Outcomes following total elbow arthroplasty for rheumatoid arthritis versus post-traumatic conditions: a systematic review and meta-analysis

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.

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.

Distal humeral hemiarthroplasty compared to total elbow replacement for distal humeral fractures: a registry analysis of 906 procedures

BACKGROUND

Total elbow replacement (TER) is an accepted treatment for complex intra-articular distal humerus fractures in elderly patients. Distal humeral hemiarthroplasty (HA) is also a potential surgical option for unreconstructable fractures and avoids the concerns regarding mechanical wear and functional restrictions associated with TER. In the current literature, there are limited data available to compare the revision rates of HA and TER for the treatment of fracture. We used data from a large national arthroplasty registry to compare the outcome of HA and TER undertaken for fracture/dislocation and to assess the impact of demographics and implant choice on revision rates.

METHODS

Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from May 2, 2005, to December 31, 2021, included all procedures for primary elbow replacement with primary diagnosis of fracture or dislocation. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazards models.

RESULTS

There were 293 primary HA and 631 primary TER procedures included. The cumulative percentage revision (CPR) rate at 9 years was 9.7% for HA (95% confidence interval [CI] 6.0, 15.7), and 11.9% (95% CI 8.5, 16.6) for TER. When adjusted for age and gender, there was a significantly higher risk of revision after 3 months for TER compared to HA (HR 2.47, 95% CI 1.22, 5.03, P = .012). There was no difference in the rate of revision for patients aged <55 years or ≥75 years when HA and TER procedures were compared. In primary TER procedures, loosening was the most common cause of revision (3.6% of primary TER procedures), and the most common type of revision in primary TER involved revision of the humeral component only (2.6% of TER procedures). TER has a higher rate of first revision for loosening compared to HA (HR 4.21, 95% CI 1.29, 13.73; P = .017). In HA procedures, instability (1.7%) was the most common cause for revision. The addition of an ulna component was the most common type of revision (2.4% of all HA procedures).

CONCLUSION

For the treatment of distal humerus fractures, HA had a lower revision rate than TER after 3 months when adjusted for age and gender. Age <55 or ≥75 years was not a risk factor for revision when HA was compared to TER. Loosening leading to revision is more prevalent in TER and increases with time. In HA, the most common type of revision involved addition of an ulna component with preservation of the humeral component.

Outcomes of Humeral Allograft-Prosthetic Composites with Plate Fixation in Revision Total Elbow Arthroplasty

Background

Traditionally, the reconstruction of severe distal humeral bone loss at the time of revision total elbow arthroplasty (TEA) has used allograft-prosthetic composites (APCs) stabilized with cerclage wires or cables. We have migrated to plate fixation when revision TEA using a humeral APC is performed. This study shows the outcomes of patients treated with a humeral APC with plate fixation during revision TEA.

Methods

Between 2009 and 2019, 41 humeral APCs with plate fixation of distal humeral allograft to the native humerus were performed in the setting of revision TEA. There were 12 male patients (29%) and 29 female patients (71%), with a mean age of 63 years (range, 41 to 87 years). The mean allograft length was 12 cm. All elbows had a minimum follow-up of 2 years (mean follow-up, 3.3 years). Patients were evaluated for visual analog scale pain scores, range of motion, the ability to perform select activities of daily living, and the Mayo Elbow Performance Score (MEPS). Outcomes including reoperations, complications, and revisions were noted. The most recent radiographs were evaluated for union at the allograft-host interface, failure of the plate-and-screw construct, or component loosening.

Results

The mean postoperative flexion was 124° (range, 60° to 150°) and the mean postoperative extension was 26° (range, 0° to 90°); the mean arc of motion was 99° (range, 30° to 150°). The mean MEPS was 58 points (range, 10 to 100 points). Two surgical procedures were complicated by neurologic deficits. The overall reoperation rate was 14 (34%) of 41. Of the 33 patients with complete radiographic follow-up, 12 (36%) had evidence of nonunion at the allograft-host interface with humeral component loosening, 1 (3%) had evidence of partial union, and 1 (3%) had ulnar stem loosening.

Conclusions

Revision TEA with a humeral APC using compression plating was successful in approximately two-thirds of the elbows. Further refinement of surgical techniques is needed to improve union rates in these complex cases.

Level of Evidence

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

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.

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.

