Total Elbow Arthroplasty

A review of the New Zealand National Joint Registry to evaluate the survivorship and revision rates of Nexel and Coonrad-Morrey total elbow arthroplasty

BACKGROUND

Total elbow arthroplasty (TEA) is an appropriate surgical treatment option for a variety of conditions ranging from inflammatory arthritis to trauma. Because of a high complication profile, implant companies have attempted to improve patient outcomes with evolving design mechanics and philosophy. However, the Nexel TEA prosthesis has been criticized for its unacceptably high revision rate by other research groups in the literature. The purpose of this study was to evaluate the survivorship and revision rates of the Nexel and Coonrad-Morrey TEA implant systems in New Zealand.

METHODS

Prospectively collected National Joint Registry data were used to compare the survival rates of these prostheses. Underlying diagnoses, reasons for revision, and patient demographics were all recorded. Statistical analysis included survival analysis using Kaplan-Meier curves and comparison between groups using independent t tests.

RESULTS

Over the 23-year study interval, the Nexel and Coonrad-Morrey prostheses showed similar survivorship and revision rates. The revision rates at 5 years were 7.3% for Nexel and 4.5% for the Coonrad-Morrey cohorts. The average time to revision for those who are revised was 3.13 ± 1.74 years in the Nexel group and 4.93 ± 4.13 years in the Coonrad-Morrey population.

CONCLUSION

Our study confirms a lower revision rate of the Nexel TEA compared to other studies in the literature. Additionally, the Nexel TEA implant performs comparably to its predecessor, the Coonrad-Morrey prosthesis in New Zealand. Although it is difficult to explain the discrepancy in results with the study by Morrey et al, future studies should focus on investigating postoperative radiographs and a deep analysis of the specific surgical technique used for this implant.

Long-term outcomes and trends in elbow arthroplasty with Coonrad-Morrey prosthesis: a retrospective study in large group of patients

PURPOSE

Total Elbow Arthroplasty (TEA) was first developed to treat severe rheumatoid arthritis, but its uses have grown to encompass end-stage osteoarthritis, post-traumatic arthritis, and distal humeral fractures. This study analyzes indications changes, long-term survival, complications, and post-operative functional results of the Coonrad-Morrey prostheses, enhancing the existing literature on this technique and substantial case history.

METHODS

We included 122 arthroplasties in 117 patients, 28 males and 89 females (mean age of 67 years) treated in our hospital between 2002 and 2016. Minimum follow-up was four years. We collect functional parameters of 48 patients (51 elbows), due to death of patients due to old age and loss at follow-up.

RESULTS

Survival rate at five years was 90%, 85% at 10 years and 83% at 15 years. The overall medium Mayo elbow score was 79.7 ± 18.3 with the highest result in osteoarthritis patients (p < 0.005); QuickDASH score was 33.1 ± 25.5 with the worse result in rheumatoid group. Average post-operative arc of motion (ROM) was 95°±27°. There were complications in 46 out of 122 cases (37.7%) and revision surgeries were performed in 12 of them (9.8%): seven aseptic loosening, four late septic loosening, one bushing wear. In 27 instances (22.1%) was reported ulnar nerve involvement.

CONCLUSION

Coonrad-Morrey prosthesis has shown satisfactory clinical results in the treatment of a wide range of pathologies. The long-term implant survivorship was satisfactory, yet the occurrence of failures and complications cannot be overlooked, above all the ulnar nerve paresthesia. There was a good recovery in quality of life, pain-free with limited residual limb disability.

Midterm follow-up of the Nexel total elbow arthroplasty

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.

Influence of Training Background on Elbow Arthroplasty Case Numbers: An Analysis of the American Board of Orthopaedic Surgery Part II Oral Examination Case List Database

INTRODUCTION

This study aimed to evaluate the influence of training background on the frequency and indications of elbow arthroplasty performed by early-career surgeons.

METHODS

A review of the American Board of Orthopaedic Surgery Part II Oral Examination Case List database from 2010 to 2021 was completed. The number of cases performed by surgeons from each individual training background were calculated and compared with the total number of surgeons who completed each fellowship during the study period.

RESULTS

Hand surgeons performed the most elbow arthroplasty cases (132, 44%), but a higher percentage of shoulder/elbow surgeons performed elbow arthroplasty in comparison (15% vs. 7%). The mean number of TEA cases performed by shoulder/elbow surgeons was significantly higher than in other subspecialties (P < 0.01). However, when comparing only surgeons who performed elbow arthroplasty during the board collection period, there was no significant difference between training backgrounds (P = 0.20).

DISCUSSION

While hand surgeons performed the most elbow arthroplasty cases, a higher percentage of shoulder/elbow surgeons performed elbow arthroplasty during the study period. The high prevalence of distal humerus fracture as an indication for arthroplasty reflected a shift in indications and was not related to training background.

Incidence of and Risk Factors for Reoperation and Revision Following Total Elbow Arthroplasty with an Anatomic Convertible Prosthesis

BACKGROUND

Total elbow arthroplasty (TEA) remains a valuable tool for treating inflammatory, degenerative, and traumatic elbow conditions. This study aimed to understand the incidence of and risk factors for reoperation following TEA at a high-volume center utilizing an implant with a convertible linkage and the potential for anatomic lateral column reconstruction.

METHODS

All patients undergoing primary TEA with the Latitude prosthesis (Stryker) from July 2001 to May 2020 were identified. Patient characteristics, the surgical indication, and implant characteristics were obtained. Additionally, the indications and timing were identified for reoperations. Postoperative radiographs were analyzed to assess cement quality, implant position, lateral column reconstruction, and distal humeral bone loss.

RESULTS

Two hundred and nineteen TEAs were performed in 206 patients; 162 (74.0%) were in female patients, the mean patient age was 61 years (range, 23 to 95 years), and the mean follow-up was 11.8 years (range, 2 to 21 years). The most common indication for surgery was sequelae of trauma (36%). Ninety elbows (41.1%) required 200 reoperations at a mean of 19.6 months. Forty TEAs (18.3%) required revision of nonmodular implants, with 14 (6.4%) undergoing definitive explantation. The 5 and 10-year survivorship was 86.1% and 79.7%, respectively. The most common of the reasons for revision was aseptic loosening (53.8%), and the most common cause for non-revision reoperation was infection (23%). Younger age and greater follow-up duration were associated with greater revision and reoperation risks. Aseptic ulnar loosening was associated with a short ulnar stem length and component linkage (30% of short linked ulnar stems loosened; p < 0.001). Aseptic humeral loosening was associated with less-than-adequate cement-mantle quality (p = 0.04).

CONCLUSIONS

Extended follow-up of the Latitude prosthesis at a high-volume center demonstrates that TEA continues to be hampered by a high reoperation rate, primarily due to infection and aseptic loosening. Technical factors such as good cement-mantle quality, longer stem length, and unlinked implants may play a role in preventing aseptic loosening. Further work is required to optimize long-term outcomes following TEA through improved understanding of appropriate surgical indications, techniques, and implant utilization.

