Neurolysis of the ulnar nerve for neuropathy following total elbow replacement

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.

Low risk of postoperative ulnar nerve affection in surgically treated distal humeral fractures when the nerve is released in situ

BACKGROUND

Adult distal humeral fractures (DHF) comprise 2%-5% of all fractures and 30% of all elbow fractures. Treatment of DHF may be technically demanding due to fracture complexity and proximity of neurovascular structures. Open reduction and internal fixation (ORIF) are often the treatment of choice, but arthroplasty is considered in case of severe comminution or in elderly patients with poor bone quality. Ulnar nerve affection following surgical treatment of distal humerus fractures is a well-recognized complication.

AIM

To report the risk of ulnar nerve affection after surgery for acute DHFs.

METHODS

We retrospectively identified 239 consecutive adult patients with acute DHFs who underwent surgery with ORIF, elbow hemiarthroplasty (EHA) or total elbow arthroplasty (TEA) between January 2011 and December 2019. In all cases, the ulnar nerve was released in situ without anterior transposition. We used our institutional database to review patients’ medical records for demographics, fracture morphology, type of surgery and ulnar nerve affection immediately; records were reviewed after surgery and at 2 wk and 12 wk of routine clinical outpatient follow-up. Twenty-nine percent patients were excluded due to pre- or postoperative conditions. Final follow-up examination was a telephone interview in which ulnar nerve affection was reported according to the McGowen Classification Score. A total of 210 patients were eligible for interview, but 13 patients declined participation and 17 patients failed to respond. Thus, 180 patients were included.

RESULTS

Mean age at surgery was 64 years (range 18-88 years); 121 (67.3%) patients were women; 59 (32.7%) were men. According to the AO/OTA classification system, we recorded 47 patients with type A3, 55 patients with type B and 78 patients with type C fractures. According to the McGowen Classification Score, mild ulnar nerve affection was reported in nine patients; severe affection, in two. A total of 69 patients were treated with ORIF of whom three had mild temporary ulnar nerve affection and one had severe ulnar nerve affection. In all, 111 patients were treated with arthroplasty (67 EHA, 44 TEA) of whom seven had mild ulnar nerve affection and one had severe persistent ulnar nerve affection. No further treatment was provided.

CONCLUSION

The risk of ulnar nerve affection after surgical treatment for acute DHF is low when the ulnar nerve is released in situ without nerve transposition, independently of the treatment provided.

A systematic review of the complications of contemporary total elbow arthroplasty

BACKGROUND

Total elbow arthroplasty is a low volume procedure. We aimed to evaluate complication rates and cumulative percentages associated with the most frequently used contemporary implants and for the commonest indications.

METHODS

A systematic literature search of all studies reporting complications following total elbow arthroplasty with 12-month minimum follow-up was undertaken. Quality of studies was assessed with the Methodological-Index-for-Non-Randomised-studies criteria. British NJR data identified the most common UK prostheses and indications. The complication rates for all undesirable events contributing to patient outcome were extracted and cumulative percentages were calculated.

RESULTS

One hundred seventeen studies were screened, 12 studies included, totalling 815 procedures. Mean follow-up was 3.8 years. The overall complication cumulative percentage was 60.7%, significantly higher than that seen in other joint arthroplasty, including a 6.5% deep infection rate. Nerve injury was comparable between implants at around 4.1%. Radiographic loosening had a cumulative rate of 17.2%. Revision for symptomatic aseptic loosening was 6.3%.

CONCLUSIONS

This is the largest systematic review of the complications of total elbow arthroplasty. Surgeons should be aware of differing complications related to their implant of choice, each having its own specific complication. Trauma as an indication appears to have an increased complication rates compared to inflammatory arthropathy. There is a lack of literature regarding the independent results of osteoarthritis as a specific indication for total elbow arthroplasty.

Complications of modern design total elbow replacement

Total elbow arthroplasty is an important surgical option for advanced arthritis of the elbow. Semi-constrained linked prosthesis is still a popular choice, however, complications and revisions after TER remain high. Aseptic loosening and infection are two most common mode of failure. Periprosthetic fracture, implant failure, and triceps insufficiency have also been reported. Revision arthroplasty needs careful preoperative planning to tackle deficiency in soft tissue and osseous structure. Impaction, strut allograft or allograft prosthesis composite graft should be considered for failed TER.

Outpatient total elbow arthroplasty: 90-day outcomes

BACKGROUND

Interest in outpatient arthroplasty has grown in response to increasing emphasis on the efficient delivery of safe, high-quality medical care. This study evaluated 90-day episode-of-care complications after outpatient total elbow arthroplasty (TEA).

MATERIALS AND METHODS

We retrospectively evaluated 28 patients discharged the same day after primary TEA for 90-day episode-of-care complications, reoperations, and readmissions. Postoperative complications and elbow range of motion measurements were recorded and evaluated at the latest follow-up. All patients were contacted and given a satisfaction survey to assess their outpatient experience. Univariate logistic regression was performed for each risk factor to evaluate the risk for major and minor complications. Statistical significance was set as P < .05.

RESULTS

Final follow-up data were available for 28 patients at an average of 14 months. Major complications within 90 days of surgery occurred in 7.1% of patients, ulnar nerve paresthesias occurred in 42.8% of patients, and minor wound problems occurred in 39.2% of patients. Five reoperations occurred after the 90-day postoperative period. All ulnar paresthesias and minor wound complications had resolved by the latest follow-up. Univariate regression analysis revealed a significant correlation between smoking and minor wound complications (P = .038). The satisfaction survey had an 85.7% response rate, with 91.7% of patients stating they were happy they went home the same day, and 95.8% feeling more confident and in control of their lives.

