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.

total elbow arthroplasty

Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion.

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.

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.

Morphometric analysis of the lateral column of the distal humerus with an interest on radio-capitellar arthroplasty design. A computed tomography anatomical study on 50 elbows

PURPOSE

To perform a morphometric analysis of the distal humerus lateral column medullary canal (LCMC).

METHODS

Fifty computed tomography(CTs) from 24 males and 26 females were examined. Two observers measured: (1) the capitellum sagittal (R_S) and axial (R_T) radii of curvature; (2) the sagittal(Sd) and coronal(Cd) diameters of the LCMC in 5 different disto-proximal sites spaced 4 mm apart; (3) the capitellum and LCMC axis offsets on the sagittal (capSO,axSO) and coronal (capCO,axCO) planes; (4) the sagittal (Si) and coronal (Ci) inclination of the LCMC axis.

RESULTS

The mean R_S and R_T were 1.07 cm (SD, 0.11) and 1.30 cm (SD, 0.11), respectively. The mean Sd and Cd values were 1.17 cm (SD, 0.17) and 1.58 cm (SD, 0.24), respectively, with a disto-proximal decrease on both planes. The capSO, capCO, axSO and axCO mean values were 0.76 (SD, 0.21), 1.60 (SD, 0.27), - 0.16 (SD, 0.30) and 0.79 cm (SD, 0.30), respectively. Si and Ci were 70° and 72°, respectively. A strong correlation (r = 0.78) was found between R_S and R_T and between adjacent levels of Sd and Cd. AxSO and axCO yielded a strong inverse correlation. Male patients showed higher values than female ones in all variables (p < 0.03). The intra-class correlation coefficient (ICC) was always > 0.9.

CONCLUSION

The dimensions of the LCMC decrease disto-proximally, with the coronal diameters being greater than the sagittal diameters, resembling a portion of an elliptic torus with an antero-medial concavity. The articular surface of the humeral capitellum is non-spherical, with two strongly correlated radii of curvature. The results of this study may be relevant to the stem design of radiocapitellar arthroplasty.

Elbow arthroplasty is safe for the management of simple open distal humeral fractures

BACKGROUND

Elbow arthroplasty (EA) is an established technique for the treatment of select distal humeral fractures, yet little data exists regarding the safety and outcome of EA in the presence of an open distal humeral fracture where the risk of periprosthetic infection is an even greater concern. We hypothesized that EA does not carry an increased risk of infection or other postoperative complications when performed for simple open distal humeral fractures.

METHODS

Seventeen patients underwent total EA (n = 9) or hemiarthroplasty (n = 8) for an open distal humeral fracture. The open fracture component was classified according to the Orthopaedic Trauma Society system as "simple" or "complex." Outcome measures collected included the Mayo Elbow Performance Score (MEPS), range of motion, complications, and reoperations. Patients who underwent primary débridement and implantation were compared with those who underwent preliminary débridement procedures and subsequent staged arthroplasty. A systematic review of the existing literature was performed to analyze other reported cases and contextualize our findings.

RESULTS

The mean follow-up was 46 months (range, 12-138 months). All fractures were multifragmentary and intra-articular. Sixteen patients had a "simple" open fracture and 1 had a "complex" fracture. The overall mean MEPS was 83 (range, 30-100; standard deviation ± 17), with a mean flexion-extension arc of 96°. Patients who underwent primary débridement and implantation demonstrated a higher mean flexion arc (116° vs. 79°, P = .02) than those who underwent staged arthroplasty. The mean MEPS was not significantly different between the groups (90 vs. 78, P = .12). Complications included asymptomatic ulna component loosening (n = 1), joint instability (n = 1), and symptomatic heterotopic ossification (n = 3). There were no deep or superficial infections recorded.

CONCLUSION

EA is safe and effective when performed for simple open distal humeral fractures. Primary débridement and implantation may offer functional benefits over a staged approach.

Involvement of the medial and lateral epicondyles in distal humeral coronal shear fractures: Case series and literature review

PURPOSE

Epicondyle involvement in capitellar and trochlear fractures is often considered a simple associated lesion that does not substantially change treatment or prognosis. Although theoretically predicted in reviews, case series almost never report elbow prosthesis use in comminuted coronal shear injuries associated with epicondylar fracture in the elderly. The purpose of this study is to focus on this underestimated injury pattern that can be a negative risk factor for treatment and prognosis.

METHODS

We retrospectively reviewed all cases with coronal shear fracture of the distal humerus treated from 2016 to 2019. Fractures were classified according to Dubberley. Open reduction and internal fixation (ORIF) were performed when possible. Partial or total elbow replacement was used in severely comminuted fractures with epicondylar involvement in four elderly patients.