LEVEL OF EVIDENCE

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

Update on elbow arthroplasties with emphasis on imaging

Elbow arthroplasty is increasing in popularity and can be used to treat many conditions, such as trauma, primary and secondary osteoarthritis, inflammatory arthritis, and osteonecrosis. Total elbow arthroplasty (TEA) is reserved for patients with severe symptoms refractory to more conservative management. In addition to TEA, hemi-arthroplasty, interposition arthroplasty, and resection arthroplasty also play roles in the management of elbow pain. There are specific indications for each type of arthroplasty. Postoperative complications may occur with elbow arthroplasties and may be surgery or hardware related. Imaging is important in both pre-operative planning as well as in post-surgical follow-up. This article reviews the different types of elbow arthroplasties, their indications, their normal postoperative imaging appearances, and imaging findings of potential complications.

Prognostic factors associated with failure of total elbow arthroplasty

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.

Rehabilitation after total or hemi elbow arthroplasty: a systematic review

Introduction

Total and hemi elbow arthroplasty (TEA/HEA) are relatively uncommon orthopedic procedures, but physiotherapists are involved in both pre- and postoperative treatment of people who undergo TEA/HEA. The purpose of this article is to summarize existing knowledge about the effects of rehabilitation versus standard care after total and hemi elbow arthroplasty (TEA/HEA).

Methods

A systematic literature review was conducted searching Ovid MEDLINE ®, SweMED+, Cochrane, Embase, AMED and PEDro. "The Preferred Reporting Items for Systematic Review and Meta-Analysis" was followed.

Results

No one has studied the effects of rehabilitation after TEA/HEA. The aim of the only study included was to assess the safety and length of hospital stay (LOS) after omission of casting, start of early mobilization and implementation of functional discharge criteria. Results show that the non-casting cohort had a shorter mean LOS (5.4 days) than the index cohort (6.2 days). The cohort with functional discharge criteria had a shorter mean LOS (3.8 days) than the cohort without functional discharge (5.4 days).

Conclusion

Effects of rehabilitation components or programs after TEA/HEA are still unknown. It is important to focus on the lack of evidence in this field, and plan for more studies to come.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Valgus instability and related factors beyond 2 years following unlinked total elbow arthroplasty

HYPOTHESIS AND BACKGROUND

Total elbow arthroplasty (TEA), categorized into linked and unlinked types, is a commonly reported treatment for rheumatoid arthritis of the elbow. Although unlinked TEA preserves bone, it may result in instability. This study aimed to assess the outcomes of unlinked TEA in rheumatoid arthritis of the elbow beyond 2 years and to identify factors correlating with postoperative valgus instability of unlinked TEA.

METHODS

This study included patients who underwent TEA for rheumatoid arthritis of the elbow at our department between August 2009 and January 2017, with a follow-up period exceeding 2 years. Elbow joint range of motion (ROM) and clinical scores were evaluated preoperatively and at the final follow-up. Factors contributing to valgus instability, such as the Larsen grade, sex, age, side, preoperative ROM, postoperative ROM, implant placement, preoperative carrying angle, and the use of biological disease-modifying antirheumatic drugs (bDMARDs), were also assessed.

RESULTS

This study encompassed 26 elbows from 23 patients, with a mean patient age at surgery of 64.8 years and a mean follow-up duration of 92.4 months. Significant improvements were observed in the ROM (extension: from -31° preoperatively to -21° postoperatively [P = .02], flexion: from 116° to137° [P < .001]), Japanese Orthopaedic Association-Japan Elbow Society Elbow Function Score (from 45.9 to 86.3 points [P < .001]), and Mayo Elbow Performance Score (from 43.6 to 91.7 points [P < .001]). At the last follow-up, 2 elbows exhibited radiolucent lines around the humeral stem, whereas 7 had valgus instability. Factors correlated with valgus instability included total arc at the final follow-up, preoperative carrying angle, and the use of bDMARDs.

DISCUSSION AND CONCLUSION

Unlinked TEA demonstrated favorable midterm outcomes for rheumatoid arthritis of the elbow, albeit with occasional valgus instability. Surgeons should consider preoperative carrying angle and bDMARD use, and exercise caution regarding intraoperative extensions.

Treatment of post-traumatic complete bony ankylosed elbow using total arthroplasty and hernia patch - A case report

INTRODUCTION AND IMPORTANCE

The elbow is one of the most mobile joints, and its movement is very important. Bony ankylosed elbow is an uncommon condition leading to complete loss of activity of elbow, and then lead to severe disability and limitation in activities of daily living.

CASE PRESENTATION

A 63-year-old woman sustained comminuted fracture of left distal humerus. She underwent open reduction and internal fixation by plates. After the plates were removed in 2016，stiffness developed.The elbow was stable but fixed at 90°，there was no vascular injury or deficit in sensory and motor function of the ulnar nerve. She hopes to eliminate pain and restore normal mobility compatible with ADL.

CLINICAL DISCUSSION

Complete bony ankylosis of the elbow joint may be caused by trauma, rheumatic disease, burns, congenital stiffness and other conditions. Even with the compensation of shoulder and wrist, it will still have a great impact on upper limb function. Whether to treat mainly depends on whether the patient has the require to improve the functionality and return to daily activities. Treatment methods are very limited, including interposition arthroplasty and TEA. Defect of soft tissue appeared was seen in our case, Hernia Patch was innovatively applied to reconstruct the defect of soft tissue and maintain continuity of elbow extension mechanism.

CONCLUSION

Patients with post-traumatic elbow joint ankylosis were suffered from severe bony abnormalities, but also soft tissue contracture or defects due to multiple operations and trauma. We present a case of complete bony ankylosed elbow treated with total elbow arthroplasty and Hernia Patch.

Failure of the linkage mechanism in a semi-constrained total elbow arthroplasty is a rare and unpredictable event: a review of seven cases

PURPOSE

Linked component of total elbow arthroplasty (TEA) consisted of bushing and locking pins. Failure of linked components is a rare complication of TEA. This study aims to investigate the mechanism and consequence of failure of the linkage mechanism in TEA surgeries.

METHODS

Between 2010 and 2021, five patients received revision operation due to linked component failure. Besides, two patients underwent primary operation at another institute were also analyzed due to failure of the linkage mechanism.

RESULTS

All seven patients underwent primary TEA and mean age for primary TEA was 48 (range, 27-62). Two patients had TEA for post-traumatic arthritis, three patients for rheumatoid arthritis, and two patients for comminuted distal humerus fracture. The average time between primary TEA and revision TEA for linked component failure was 13.6 years. Three bushing wear and four locking pin dissociation were diagnosed according to pre-operative radiography. Elbow pain and swelling are the most common clinical symptoms. Severe osteolysis, periprosthetic fracture, and stem loosening were noted in three bushing wear cases. In four dissociation of locking pin cases, breakage of male locking pin phalanges was demonstrated in two patients. For revision procedures, both the locking pins and bushings were replaced. No patients in the study required additional surgery after the revision operation for linked component failure.

CONCLUSION

Osteolysis, component loosening, periprosthetic fracture may be expected after linked component failure. Patients should be regularly followed up from short-term to long-term with radiography. Early diagnosis and intervention with linked component exchange can prevent extensive revision surgery.

Elbow joint loads during simulated activities of daily living: implications for formulating recommendations after total elbow arthroplasty

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.