Total elbow arthroplasty cases involving orthopaedic residents do not affect short-term postoperative complications

Background

Impact of resident participation on short-term postoperative outcomes after total elbow arthroplasty has not been studied. The aim was to investigate whether resident participation affects postoperative complication rates, operative time, and length of stay.

Methods

The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2012 for patients undergoing total elbow arthroplasty. A 1:1 propensity score match was performed to match resident cases to attending-only cases. Comorbidities, surgical time, and short-term (30-day) postoperative complications were compared between groups. Multivariate Poisson regression was used to compare the rates of postoperative adverse events between groups.

Results

After propensity score match, 124 cases (50% with resident participation) were included. Adverse event rate after surgery was 18.5%. On multivariate analysis, there were no significant differences between attending-only cases and resident involved cases, with regards to short-term major complications, minor complications, or any complications (all p > 0.071). Total operative time was similar between cohorts (149.16 vs. 165.66 min; p = 0.157). No difference was observed in the length of hospital stay (2.95 vs. 2.6 days), p = 0.399.

Discussion

Resident participation during total elbow arthroplasty is not associated with increased risk for short-term medical or surgical postoperative complications or operative efficiency.

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.

Comparison of 90-day complication rates and readmissions of primary total elbow arthroplasty in elective and traumatic cases: a single center experience

INTRODUCTION

The purpose of this study is to compare the 90 day complication rates of primary Total Elbow Arthroplasty (TEA) performed for arthritis (primary-OA; rheumatoid arthritis-RA) versus those performed for distal humerus fractures (DHF).

METHODS

Patients who underwent a TEA from 2015 to 2021 were identified from our institutional database and placed into cohorts based on surgical indications (TEA-OA, TEA-RA and TEA-DHF). Chart review was conducted to analyze the prevalence of complications, emergency department (ED) visits, readmissions, and secondary procedures in the first 90 day post-operative period. Complications included but were not limited to wound complications, hematoma, infection (superficial or deep), nerve palsy, periprosthetic fracture/failure and others.

RESULTS

49 patients who underwent TEA were included in this study: (DHF = 19, OA = 14, RA = 16). Six complications occurred within the first 90 days of surgery. There were two periprosthetic joint infections (PJI) in the OA group, requiring irrigation and debridement (I & D) within the first 90 days of surgery. There were three post-operative ulnar nerve palsies and one PJI requiring I & D in the TEA-RA group. Compared to the TEA-DHF and TEA-OA groups, the RA group had higher rates of all-cause complications (p = 0.03) and nerve palsy (p = 0.03). There were no significant differences between groups in readmissions (p = 0.27) or secondary interventions (p = 0.27).

CONCLUSION

The 90-day complication/readmission rates of TEA preformed for DHFs is lower than those preformed for OA and RA. These differences could be related to the underlying chronic inflammatory etiology and side effect of treatments (intraarticular steroid injection, and biologics) received by patients with arthritis.

LEVEL OF EVIDENCE

Retrospective Cohort Study, level IV.

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.

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.

Long-term outcomes of total elbow arthroplasty: a systematic review of studies at 10-year follow-up

BACKGROUND

The purpose of this study was to systematically review the literature to evaluate the functional outcomes, dislocation, and revision rates following total elbow arthroplasty (TEA) at a minimum 10 years' mean follow-up.

MATERIALS AND METHODS

Two independent reviewers performed a literature search using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and Cochrane Library databases. Studies were only included if they focused on outcomes post-TEA at a minimum 10 years' mean follow-up.

RESULTS

Our search found 23 studies including 1429 elbows (60.4% linked TEA) that met our inclusion criteria. There were 1276 patients (79.0% female), with an average age of 64.7 years (19-93) and a mean follow-up of 137.2 months (120-216). At final follow-up, the mean Mayo Elbow Performance Score, Oxford Elbow Score, and Quick Disabilities of the Arm, Shoulder, and Hand scores were 89.1 (35-100), 64.4 (16-48), and 39.2 (3-93), respectively, and 63.3% of patients reported having no pain. The rates of aseptic loosening, infection, implant dislocation, and nerve injury were 12.9%, 3.3%, 4.2%, and 2.1%, respectively. The overall complication and revision rates were 16.3% and 14.6%, respectively.

DISCUSSION AND CONCLUSION

Our systematic review established that TEA offers patients satisfactory clinical outcomes at long-term follow-up, with relatively stable revision and complication rates compared to short and medium term.