RESULTS

Nineteen consecutive patients were selected (mean age: 62.4 years), of which 10 had type 3A/3B fractures, and seven had both medial and lateral epicondylar involvement. The mean follow-up duration was 31.78 months. The average Mayo Elbow Performance Index (MEPI) score was 81.05 points, with 7 excellent, 8 good, 1 fair, and 3 poor results. The average MEPI score of Dubberley's type 1 and type 2 was better than that of type 3 (mean: 92 vs. 72, p = 0.02). Further, the results of average range of motion were better in patients who had sustained Dubberley types 1 and 2 lesions than those with Dubberley type 3 lesion (mean: 133° vs. 85°, p = 0.002). Two patients out of three who required intra-operative conversion to total elbow arthroplasty had poor outcomes.

CONCLUSIONS

The simultaneous presence of fracture of one or both epicondyles are usually associated with severe joint comminutions and makes ORIF more challenging, especially among elderly women. In these cases, primary total elbow prosthesis implantation could be a valid treatment option.

Mid- to long-term survivorship of the cemented, semiconstrained Discovery total elbow arthroplasty

BACKGROUND

The incidence of total elbow arthroplasty (TEA) is increasing, and an improved understanding of elbow kinematics and biomaterials has driven advances in implant design. In modern practice, cemented, semiconstrained devices are most frequently used. The Discovery TEA has demonstrated promising early results, although there are a paucity of follow-up studies and no dedicated mid- to long-term series. We therefore present the longest, most complete such study to date.

METHODS

A prospectively maintained local joint registry was interrogated to yield a consecutive series of Discovery TEAs performed at a single non-design center. The minimum follow-up period was set at 5 years. Revision procedures and TEAs performed for acute trauma were excluded. The primary outcome was survivorship of the implant. The secondary outcomes included clinical, radiographic, and patient-reported outcomes.

RESULTS

We identified 67 TEAs in 58 patients for inclusion at a mean of 98.5 ± 20.4 months from surgery. Four cases (6%) were lost to follow-up, and implant survival was censored accordingly. The implant was revised in 14 cases (20.9%). The Kaplan-Meier method showed an implant survivorship rate of 76.8% at 119 months. A significant difference in survival was found between dominant and nondominant elbows (P = .012, Breslow test), with elbow dominance conferring a 4.5-fold increased risk of revision (relative risk, 4.5; 95% confidence interval, 1.1-18.5). Pooled clinical outcomes (70.9% follow-up at minimum of 60 months and median of 77.8 months) were also determined.

CONCLUSIONS

We present the longest-term and most complete single-center follow-up study of the Discovery TEA to date. Further long-term survival studies are required to elucidate the performance of this implant compared with more established designs. We have also demonstrated differences in implant survivorship owing to hand dominance for the first time.

Radiocapitellar arthroplasty

This article sets out the evidence demonstrating that the clinical need for a prosthetic arthroplasty designed specifically for the radiocapitellar joint has been underestimated. The prevalence of radiocapitellar degenerative change requiring treatment is discussed and the relationship between 'isolated' radiocapitellar joint arthritis and more generalised elbow arthritis is explained. Current literature now supports our view that radiocapitellar joint arthroplasty is not only an effective long-term solution for patients with localised radiocapitellar arthritis but also for those patients with more severe degenerative changes involving the elbow joint irrespective of their cause. We consider that is important to avoid resection of the radial head and therefore that resurfacing implants rather than joint replacement implants are more likely to provide a good longterm outcome for patients with elbow arthritis.

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.

Revision total elbow arthroplasty with the ulnar component implanted into the radius for management of large ulna defects

BACKGROUND

Total elbow arthroplasty (TEA) has a higher rate of revision and complications than other total joint arthroplasties. Salvage options for failed TEAs are limited, especially when patients have poor ulna bone stock. The purpose of this study is to describe a surgical technique and report outcomes of patients who underwent revision TEA with implantation of the ulnar component into the radius to address ulna bony defects.

METHODS

A retrospective review of 5 patients at a single institution from 2014 to 2019 in which the ulnar component was implanted into the radius to address large bony defects in the setting of revision TEA was performed.

RESULTS

At follow-up of 2.1 ± 1.9 years, patients experienced an increase in total arc of motion from 86 ± 17° to 112 ± 8°, with infection eradication and no instances of distal component loosening.

CONCLUSION

This salvage technique was effective at providing a stable elbow in patients with large ulna bony defects as a result of prosthetic joint infection or periprosthetic fracture.

Interpositional elbow arthroplasty using fascia lata autograft in stiff elbow: Case series of 8 patients

INTRODUCTION

Constrain of a total elbow replacement and elbow arthrodesis are too much for the working population to bear. As such interpositional elbow arthroplasty using fascia lata autologous graft to reconstruct the elbow joint is a viable option in this age group.

MATERIALS AND METHOD

8 patients were operated for arthritic stiff elbow, and joint reconstruction was done using fascia lata autologous graft, with out the use of any hinged external fixator. Pre-operative and post-operative functional assessment was done using Mayo Elbow Performance Score (MEPS) and statistically measured using a paired t-test. Result There was significant improvement in range of motion in coronal (flexion-extension) and axial (supination-protonation) with p-value of <0.001. The mean pre-operative MEPI increased from 40.6 points to 91.9 points (p < 0.0001). All parameters of MEPI had statistically significant improvement with exception of stability (p-value = 0.0824).