The management of elbow trauma from a historical perspective

The origins of contemporary orthopedics can be traced all the way back to antiquity. Despite the absence of modern imaging techniques, a few bright minds were able to lay the groundwork for understanding these fractures. This historical review will cover the process behind the various treatments for elbow fractures, such as splinting and casting, mobilization, amputation, fracture fixation, arthroplasty, and arthroscopy.

The 5-Item Modified Frailty Index for Risk Stratification of Patients Undergoing Total Elbow Arthroplasty

BACKGROUND

Frailty, quantified using the 5-item modified frailty index (mFI-5), has been shown to predict adverse outcomes in orthopaedic surgery. The utility in total elbow arthroplasty (TEA) patients is unclear. We evaluated if increasing frailty would correlate with worse postoperative outcomes.

METHODS

A retrospective assessment of patients in the American College of Surgeons National Surgery Quality Improvement Program undergoing primary TEA was performed. The mFI-5 was calculated by assigning 1 point for each comorbidity (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status). Poisson regression was used to evaluate mFI-5 scores on complications, length of stay (LOS), and adverse discharge. A significance threshold was at P < .05.

RESULTS

In total, 609 patients were included; 34.5% (n = 210) were not frail (mFI = 0), 44.0% (n = 268) were slightly frail (mFI = 1), and 21.5% (n = 131) were frail (mFI ≥ 2). As mFI score increased from 0 to ≥ 2, the following rates increased: any complication (9.0%-19.8%), major complication (11.0%-20.6%), cardiac complication (0.0%-2.3%), hematologic complication (3.3%-9.2%), adverse discharge (2.9%-22.9%), and LOS from 2.08 to 3.97 days (all P < .048). Following adjustment, Poisson regression demonstrated patients with a mFI ≥ 2 had increased risk of major complication (risk ratio [RR]: 2.13; P = .029), any complication (RR: 2.49; P = .032), Clavien-Dindo IV complication (RR: 5.53; P = .041), and adverse discharge (RR: 5.72; P < .001).

CONCLUSIONS

Frailty is not only associated with longer hospitalizations, but more major complications and non-home discharge. The mFI-5 is a useful risk stratification that may assist in decision-making for TEA.

Outcomes After Acute Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures

Purpose

Compare outcomes of acute versus delayed total elbow arthroplasty (TEA) following distal humerus fractures (DHF).

Methods

This retrospective study included 39 patients who underwent primary TEA with semiconstrained implants for DHF, either within 4 weeks of their injury or after failing initial open reduction and internal fixation (ORIF) or nonsurgical management, between June 1, 2003 and February 1, 2018 with minimum 1-year follow-up. Our outcome measures included QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score, complications, reoperations, and range of motion (ROM). Demographics, clinical variables, and outcomes were compared using the Student's t-test, Mann-Whitney U test, and Fisher's exact test as appropriate. Kaplan-Meier curves for mortality, implant survivorship, and reoperation were created.

Results

Our patients were categorized into acute TEA (n = 22), ORIF to TEA (n = 10), and nonsurgical to TEA (n = 7) treatment groups. Additional analysis was performed comparing acute to delayed TEA, which combined data from failed ORIF and nonsurgical cohorts. The median follow-up, average age, and median Charlson comorbility index were similar between groups. The most common fracture pattern was AO13C. At median follow-up of 5.8 years, QuickDASH differed between cohorts: mean of 31 (SD 19) in acute TEA and 52 (SD 27) in delayed TEA, which further subdivided to 44.2 (SD 25) in failed ORIF and 76 (SD 23) in failed nonsurgical management. Poorer QuickDASH scores at final follow-up were associated with delayed TEA, initial nonsurgical management, and depression. Surgical complications were associated with delayed TEA. Higher Charlson comorbidity index was associated with death. No variables were associated significantly with ROM, revision, or reoperation.

Conclusion

Comminuted DHFs are difficult to treat in the elderly with high rates of complication and poor function after surgery. Our study suggests TEA performed acutely result in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management.

Type of Study/Level of Evidence

Therapeutic, III.

Prognostic factors associated with failure of total elbow replacement: a protocol for a systematic review

INTRODUCTION

Total elbow replacement (TER) has higher failure rates requiring revision surgery compared with the replacement of other joints. Understanding the factors associated with failure is essential for informed decision-making between patients and clinicians, and for reducing the failure rate. This review aims to identify, describe and appraise the literature examining prognostic factors for failure of TER.

METHODS AND ANALYSIS

This systematic review will be conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Electronic literature searches will be conducted using Medline, EMBASE, PubMed and Cochrane. The search strategy will be broad, including a combination of subject headings (MESH) and free text search. This search will be supplemented with a screening of reference lists of the included studies and relevant reviews. Two independent reviewers will screen all search results in two stages (title and abstract, and full text) based on the Population, Index prognostic factor, Comparator prognostic factor, Outcome, Time and Setting criteria. The types of evidence included will be randomised trials, non-randomised trials, prospective and retrospective cohort studies, registry studies and case-control studies. If the literature lacks enough studies, then case series with 50 or more TERs will be considered for inclusion. Data extraction and risk of bias assessment for included studies will be performed by two independent reviewers using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies for Prognostic Factors and Quality In Prognostic Studies tools.Meta-analyses of prognostic estimates for each factor will be undertaken for studies that are deemed to be sufficiently robust and comparable. Several challenges are likely to arise due to heterogeneity between studies, therefore, subgroup and sensitivity analyses will be performed to account for the differences between studies. Heterogeneity will be assessed using Q and I2 statistics. If I2>40% then pooled estimates will not be reported. When quantitative synthesis is not possible, a narrative synthesis will be undertaken. The quality of the evidence for each prognostic factor will be assessed using the Grades of Recommendation Assessment, Development and Evaluation tool.

PROSPERO REGISTRATION NUMBER

CRD42023384756.

Revision Arthroplasty in the Challenging Elbow

Compared with hip and knee arthroplasty, total elbow arthroplasty (TEA) has a higher complication rate and lower survivorship. Modern TEA implants most commonly require revision due to implant loosening, infection, and periprosthetic fracture. Concerns with revision TEA include handling of the soft tissues and possible necessity of flap coverage, triceps management, preservation of bone stock, and management of concurrent infection or fracture. In this review, we will discuss preoperative evaluation of the failed elbow arthroplasty, surgical approaches, techniques for revision, outcomes, and complications following revision total elbow arthroplasty.

