. CONCLUSIONS The MAUDE database is a publicly funded and publicly available means by which surgeons can identify adverse events for the prostheses they use before such information becomes available through journal publication or recall notification. In this study, MAUDE data revealed a higher relative frequency of mechanical dissociation of elbow implants than what has been represented in the literature. Early identification of these adverse events may help surgeons by informing their implant selection and surgical technique.
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