CONCLUSIONS

The risk profile of carefully selected patients undergoing same-day discharge after TEA is acceptable when combined with close follow-up.

Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty

PURPOSE

Ulnar nerve (UN) lesions are a significant complication after total elbow arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a center, which routinely performs an in situ release of the nerve without transposition, were investigated.

METHODS

Eighty-three primary TEAs were retrospectively reviewed for the intraoperative management of the UN and presence of postoperative UN symptoms.

RESULTS

Three patients had documented preoperative UN symptoms. One patient had a prior UN transposition. The nerve was transposed at the time of TEA in 4 of the remaining 82 elbows (5%). The indication for transposition in all cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. Of the 4 patients who underwent UN transposition, 2 had postoperative UN symptoms. Both were neuropraxias, which resolved in the early postoperative period. The remaining 78 TEAs received an in situ release of the nerve. The incidence of postoperative UN symptoms in the in situ release group was 5% (4 of 78). Two patients had resolution of symptoms, whereas 2 continued to experience significant UN symptoms requiring subsequent transposition. Seven patients had preoperative flexion of less than 100°. Of these, 2 had a UN transposition at the time of TEA. Of the remaining 5 elbows with preoperative flexion less than 100°, 2 had postoperative UN symptoms after in situ release, with 1 requiring subsequent UN transposition.

CONCLUSIONS

A 3% incidence of significant UN complications after TEA compares favorably with systematic reviews. We do not believe that transposition, which adds to the handling of the nerve and increases surgical time, is routinely indicated and should rather be reserved for cases with marked limitation of preoperative elbow flexion or when intraoperative assessment by the surgeon deems it necessary.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Semiconstrained total elbow arthroplasty for rheumatoid arthritis patients: clinical and radiological results of 1-8 years follow-up

INTRODUCTION

We investigated whether the Discovery total elbow arthroplasty (TEA) system had good results and survival in rheumatoid arthritis (RA) patients.

METHODS

In a prospective cohort study, one elbow surgeon performed TEA on 25 consecutive RA patients (31 elbows) between December 2004 and November 2012 using the Discovery system. We evaluated the preoperative elbow range of motion (ROM), functional outcome with QuickDash and quality of life with EQ-5D. An independent colleague evaluated the same parameters 1-8 years (mean 4.5) postoperatively. The medical records of the follow-up visits for the study period were available for review.

RESULTS

A complete set of results was available for 19 patients (25 elbows). The mean ROM improved in flexion/extension from 88° (SD 27) to 113° (SD 19) and in pronation/supination from 55° (SD 28) to 68° (SD 22) (p < 0.05). The mean QuickDash also improved from 66.5 (SD 25.7) to 40.2 (SD 24) (p < 0.01). The mean EQ-5D improved from 0.68 (SD 0.2) to 0.75 (SD 0.13) but was not statistically significant (p = 0.09). Three patients were revised because of loosening, 2 more patients were re-operated. This resulted in a Kaplan-Meier survival of 90 % (CI 72-97) for the study period.

CONCLUSION

The Discovery system has shown satisfactory results in RA patients even if the rate of complication remained relatively high. Further follow-up is required to investigate the radiological changes observed in some of our patients.

Long-term effectiveness of Sorbie-QUESTOR elbow arthroplasty: single surgeon's series of 15 years

With increasing usage of many types of total elbow replacements, there is a continuing need for clinical series that report survivorship, complications and revisions, and performance of single types of implants over extended time periods. The purpose of this study was to assess the long-term effectiveness of all implants of the Sorbie-QUESTOR (SQ) unlinked surface arthroplasty conducted by a single surgeon (C.S.) over 15 years at a single site, and to determine whether there were diagnostic group differences. Between 1995 and 2002, 51 S-Q prosthetic elbows were implanted into 44 patients. The patient groups were hemophilia, rheumatoid arthritis, and "other," which included osteoarthritis, traumatic arthritis, psoriatic arthritis, and reactive arthritis. Annual evaluations included scores of pain, range of motion, and function. The most recent annual evaluation was included in the data set. Details of complications and revisions were recorded. The hemophiliac group had the best survival outcomes at 87.5%. Eighteen prostheses required revision or removal with all but 3 retained or replaced. Postoperatively, 73% rated their pain as 'slight' or 'none'. The hemophilia and rheumatoid arthritis groups made very large total flexion/extension gains. The rheumatoid arthritis group made significant forearm motion gains. Average functional assessment gains were nearly 2 grades of 5 functional levels and were significant for all groups. The S-Q surface arthroplasty has demonstrated long-term effectiveness in patients with a variety of elbow joint pathologies showing reduction in pain, large gains in joint range and function, and good long-term survival.

Complications of total elbow arthroplasty

Modifications in implant design and improvements in surgical technique have expanded the applications of total elbow arthroplasty. Complications associated with reconstructive elbow surgery persist, however, often leading to profound and sometimes nonsalvageable disability. The most recognized complications include implant loosening, periprosthetic fracture, implant failure, infection, triceps insufficiency, and nerve palsy. Although far fewer elbow arthroplasties than lower extremity arthroplasties are performed, the proportion of complications is greater with elbow arthroplasty, and the outcomes of secondary reconstruction are less favorable.