Outcomes of Revision Unlinked Total Elbow Arthroplasty for Rheumatoid Elbow

Background: Although unlinked total elbow arthroplasty (TEA) is a treatment option for end-stage rheumatoid arthritis (RA) of the elbow, its long-term outcomes were inferior. Moreover, revision TEA could be technically challenging. The unlinked TEA procedure comprises the ease of implant removal at revision and advantage of bone preservation. This study evaluated the clinical outcomes in patients who underwent revision TEA using primary unlinked TEA for rheumatoid elbows. It also aimed to determine whether selecting the unlinked prosthesis for the primary TEA would make revision more accessible and successful. Methods: We retrospectively reviewed data of 13 consecutive patients (14 elbows) who underwent revision TEAs for implant failure due to different aetiologies, excluding septic loosening. Three different unlinked TEA implants were used: the Kudo type-5 with all-polyethylene (AP) ulnar component, Kudo type-5 with metal-backed (MB) ulnar component and K-Now TEA. We evaluated the patients' pre- and postoperative outcomes, including the range of motion, pain score and Mayo Elbow Performance Index (MEPI). Results: Among the 14 elbows, 11 were revised using the Kudo type-5 ulnar component (nine and two with AP and MB ulnar component, respectively), and three using the K-Now. We found that each model of TEA had different tendencies to indication for revision surgery. Three more resulted in further failure. The clinical outcomes were assessed in the 11 surviving elbows. Eight of the 11 elbows showed no pain at the final follow-up. However, the remaining three showed only mild pain. The MEPI revealed that seven cases were excellent, two were good and two were fair. Conclusions: The mode of implant failure was largely dependent on the implant design. Furthermore, partial revision with the same implant design was sufficient in managing implant failure in the early phase. However, conversion from unlinked to linked design could be recommended in patients with progressive failure or instability. Level of Evidence: Level IV (Therapeutic).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Distal Humeral Replacement in Patients with Primary Bone Sarcoma: The Functional Outcome and Return to Sports

Distal humeral replacement (DHR) is a limb-salvage option for the endoprosthetic reconstruction of bone defects following the resection of a primary bone sarcoma. As primary bone sarcomas are only occasionally located around the distal humerus, there is a paucity of information regarding postoperative function, and patients' resumption of sporting activities. With advances in diagnostics and in surgical and oncological treatment leading to an increased patient life expectancy and higher quality of life, patients' functional outcome and return to sports activities are of increasing interest. Between 1997 and 2021, a total of 24 patients underwent DHR with a single-design modular implant at a tertiary sarcoma center. A total of 14 patients who died of their disease were excluded, leaving a study cohort of 10 patients, with a median age of 30 years on the day of surgery (IQR 20-37). At the last follow-up, after a median of 230 months (IQR 165-262), the median MSTS was 19 (IQR 13-24), the median TESS was 79 (IQR 66-87), the median SEV was 38% (IQR 24-53), the median TS was 6 (IQR 4-7), and the median WAS was 3 (IQR 1-8). Among the variables of gender, surgery on the dominant extremity, intraoperative nerve resection, extra-articular tumor resection, chemotherapy, radiotherapy, and revision surgeries, none were associated with a better/lower functional outcome score or return to sports activities. However, a higher level of sports performance prior to diagnosis (WAS > 10) was associated with a higher level of sports performance postoperatively (p = 0.044).

A Soft-Tissue Landmark to Assess Humeral Component Rotation in Total Elbow Arthroplasty

HYPOTHESIS

Assessing the rotational alignment of the humeral component during total elbow arthroplasty is dependent upon bony landmarks that can be absent or altered in cases of distal humerus fractures, revision arthroplasty, severe bone loss, or deformity. We hypothesize that the intermuscular septum can be used as a reliable soft-tissue landmark to set the rotation of the humeral component intra-operatively when previously described bony landmarks are not reliable or present.

MATERIALS AND METHODS

Forty-eight unpaired cadaveric human subjects (mean age and standard deviation 63 ± 12 years; 24 males, 24 females) underwent computed tomography (CT) scans. The geometric centers of the trochlea and capitellum were assessed, and the line through these two points was set as the flexion-extension axis (FEA) of the elbow. The intermuscular septum axis (IMSA) was drawn proximal to the olecranon fossa and at least 4 cm proximal to the most distal point of the articular surface, where the posterior humeral cortex was flat. The angles between the FEA and IMSA were calculated and compared using a two-tailed t-test. Regression analysis was used to assess the inter- and intra-observer reliability of the IMSA.

RESULTS

The IMSA was externally rotated 10.3° ± 2.8 compared to the FEA (p < 0.001 and confidence interval (CI) of 2.8 with α set to 0.01). The inter- and intra-observer reliability of the IMSA was high, with an R-value of 0.91 and 0.97, respectively.

CONCLUSIONS

The intermuscular septum can be used as a soft-tissue landmark to set humeral component rotation and is 10.3° externally rotated with respect to the FEA of the ulnohumeral joint.

Intraoperative modification of total elbow arthroplasty implants

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.

Total elbow arthroplasty with tricep turn-down flap in an old unreduced elbow dislocation: A case report

INTRODUCTION AND IMPORTANCE

The treatment preference for neglected elbow dislocation is by open reduction and lengthening the tricep muscle. If the dislocation is not reduced for more than 6 months, degenerative resorption would have occurred. We did total elbow arthroplasty (TEA) with a tricep turn-down flap for the management in this case. The use of a tricep flap for tricep shortening after unreduced elbow dislocation has been reported in previous publications but none used a turn-down flap.

CASE PRESENTATION

An 82-year-old woman came to the orthopedic outpatient clinic with pain and discomfort on her right elbow. The arm affected by the injury was her dominant hand, restricting her from farming and leisure activities. Exploration findings confirmed the presence of a dislocated elbow with associated soft tissue complications. The cartilage was degeneratively destructed, and the tricep muscle was retracted.

CLINICAL DISCUSSION

In our case, tricep shortening was managed with elongation using a turn-down flap. The lack of soft tissue layers and thin fibrous fascias results in tension-vulnerable TEA surgical wounds. This is caused by the insufficient coverage of the joint, which leads to wound complications. Previous studies of turn-down flap procedures showed good flap survival and functional outcomes.

CONCLUSION

Tricep turn-down flap could be an option for tricep lengthening procedures in unreduced neglected elbow joint dislocation.

Implant survival of total elbow arthroplasty: analysis of 514 cases from the Dutch Arthroplasty Registry

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions.

Elbow Arthritis

Elbow arthritis is an uncommon condition that can cause debilitating pain, stiffness, or instability. The most common etiologies include rheumatoid arthritis, posttraumatic arthritis, and primary osteoarthritis. Treatment begins with nonsurgical modalities, including activity modification, anti-inflammatories, hand therapy, and corticosteroids. Operative intervention may be considered once nonsurgical management has failed. Surgical treatment depends on the underlying etiology, chief complaint, patient age, and functional demand. Advances in technology, especially arthroscopic techniques, have expanded the treatment options available to surgeons. The goals of treatment include pain relief and restoration of functional range of motion. The purpose of this article is to review the pertinent soft tissue and osseous anatomy, discuss the etiologies, review the principles of diagnosis and evaluation, and finally, study the treatment options for elbow arthritis.

Revision surgery for periprosthetic elbow infection: eradication rate, complications, and functional outcomes-a systematic review

INTRODUCTION

The aim of this systematic review was to investigate the outcomes of revision surgery after periprosthetic elbow infection (PEI).

MATERIAL AND METHODS

Eighteen studies with 332 PEI that underwent revision surgery were included. Demographics, laboratory and microbiological data, types of implants, surgical techniques with complications and reoperations, eradication rates, and clinical and functional outcomes were reported.

