Shoulder and elbow arthroplasty: one-stage or two-stage

Shoulder and Elbow Surgery in Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory arthropathy that manifests itself prior to the age of sixteen years with symptoms lasting six weeks or longer. As JIA frequently effects the upper extremities, activities of daily living become compromised during the stages of development when young adults are striving for independence. Symptomatology includes ankylosing, pain and early growth plate closure. Patients with joint involvement prior to growth plate closure have the most destruction in terms of joint abnormality and surgical complexity.Medical management of JIA has allowed for better non-surgical management, yet, there is a continued need to understand the appropriate surgical intervention and order for the greatest functional gains. Comparative studies have shown that varied results as to whether the shoulder replacement should supersede the elbow replacement or should that be reversed or both joint replacements done simultaneously. Our experience found a more significant functional improvement after total elbow replacement due to the unpredictable nature from the shoulder replacement outcomes and an inability for patients to do simple tasks such as bringing a cup to their mouths or handling a toothbrush. The exception to this occurs if the ipsilateral shoulder joint is severely limited to the point that the stressors placed on the elbow due to compensation will lead to early loosening or failure of the elbow joint replacement.Various methods for performing joint replacement of the shoulder and elbow in the JIA population will be discussed. Soft tissue integrity including the functional status of the rotator cuff will be a consideration for which surgical procedure should be considered. Surgical approaches for the elbow present fewer options for improving pain and function in this patient population. Pre, peri and postoperative management is reviewed as careful attention to irregular bony dimensions and dysmorphic anatomy precludes the use of standard implants.Total shoulder and total elbow arthroplasty should be considered in the JIA population where pain and significant functional compromise are present. The order of procedures is dependent on multiple factors and expected outcomes. Educating patients on postoperative expectations over the lifespan is an important part of surgical management for patients with JIA.

Shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in the elderly

PURPOSE

The aim of this paper was to present our experience and the outcomes in 3 elderly patients who underwent combined shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in our center. Also, we evaluate difficulties in their treatment and report their final follow-up.

MATERIAL AND METHODS

Three cases of elderly patients who underwent shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus were reviewed. Demographic, clinical, and radiological data were analyzed. Also, Constant Shoulder Score, Mayo Elbow Performance Score, Short-Form Health Survey, and four-point Likert scale were evaluated.

RESULTS

All patients were females (100%). Mean age was 75 years (range 73-78). Mean follow-up was 36.6 months (SD 11.5). Mean time between injury and surgery was 12 days (SD 7.6). The 3 patients had a displaced and comminuted fracture of the humeral head (4-part, by Neer classification) and a comminuted intraarticular fracture of the distal humerus (13-C3, by AO classification). One patient presented a wound infection that required debridement. Despite the complications, at final follow-up, all patients showed a sufficient capacity to perform comfortably in their daily activities. Radiographs showed good fixation of all components, without evidence of prosthetic loosening or migration. All evaluated scores had good or excellent results.

CONCLUSIONS

Our study provides further evidence that the shoulder and elbow arthroplasty could be a reliable management for ipsilateral fractures of the proximal and distal humerus in the elderly. In our study, this technique showed in the final follow-up patient's good outcomes.

Concomitant Total Wrist and Total Elbow Arthroplasty in a Rheumatoid Patient

Background Concomitant arthroplasty has been described to have several benefits over multistage procedures. Ipsilateral total elbow and total shoulder arthroplasty has been reported with good outcomes in upper extremity concomitant arthroplasty. Case Description A 65-year-old woman presented with ipsilateral left-sided wrist and elbow joint degeneration as a result of longstanding rheumatoid arthritis. Concomitant total wrist and total elbow arthroplasty was performed with satisfactory results at both joints. She tolerated the procedure well and had an uneventful clinical course postoperatively. Literature Review Currently, no literature exists that describes one-stage total wrist and total elbow arthroplasty. Individually, total wrist and total elbow arthroplasty have both been reported to result in good outcomes and patient satisfaction. Previous studies have reported the utility of concomitant ipsilateral upper extremity procedures with a one-stage total elbow and total shoulder arthroplasty having been identified as a cost-saving procedure with expedited return to functionality versus a two-stage procedure. Clinical Relevance Patients with ipsilateral degenerative changes in the wrist and elbow should be considered on an individual case basis for concomitant total wrist and total elbow arthroplasty.

Is there sufficient evidence to support intervention to manage shoulder arthritis?

BACKGROUND

We explore the nature, extent and validity of research studies concerning the management of shoulder arthritis to identify whether current management recommendations are adequate.