The flail elbow: Every surgeon's nightmare

A flail elbow joint has an excessive or abnormal degree of mobility resulting in loss of function. Such a situation can arise from structural damage or loss of neuromuscular control. Structural damage may be in terms of loss of integrity of bony, ligamentous, or both components, and this is commonly caused by trauma, failed arthroplasty, infections - either in the native joint or associated with the above, or inflammatory arthritides. Arm paralysis from any cause may also leads to a loss of muscle control making the elbow flail. The management of the condition varies according to etiology; and concurrent issues like infection and instability need to be addressed in addition to the structural problems. Treatment can be non-surgical with the use of orthotics to support the elbow, and maybe more appropriate in certain circumstances. Surgical treatment can involve fixation, repair or reconstruction. Often the deficiency is not amenable to these methods and arthroplasty has to be considered. The situation becomes more fraught in case of failure of arthroplasty and/or infection, where reconstruction can be challenging. In this review we have considered diverse clinical scenarios that fall under this broad umbrella, with a focus on those encountered commonly in practice.

Relationship between particulate matter exposure and female breast cancer incidence and mortality: a systematic review and meta-analysis

OBJECTIVES

The associations of PM with the risk and prognosis of breast cancer have not been determined. This systematic review aimed to provide an updated understanding of the relationship between PM exposure level and breast cancer incidence and mortality.

METHODS

Articles from Web of Science and PubMed databases were methodically inspected until March 8, 2020. In final, 15 studies were kept for analysis, which provided necessary information to estimate the impact of PM on breast cancer risk and prognosis. These studies were combined for quantitative analyses to evaluate the effect of per 10 μg /m³ increment exposure of PM_2.5 (< 2.5 μm in aerodynamic diameter) and PM₁₀ (< 10 μm in aerodynamic diameter) using random-effects model.

RESULTS

PM_2.5 exposure was associated with increased breast cancer mortality (relative risk [RR] = 1.09; 95% confidence interval [CI]: 1.02, 1.16; P_Q-test = 0.158). No association of PM_2.5 (1.02; 0.97, 1.18; 0.308) and PM₁₀ (1.03; 0.98, 1.09; 0.009) with the increase incidence of breast cancer was observed. Stratified analysis suggested that PM_2.5 was associated with the increase mortality of breast cancer (1.10; 1.03, 1.17; 0.529) in subgroup of developed country. PM₁₀ was associated with breast cancer incidence based on studies published after 2017 (1.08; 1.00, 1.15; 0.157) and European studies (1.15; 1.06, 1.25; 0.502).

CONCLUSIONS

Our study indicated that PM_2.5 exposure was related to breast cancer mortality. Further researches in this field are needed to validate the conclusion.

Total elbow arthroplasty in patients with rheumatoid arthritis

AIMS

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

METHODS

We searched PubMed, MEDLINE, Cochrane Reviews, and Embase from between January 2003 and March 2019. The primary aim was to determine the implant failure rate, the mode of failure, and risk factors predisposing to failure. A secondary aim was to identify the overall complication rate, associated risk factors, and clinical performance. A meta-regression analysis was completed to identify the association between each parameter with the outcome.

RESULTS

A total of 38 studies including 2,118 TEAs were included in the study. The mean follow-up was 80.9 months (8.2 to 156). The implant failure and complication rates were 16.1% (95% confidence interval (CI) 0.128 to 0.200) and 24.5% (95% CI 0.203 to 0.293), respectively. Aseptic loosening was the most common mode of failure (9.5%; 95% CI 0.071 to 0.124). The mean postoperative ranges of motion (ROMs) were: flexion 131.5° (124.2° to 138.8°), extension 29.3° (26.8° to 31.9°), pronation 74.0° (67.8° to 80.2°), and supination 72.5° (69.5° to 75.5°), and the mean postoperative Mayo Elbow Performance Score (MEPS) was 89.3 (95% CI 86.9 to 91.6). The meta-regression analysis identified that younger patients and implants with an unlinked design correlated with higher failure rates. Younger patients were associated with increased complications, while female patients and an unlinked prosthesis were associated with aseptic loosening.

CONCLUSION

TEA continues to provide satisfactory results for patients with RA. However, it is associated with a substantially higher implant failure and complication rates compared with hip and knee arthroplasties. The patient's age, sex, and whether cemented fixation and unlinked prosthesis were used can influence the outcome. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Joint J 2020;102-B(8):967-980.