RESULTS

Staphylococcus aureus was the most common microorganism (40%). Pre-operatively, the mean white blood cell count was 8400 ± 4000 per microliter; the mean C-reactive protein level was 41.6 ± 66.9 mg/dl, and the mean erythrocyte sedimentation rate was 45 ± 66.9 mm/h. The Coonrad-Morrey total elbow prosthesis represented 41.2% of the infected implant, and it also represented the most common system used for the PEI revision surgery. Two-stage revision and debridement and implant retention (DAIR) were the most common procedures performed for PEI, and, on the whole, they represented 35.7 and 32.7%, respectively. The eradication rate was 76% with 2-stage, 71% with resection arthroplasty (RA), 66.7% with 1-stage, 57.7% with DAIR, and 40% with arthrodesis (EA). DAIR showed a significantly lower eradication rate than 2-stage (P = 0.003). The mean postoperative Mayo Elbow Performance Score was significantly higher in patients who underwent DAIR, and 2-stage compared with RA (P < 0.001 for all). Postoperative flexion-extension ROM was significantly higher in patients who underwent DAIR compared with 1-stage, 2-stage, and RA (P < 0.001 for all). Moreover, 1-stage and 2-stage showed a significantly greater postoperative flexion-extension ROM compared with RA (P < 0.001 for all). Reoperations occurred in 40% of patients after EA, 33.3% after 1-stage, 26.9% after DAIR and RA, and 24.1% after 2-stage. Conversion to amputation occurred in 2.2% of patients after RA and 1% after DAIR.

CONCLUSIONS

Two-stage revision and DAIR are the most common procedures used to manage PEI; however, the former procedure showed a significantly higher eradication rate. Resection arthroplasty showed a high eradication rate, but postoperative lower clinical and functional outcomes limit the indications for this technique. One-stage procedure showed a limited role in the current practice of PEI treatment.

LEVEL OF EVIDENCE

Level IV.

Elbow joint biomechanics during ADL focusing on total elbow arthroplasty - a scoping review

BACKGROUND

Overloading is hypothesized to be one of the failure mechanisms following total elbow arthroplasty (TEA). It is unclear whether the current post-operative loading instruction is compliant with reported failure mechanisms. Aim is therefore to evaluate the elbow joint load during activities of daily living (ADL) and compare these loads with reported failure limits from retrieval and finite element studies.

METHODS

A scoping review of studies until 23 November 2021 investigating elbow joint load during ADL were identified by searching PubMed/Medline and Web of Science. Studies were eligible when: (1) reporting on the elbow joint load in native elbows or elbows with an elbow arthroplasty in adults; (2) full-text article was available.

RESULTS

Twenty-eight studies with a total of 256 participants were included. Methodological quality was low in 3, moderate in 22 and high in 3 studies. Studies were categorized as 1) close to the body and 2) further away from the body. Tasks were then subdivided into: 1) cyclic flexion/extension, 2) push-up, 3) reaching, 4) self-care, 5) work. Mean flexion-extension joint load was 17 Nm, mean varus-valgus joint load 9 Nm, mean pronation-supination joint load 8 Nm and mean bone-on-bone contact force 337 N.

CONCLUSION

The results of our scoping review give a first overview of the current knowledge on elbow joint loads during ADL. Surprisingly, the current literature is not sufficient to formulate a postoperative instruction for elbow joint loading, which is compliant with failure limits of the prosthesis. In addition, our current instruction does not appear to be evidence-based. Our recommendations offer a starting point to assist clinicians in providing informed decisions about post-operative instructions for their patients.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prótesis unicompartimental de rodilla. Resultados clínico-radiográficos y análisis de la supervivencia del implante

Objetivo: Evaluar los resultados clínicos y radiográficos en pacientes sometidos a artroplastia unicompartimental de rodilla, así como la tasa de complicaciones y la supervivencia del implante. Materiales y Métodos: Estudio descriptivo retrospectivo de 68 pacientes consecutivos (70 rodillas) sometidos a artroplastia unicompartimental de rodilla entre 2013 y 2020, con un seguimiento medio de 57.7 meses (rango 24-105) y una media de la edad de 61 años (rango 34-79). El 46,5% eran hombres. El índice demasa corporal medio era de 29,9 (rango 20-39). El diagnóstico más frecuente fue la artrosis del compartimento femorotibial medial con un varo <7°. Los resultados se evaluaron con la escala analógica visual para dolor y el Knee Society Score (KSS). Se evaluó la incidencia de complicaciones y la tasa de supervivencia del implante. Resultados: La disminución media en la escala analógica visual para dolor fue de 4,4 ± 1,9. Las puntuaciones medias posoperatorias en las escalas funcional y clínica del KSS fueron de 77,4 ± 13,7 y 70,2 ± 17,7, respectivamente. La tasa de complicaciones posquirúrgicas fue del 7% (5 casos). La tasa de reintervención quirúrgica fue del 15,5% (11 pacientes): nueve casos por persistencia del dolor, uno por rigidez articular y otro por aflojamiento aséptico. Conclusiones: La artroplastia unicompartimental de rodilla es una opción terapéutica eficaz para pacientescon gonartrosis unicompartimental de rodilla; se logran buenos resultados clínicos con una aceptable tasa de complicaciones; sin embargo, la tasa de revisión del implante es considerable. Nivel de Evidencia: IV

Total Elbow Arthroplasty from Indian Perspective: A Systematic Review

Background

Total elbow arthroplasty (TEA) provides satisfactory pain relief and restores elbow range of motion and function in patients with end-stage arthritis. Due to advances in implant design and surgical techniques, the indications for surgery have expanded to include various other conditions affecting the elbow. The previous studies and systematic reviews reported satisfactory mid-term and long-term clinical outcomes after TEA with relatively stable complication and revision rates. However, there is lack of information in the literature about the results of TEA in Indian patients.

Methods

Two reviewers performed a comprehensive literature search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in three online databases-Pubmed/MEDLINE, Google scholar and the Cochrane database for clinical trials. Only original studies published in the English literature reporting outcomes of primary TEA in Indian patients were included for analysis. Using pre-defined inclusion and exclusion criteria, articles were screened and the relevant articles identified. Data were extracted with the primary objective to assess pain relief and functional outcome after TEA in Indian patients, and secondary objective to identify indications for surgery, complication rates and incidence of implant removals.

Results

A total of 212 TEAs (210 patients) from ten articles were included in this systematic review. All the TEAs were done using Baksi's semi-constrained sloppy-hinged elbow prosthesis. The most common indication of TEA was post-traumatic sequelae (124 elbows, 58.5%), followed by comminuted intra-articular fracture distal humerus (53 elbows, 25%). At a weighted mean follow-up of 7.5 years, 80.7% cases had complete pain relief. The weighted mean flexion, extension restriction, supination and pronation were 122.6°, 20.8°, 57.3°, and 48.6°; respectively. The weighted mean Mayo Elbow Performance Score was 92.1 points with excellent outcome. Overall, a total of 68 complications were reported (32%) and the implants needed to be removed in 14 elbows (6.6%) including two revisions.

Conclusions

This systematic review found that the functional outcome and pain relief obtained with TEA using Baksi's sloppy-hinged prosthesis in Indian patients were satisfactory overall. The complication rates and implant removal rates were lower than those reported with other patient populations.

The Impact of Cement Mantle Characteristics on Early Loosening in Primary Total Elbow Arthroplasty

PURPOSE

To assess the association between cement mantle characteristics and early radiographic loosening in total elbow arthroplasty (TEA). We aimed to determine whether shorter mantle heights (<20 mm) were associated with loosening.