METHODS

A full electronic search for relevant studies published between 2002 and 2012 was performed. The search focused on level 1 and level 2 studies. Full texts of selected articles were retrieved and assessed for quality against validated criteria.

RESULTS

Four hundred and eleven studies were identified on the initial search and screened. Sixteen studies were selected for inclusion in the review. The studies identified were unable to provide a clear indication of best intervention for shoulder arthritis. The inclusion of a range of shoulder pathologies in some studies and the diversity in outcome measures used made it difficult for systematic reviews to effectively pool data. Better outcomes have been shown with total shoulder replacement over hemiarthroplasty for shoulder osteoarthritis; however, primary studies were often of limited quality. Sparse evidence is available for all other interventions, regardless of whether operative or non-operative.

CONCLUSIONS

The present review highlights the need for standardization of outcome assessment following treatment of shoulder arthritis. More rigorous and robust primary studies are needed to guide clinical practice on the best interventions for arthritis of the shoulder.

Total elbow arthroplasty in bleeding disorders: an additional series of 8 cases

BACKGROUND

Total elbow arthroplasty (TEA) is a surgical option for an arthropathy secondary to a bleeding disorder. The literature consists of small case series. Our series provides further understanding into the outcomes of TEA in this population of patients.

METHODS

Five patients underwent 8 primary TEAs for a bleeding disorder. Average age at time of surgery was 47 years. Four patients had hemophilia type A and 1 had von Willebrand disease. Clinical outcomes were evaluated with the Mayo Elbow Performance Score (MEPS) and the visual analog scale (VAS) for pain. Follow-up radiographs were evaluated for signs of loosening and infection.

RESULTS

Revision surgery was performed in 3 TEAs. Two revisions were performed for aseptic loosening (104 and 118 months postoperatively). The third elbow underwent an excision arthroplasty for a deep infection 44 months postoperatively. Mean follow-up for the primary TEAs still in situ (5 elbows) was 114 months. The mean VAS score improved from 8 to 0 and MEPS from 35 to 95. The mean flexion arc improved from 70° to 100°, and rotation improved from 60° to 160°. Mean follow-up for the revised TEAs (3 elbows) was 94 months. The mean VAS score improved from 7 to 0 and the MEPS from 40 to 85. The mean flexion arc improved from 60° to 95°, and rotation improved from 70° to 160°.

CONCLUSIONS

Excellent clinical outcomes and an acceptable survival rate for TEAs, comparable with the nonhemorrhagic population, can be achieved in patients with bleeding disorders. Revision arthroplasty in this group of patients yields good clinical outcomes at medium-term follow-up.

Update on the state of outcome measurement in total elbow arthroplasty research: identifying a need for consensus

BACKGROUND

There is little consensus for a standard set of metrics to express outcome after total elbow arthroplasty. In order to set the stage for future work toward a core set of measurement tools, our goal was to gather a complete view of the outcomes used in total elbow arthroplasty research, the concepts of their focus, and their quality as measures of the target concept.

METHODS

We reviewed the outcome measures for total elbow arthroplasty presented in the literature from 2004 to 2011 in terms of the instruments used and their concepts of focus. We reviewed the reliability, validity, and responsiveness of the prevailing measurement tools.

RESULTS

Of the seventy-two articles identified, 90% (sixty-five) used elbow-specific aggregate outcome measures, which combine concepts, such as physiological variables, with symptom status and functional status. The Mayo Elbow Performance Score, or a variation of that scoring system, was used in fifty-four (75%) of the seventy-two articles. Most outcomes pertained to biological and physiological variables, with fewer outcomes focusing on symptoms, function, or overall health status. A review of the measurement properties of the elbow-specific aggregate outcome measures did not reveal one to be superior.

CONCLUSIONS

Overall, total elbow arthroplasty outcomes are heterogeneous in their reporting and lack standardization. The total elbow arthroplasty literature relies on several physician-derived elbow-specific aggregate measures and focuses primarily on physiological variables. The relative merits of aggregating findings into a single scoring system versus as separate components should be explored further. Finally, consideration should be given to patient-reported outcome measures in total elbow arthroplasty research.

CLINICAL RELEVANCE

This study of the current "state of practice" for outcome measurement in total elbow arthroplasty revealed gaps in the breadth of measurement and a lack of comparability in elbow scoring systems that could hinder our ability to clearly and fully understand outcome after total elbow arthroplasty. Future consensus work could address both concerns and assist in the development of a core set of outcome measures.