METHODS

We reviewed primary TEAs from a single healthcare system from 2006 to 2020. TEAs complicated by infection or performed for oncologic conditions were excluded. Initial postoperative radiographs were reviewed to determine cement mantle and component characteristics (mantle quality, mantle height, and component angulation). One-year postoperative radiographs were reviewed to assess for implant loosening, and we compared demographics and radiographic criteria for cases with and without early loosening. We noted whether cases underwent subsequent revision for aseptic osteolysis.

RESULTS

A total of 54 TEA cases were included. Forty percent of ulnar and 24% of humeral mantles were classified as short (between 1 and 19 mm). According to the Morrey classification, 6 (11%) cases had an inadequate cement mantle Twenty-four (45%) cases had radiographic evidence of loosening at 1 year. Of the cases with early loosening, 6 (25%) had initial inadequate mantle quality. There were no inadequate mantles in the group without loosening. There were no statistically significant differences in mantle heights for cases with and without loosening at 1 year after surgery. Eight (33%) cases underwent revision in the group with early loosening compared with 1 (3%) case without early loosening.

CONCLUSIONS

Inadequate cement mantle quality was associated with an increased risk of early aseptic loosening after primary TEA. Cement mantles that extended past the tip of the prosthesis were not associated with loosening. Considering the potential need for future revision and morbidity of cement removal, surgeons should focus on mantle quality and carefully plan mantle height because shorter heights may not be associated with early implant failure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Elbow arthroplasty research methods, outcome domains, and instruments used in clinical outcome studies : a scoping review

AIMS

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

METHODS

A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review.

RESULTS

A total of 362 studies met the inclusion criteria. Most were of total elbow arthroplasty (246; 68%), followed by radial head arthroplasty (100; 28%), distal humeral hemiarthroplasty (11; 3%), and radiocapitellar arthroplasty (5; 1%). Most were retrospective (326; 90%) and observational (315; 87%). The median sample size for all types of implant across all studies was 36 (interquartile range (IQR) 21 to 75). The median length of follow-up for all studies was 56 months (IQR 36 to 81). A total of 583 unique outcome descriptors were used and were categorized into 18 domains. A total of 105 instruments were used to measure 39 outcomes.

CONCLUSION

We found that most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. Many outcomes have been used with many different instruments for their measurement, indicating a need to define a core set of outcomes and instruments for future research in this area.Cite this article: Bone Joint J 2022;104-B(10):1148-1155.

Comparison of the Complications, Reoperations, and Clinical Outcomes between Open Reduction and Internal Fixation and Total Elbow Arthroplasty for Distal Humeral Fractures in the Elderly: A Systematic Review and Meta-Analysis

Distal humeral fractures are challenging injuries seen in the elderly. Open reduction and internal fixation (ORIF) are the gold standard treatments. Total elbow arthroplasty (TEA) is an alternative to ORIF. This study aimed to pool and analyze the outcomes and complications in elderly patients with distal humeral fractures treated with either ORIF or TEA by performing a meta-analysis. We searched the PubMed, Embase, Google Scholar, and Cochrane Library databases for studies that compared the clinical and functional outcomes of ORIF and TEA in patients aged 60 years or older. After screening and performing a quality assessment of the articles, we obtained one randomized control study and nine retrospective comparative studies. The odds ratio and standardized mean difference were used to analyze the differences in outcomes between the two surgical options. In terms of the flexion/extension arc, TEA produced significantly better outcomes than ORIF (p = 0.02). The rates of reoperation and elbow stiffness were significantly lower in the TEA group than in the ORIF group (p = 0.003 and p = 0.04, respectively). However, the functional scores and other ranges of motion (flexion, loss of extension, pronation, supination) after surgery were similar between the two groups. The outcomes from the present meta-analysis can provide guidance when selecting a surgical option for distal humeral fractures in the elderly.

Distal Humerus Morphological Analysis of Chinese Individuals: A Statistical Shape Modeling Approach

Objective

A detailed analysis of the morphology of distal humeral articulation can help in the creation of anatomic prostheses of hemiarthroplasty. This study used statistical shape modeling to evaluate the 3D morphology of the distal humerus in healthy Chinese individuals and to investigate the proper articular morphology differences.

Methods

A statistical shape model (SSM) of the distal humerus was created using CT scans of 106 survey‐confirmed nonpathologic elbows. In addition, the articular components of each principal component (PC) were selected and fitted on the mean mode. The Euclidean point‐to‐mesh distance of articular modes was calculated as a measurement the proper change in the morphology of the articulation.

Results

The first seven PCs jointly accounted for 80.9% of the total variation (44.4%, 12.2%, 7.9%, 5.9%, 4.1%, 3.4% and 3%, respectively). In the mean model, the distance between the medial and lateral epicondyles was 57.4 mm, the width of the articulation was 42.1 mm, and the angle of the transepicondylar line (TEL) and C line was 4.8°. The articular surface differences of the first PC were significant (RMS: 1.43 mm in the −3 SD model and 2.38 mm in the +3 SD model), whereas under other conditions, the differences were not remarkable despite the maximum deformation not exceeding 1 mm.

Conclusion

A novel method (SSM) was used to evaluate the 3D morphology of the distal humerus in healthy Chinese individuals and investigate the proper articular shape differences. We found the proper shape of articular surface basically transformed into one variation pattern which was relevant to the bone size, even though the morphology of distal humerus possessed complicated variation modes. The findings of this study can be helpful to design the next generation of elbow hemiarthroplasty in the future.

[Elbow prosthesis after acute fractures : Indications and technique]

Good to very good clinical results can be achieved in older patients with the implantation of a total elbow prosthesis in cases of distal humeral fractures by taking the morphological features of the fractures, the bone quality as well as the individual patient requirements and variables into account. The most commonly used design is the cemented semiconstrained linked total elbow endoprosthesis. The unlinked prosthesis design and hemiarthroplasty require intact or adequately reconstructable musculoligamentous structures or condyles and a preserved or replaced radial head. The recommended weight limit after total elbow prosthesis as well as potential intraoperative and postoperative complications must be considered and discussed with the patients. A secondary total elbow arthroplasty is also possible after primary conservative treatment approaches, e.g., in the case of contraindicated surgery in the fracture situation, persistent pain and functional restrictions. This article provides an overview of the technique and the appropriate indications.

Recovery From Open Osteocapsular Débridement for Primary Elbow Osteoarthritis Is Rapid and Does Not Depend on Preoperative Motion

Background and Hypothesis

Osteocapsular débridement is a surgical treatment for functionally limiting primary elbow osteoarthritis (PEOA). We hypothesized that postoperative improvement in range of motion (ROM) following elbow osteocapsular débridement could be grouped into predictable patterns. We also hypothesized that significant improvements in ROM frequently take place for up to 6 months after surgery.

Methods

A retrospective chart review of patients who underwent open elbow débridement for PEOA was performed. Demographic information and surgical approach were recorded. ROM data were also collected at preoperative, intraoperative, and postoperative intervals of 2 weeks, 6 weeks, 3 months, and 6 months. Growth mixture modeling and latent class growth analysis were performed to identify groups of motion recovery trajectories, while Student’s t-tests were performed to compare ROM data between intervals.

Results

Our study included 76 patients who underwent open elbow débridement (9 with a lateral approach, 55 medial, and 12 both) for PEOA. The mean preoperative arc of motion was 95° ± 22°. This improved to a mean final motion arc of 127° ± 11 at final follow-up, which was 92% of the mean intraoperative arc. The mean time to achieve final motion was 3 months, with 79% of patients achieving their final ROM arc by this point. Patients achieved an average of 85% of their final arc of motion by the 2-week postoperative visit (92% of final flexion and 61% of final extension). Growth mixture modeling and latent class growth analysis did not identify any statistically significant groupings for postoperative ROM progression trajectories. Arc of motion preoperatively, intraoperatively, and at 2 weeks postoperatively did not correlate with the final arc of motion. There were no characteristics or thresholds of motion which conferred a higher likelihood of achieving a better result postoperatively.

Conclusions

ROM recovery after osteocapsular débridement for PEOA is not dependent on preoperative, intraoperative, or 2-week postoperative arcs of motion. Most of the ROM recovery occurs in the early postoperative period, with flexion restored preferentially faster than extension. The final arc of motion can be expected by 3 months postoperatively. This knowledge has potential benefit in affecting patients’ personal time commitment to rehabilitation and the overall cost for therapy and splinting beyond the 3-month time point.

Revision total elbow arthroplasty using intramedullary strut allograft for aseptic loosening of the humeral stem

Total elbow arthroplasty (TEA) has become a well-accepted treatment option for many pathologies of the elbow joint. Its use in distal humerus fractures in elderly patients has become increasingly popular and has good clinical results. However, with the aging population and the increasing number of TEAs performed, so comes the potential for an increasing number of revision TEA cases. Revision TEA can be extremely challenging. In addition to the technical difficulties of safe exposure and implant removal, reimplantation of a cemented humeral component with loss of bone stock can be a challenging step in this procedure. The purpose of this article was to describe a novel technique to address aseptic loosening of the humeral stem and loss of humeral bone stock with revision of the humeral component using a long-stemmed cemented implant and intramedullary allograft fibular strut bone grafting.

Surgical management of osteoarthritis in the shoulder and elbow

Interesting recent trends are apparent in the setting of shoulder and elbow pathology. There is an increase in utilization of shoulder arthroplasty for osteoarthritis and post traumatic arthritis. At the same time, there remain limited options for osteoarthritis of the elbow particularly in the young and or active patient. This manuscript details surgical options for osteoarthritis at the elbow and shoulder.

Functional outcomes and complications following convertible primary total elbow arthroplasty: A single surgeon series

BACKGROUND

The data on convertible total elbow arthroplasty are limited and primarily based on multiple centre/multiple surgeon series. The aim of this study was to report the mid-term functional outcomes, radiological findings, complications and survivorship of the Latitude total elbow arthroplasty performed by a single surgeon.

STUDY DESIGN & METHODS

The study included 13 patients (10 females, mean age of 72 years and varying indications) over eight years. The Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), range of movements (ROM), Subjective Elbow Value (SEV), satisfaction score (SS) and the revision rate of the implant per 100 observed component years (OCY) were assessed.

RESULTS

The mean follow-up was 5.9 years (3-10 years). The Oxford Elbow Score/Mayo Elbow Performance Score improved from 15 to 42 (p value < 0.005)/26% to 93% (p value < 0.005) respectively. The arc of extension-flexion/supination-pronation improved from 63° to 106° (p = 0.00002)/123° to 142° (p = 0.32) respectively. The Subjective Elbow Value/Satisfaction Score was 83/98 respectively. There was one re-operation for a deep infection. There were no radiologic signs of loosening and the revision rate was 0.15 per 100 observed component years.

CONCLUSIONS

With careful patient selection, convertible total elbow arthroplasty provides patients with good to excellent outcomes and substantial improvements in the range of movements.

Total elbow arthroplasty in elderly trauma patients: adding a new perspective for functional evaluation

PURPOSE

Total elbow arthroplasty (TEA) has evolved over the last years, with satisfactory early results, mainly not only in degenerative arthritis, but also increasingly after trauma. Outcome studies in recently published papers are mainly based on the range of motion (ROM), complication rate as well as patient-reported outcome scales and questionnaires. The purpose of this study was to add a new perspective with the "Purdue Pegboard" skill tests in a homogenous set of elderly trauma patients to contribute to a more precise objective outcome measurement in this specific population.

METHODS

A retrospective review was performed on a consecutive cohort of all patients with age above 60 years that received TEA after trauma. Data from follow-up examinations over a standardized time-schedule within 2 years after TEA were included. Mayo Elbow Performance Score (MEPS), "Disability of Arm, Shoulder and Hand" (DASH) Questionnaire, ROM as well as test-scores using the Pegboard test were evaluated.

RESULTS

Mean age was 76.0 years ± 10.3. Indications for TEA were posttraumatic arthrosis in 68.8% (n = 11) and extensive fractures that could not be reconstructed surgically in 31.3% (n = 5). The mean score of MEPS was 82.81 ± 16.63 and 29.18 ± 12.01 in the DASH. ROM presented with a mean of 109.7° ± 15.4. Patients demonstrated good, but marginally reduced test scores in the Pegboard skill tests in comparison with the healthy reference population. No relevant differences between the arm with and the arm without TEA (0.3 ± 3.6; p = 0.715) were noted after 2 years.

CONCLUSION

In the elderly trauma patient with complex fractures of the elbow, TEA is a good alternative to joint reconstruction using various osteosynthesis techniques. TEA is able to avoid revision surgery after open reduction and internal fixation of complex fractures. In cases of failed reconstruction, it is also a viable secondary procedure in posttraumatic arthrosis. Good outcomes in functionality and dexterity can be achieved. Skill tests like the Purdue Pegboard could add a valuable perspective in assessing functional outcomes after TEA.

Clinical results of a 10-year follow-up of surgical treatment for elbow stiffness in rheumatoid arthritis: A case series

BACKGROUND

Rheumatoid arthritis commonly causes transient limitation of joint motion, but the treatment of persistent stiffness in the rheumatoid elbow has rarely been reported. The purpose of this study was to evaluate the long-term clinical results of surgical treatment of rheumatoid elbow stiffness.

METHODS

Surgical treatment, including open arthrolysis with hinged external fixation, total synovectomy, and ulnar nerve release and anteriorization, was performed in 48 elbows in 43 patients with rheumatoid arthritis and early joint destruction. Mobility (flexion-extension and pronation-supination), Mayo Elbow Performance Score (MEPS), visual analog scale (VAS) score, muscle strength, nerve symptoms, postoperative complications, and recurrent synovitis were evaluated 9-11 years (average, 9.88 years) postoperatively.

RESULTS

The mobility of the elbow was significantly improved over the preoperative period either in extension, flexion, protonation, supination (P < .001, P < .001, P < .001, P = .002). The mean MEPS was significantly improved from 56.25 points (range, 30-90) to 87.40 points (range, 40-100) (P < .001). The pain was relieved, and the mean VAS score was reduced from 3.56 (range, 0-8) to 1.08 (range, 0-5) points (P < .001). Preoperative ulnar nerve symptoms were observed in 17 patients and relieved in 10 (59%) patients, and the mean Amadio score was raised from 6.9 (range, 3-9) to 7.96 (range, 4-9) points (P < .001). Through surgical treatment and postoperative rehabilitation, the mean grip strength of the patients was significantly improved from an average of 9.01 (range, 3.4-18.5) to 17.56 kg (range, 3.9-40.2) (P < .001). Five elbows developed recurrent synovitis, and one underwent total elbow arthroplasty. Postoperative complications were uncommon and not severe.

CONCLUSION

Surgical treatment is a reliable procedure for rheumatoid elbow stiffness and can be effective in improving elbow mobility, function, muscle strength, pain relief, and relief of nerve symptoms.

The Van Gorder approach for total elbow arthroplasty

BACKGROUND

Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA.

METHODS

All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed.

RESULTS

A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits.

CONCLUSIONS

This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.

Outcomes of radial head implants in total elbow arthroplasty

BACKGROUND

There is no consensus on the management of the radial head in total elbow arthroplasty (TEA). In 3-part TEA designs, options include radial head retention, excision, or arthroplasty. Biomechanical studies suggest improved varus-valgus stability with radial head implants in unlinked total elbows. Unfortunately, complications with radial head implants have been common with historical designs. The aim of this study was to evaluate the clinical and radiographic outcomes of radial head implants in a current 3-part TEA and identify risk factors for mechanical failure.

METHODS

We performed a retrospective review of radial head implants with a 3-part convertible TEA from 2001 to 2016. Clinical outcomes, functional scores, and radiographic outcomes were recorded. The preoperative radiocapitellar alignment was measured using the radiocapitellar ratio (RCR). Statistics include descriptive statistics, t tests, logistic regression, and Kaplan-Meier survival curves.

RESULTS

We identified 44 TEAs in 40 patients, with a mean follow-up period of 7.2 years. The average age at surgery was 58 ± 11 years; 80% of the TEAs were performed in women. The indication for surgery was rheumatoid arthritis in 86%; of the implants, 61% were unlinked. The average preoperative RCR was 10.7 ± 17.9. Postoperatively, 2 radial head implants (5%) were subluxated, 6 (14%) were dissociated, and 2 (5%) were dissociated with implant dislocation on radiographic review. The revision rate for radial head subluxation, dissociation, or dislocation was 7% (n = 3). Univariate logistic regression showed that male sex (P = .002), abnormal preoperative RCR (P = .02), linked implant (P = .03), and older age (P = .04) were risk factors for radial head subluxation, dissociation, or implant dislocation. A multivariate model with all 4 variables did not demonstrate statistical significance.

CONCLUSION

The incidence of radial head arthroplasty subluxation, dissociation, or implant dislocation was high (23%). In a univariate logistic regression model, male sex, abnormal preoperative RCR, and linked implants were all statistically significant risk factors for mechanical failure of the radial head implant. Our multivariate model did not show any statistically significant independent risk factors. Polyethylene wear or loosening of the radial head implants was not observed in this study; failure of the bipolar linkage was the principal mode of failure. Although further study is required, caution should be used when considering inserting a radial head implant in male patients with significant preoperative radiocapitellar malalignment. Radial head subluxation or dissociation is not an absolute indication for revision in an asymptomatic patient. Improvements in radial head implant designs in TEA are needed.

Mid-term results of the Latitude primary total elbow arthroplasty

BACKGROUND

The Latitude total elbow prosthesis is a third-generation implant, developed to restore the natural anatomy of the elbow. Literature on this prosthesis is scarce. The aim of this study was to analyze the mid-term results of the Latitude total elbow prosthesis.

METHODS

We retrospectively evaluated 62 patients (21 men and 41 women). The mean age at the time of surgery was 65 years (range, 28-87 years). The main indication for surgery was inflammatory arthritis. The outcome measures were complications, reoperations, self-reported physical functioning, pain, satisfaction, objectively measured physical functioning, and radiologic signs of loosening. Kaplan-Meier survival analysis was used to determine survival with revision as the endpoint.

RESULTS

Sixty-nine primary Latitude prostheses were placed in 62 patients between 2008 and 2019. Six patients (7 prostheses) died, 3 elbows underwent revision, and 9 patients were lost to follow-up. A total of 44 patients (50 prostheses) were available for follow-up. The mean length of follow-up was 51 months (range, 10-144 months). Kaplan-Meier survival analysis showed a survival rate of 82% at 10 years after surgery. The main reason for revision was aseptic loosening. Radial head dissociation was seen in 8 patients (24%), but none had complaints. Self-reported and objectively measured physical functioning yielded good results, although 23 patients (46%) did show radiolucent lines on radiographs.

CONCLUSION

Latitude total elbow arthroplasty is considered a successful procedure with low pain scores, high patient satisfaction, and good physical functioning. Survival rates nonetheless remain low and complication rates remain high yet are comparable to those of other elbow arthroplasties. We recommend biomechanical studies to concentrate on specific postoperative loading instructions to minimize wear and consequent loosening.

Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review

Background

Distal humerus fractures (DHFs) pose a treatment challenge in elderly patients. We sought to systematically review and report the clinical outcomes of the nonoperative approach (eg, "bag of bones") for the treatment of these injuries and the rate of conversion to delayed surgery.

Methods

A comprehensive review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Studies involving outcomes after nonoperative treatment of DHF in patients >65 years of age were included from 1985 to present. Data regarding patient age, DHF type, nonoperative treatment method, complications, conversion to delayed surgery, range of motion, union rate, and surgeon- and patient-reported outcome measures were extracted.

Results

A total of five studies met inclusion criteria (all level IV evidence), yielding a total of 143 patients (mean age: 73.5 years to 87.4 years) with 7.1 months to 55 months of follow-up. The mean Mayo Elbow Performance Index scores were good to excellent across several studies (range 83-93.1). Multiple studies reported good range of motion (mean arc of motion: 81 to 106 degrees) and low levels of upper extremity disability (mean Quick Disability of the Arm-Shoulder-Hand scores: 31.3 to 38.5) at the final follow-up. The rate of conversion to total elbow arthroplasty and operative fixation ranged from 0% to 7.5% and 0% to 5%, respectively.

Conclusion

Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. This information is important for patient counseling and treatment decision-making.

Assessing the hospital volume-outcome relationship in total elbow arthroplasty

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.

Patient satisfaction with total joint replacement surgery for rheumatoid arthritis: a questionnaire survey for the 2020 update of the Japan college of rheumatology clinical practice guidelines

OBJECTIVE

This study aimed to evaluate satisfaction with total joint replacement (TJR) surgery among patients with rheumatoid arthritis (RA).

METHODS

We mailed questionnaires to randomly selected members of the Japan Rheumatism Friendship Association, stratified by age and prefecture, throughout Japan. The questionnaire collected demographic and clinical characteristics as well as patients' satisfaction with TJR and their current therapy.

RESULTS

Of the 1156 patients who returned the questionnaire, 339 (29.3%) responded that they had had TJR of any type. The mean age was 66.6 years, and 94.4% were women. The mean time period from the hip and knee TJR was 14-15 years. Over half of the patients who had had TJR were satisfied with the results, especially those who had had hip (89.6%) and knee TJR (87.3%), who reported a high level of satisfaction. Multivariable linear regression analysis revealed that, in patients with knee TJR, satisfaction with current therapy was significantly related to whether they were satisfied with the results of the surgery.

CONCLUSION

Most patients with RA who had undergone TJR were satisfied with the results even after a long period of time, and their level of satisfaction was associated with their satisfaction with current therapy.