Complex open elbow fracture Gustilo-Anderson type IIIB treated with the primary elbow arthroplasty: A case report

Total elbow arthroplasty as a treatment option for open elbow fracture is relatively rare described. We reported a 39 years old polytrauma patient with complex open elbow fracture (Gustilo-Anderson type IIIB). The patient presented with large soft tissues defect on dorsal part of the left elbow, ulnar palsy due to the irreparable loss of the ulnar nerve, distal triceps loss due to the complete loss of the olecranon, loss of both humeral condyles with collateral ligaments and complex elbow instability. Only few similar cases have been published. Reconstructive surgery included repetitive radical debridement, irrigation, vacuum assisted closure system therapy, external fixation, coverage of the soft tissue defect with fascia-cutaneous flap from the forearm. Four months after the injury, total elbow arthroplasty with autologous bone graft (from the proximal radius) inserted in the ulnar component, was performed. At 3 years postoperatively, the patient is able to perform an active flexion from 0° to 110° with full prono-supination. Only passive extension is allowed. The ulnar neuropathy is persistent. Patient has no signs of infection or loosening of the prosthesis.

Long-term outcomes after Instrumented Bone Preserving total elbow arthroplasty: a radiostereometric study with a minimum follow-up of 10 years

BACKGROUND

Aseptic loosening is a main concern in elbow arthroplasty. Evaluation of implant migration using radiostereometric analysis (RSA) might increase understanding of implant loosening. Previously, 2-year RSA results of 16 Instrumented Bone Preserving (IBP) elbow prostheses showed migration of the humeral component in the first weeks but most components stabilized within 6 months postoperatively. In follow-up, the present study evaluated long-term survival, the relation between early migration and survival, and the long-term migration and clinical outcomes.

METHODS

Sixteen patients who received an IBP prosthesis were prospectively followed with a median follow-up time of 136 months (range 82-165). Migration was measured using RSA. Clinical results were described using the Elbow Function Assessment (EFA), Broberg and Morrey elbow functional rating index, Oxford Elbow Score (OES), and visual analog scale (VAS) for pain and satisfaction.

RESULTS

Four patients underwent a revision within 10 years, and 2 more were planned for revision surgery after 14 years. Five patients died with their prosthesis in situ. Early migration was not associated with survival. Long-term migration patterns varied widely. Median EFA score was 58.5, Broberg and Morrey score was 50, and OES score was 32. Median VAS score for pain was 2 and that for satisfaction was 7.5.

CONCLUSION

Ten-year survival of the IBP total elbow prosthesis was 75%, decreasing to 63% after 14 years of follow-up. Long-term implant failure could not be predicted by 2-year migration results in this study. Although short-term clinical results were promising, long-term outcomes worsened in all patients.

A giant cell rich osteosarcoma of the proximal ulnar bone treated by elbow arthroplasty: A case report

•

Osteosarcoma of the proximal ulnar bone is a malignant progressive bone tumors.

•

Diagnosis of these cases needs a comprehensive history taking physical examination and additional diagnostic test.

•

Limb salvage surgery using wide excision and reconstruction with elbow arthroplasty by our institution was a challenging procedure.

•

Latissimus dorsi flap is important to close the defect left by wide excision.

Introduction

Osteosarcoma is a malignant tumor of the bone. The treatment and prognosis have changed dramatically these days. Limb salvage surgery is a widely accepted alternative to amputation in patients with sarcoma. In most cases, the diagnosis of osteosarcoma is not difficult. We reported a rare location and a rare type of osteosarcoma case treated by elbow arthroplasty along with the challenging diagnostic and treatment.

Case presentation

We reported 46 years old female complained of pain on her left elbow for 5 months. An x-ray showed lytic lesion on the medial side of the elbow while the MRI examination suggested a malignant bone tumor in the epi-meta-diaphyseal of left ulnar bone. Core biopsy showed a Giant Cell containing lesion. The histology of resected tumor and Ki67 staining confirmed the diagnosis of giant cell-rich type osteosarcoma.

Discussion

Giant cell rich osteosarcoma is an uncommon variant of osteosarcoma which characterized by an abundance of osteoclastic giant cells and lack of tumor osteoid. Involvement of forearm in conventional osteosarcoma is extremely rare. This was the epidemiologic reason why the osteosarcoma was not the first diagnosis of our case. Being a very rare location of the osteosarcoma, the management poses a special challenge. They are the surgical technique, which is not well described, and the implant that need to be custom made.

Conclusion

Giant cell rich osteosarcoma is difficult to diagnose because its histology and radiologic feature mimic a benign giant cell tumor.

Timely recognition of total elbow and radial head arthroplasty adverse events: an analysis of reports to the US Food and Drug Administration

BACKGROUND

Recent recalls of several commonly used elbow arthroplasty implants have prompted interest in the modes by which elbow implants fail and the timing of reports of these failures.

METHODS

We reviewed the adverse event reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database from 2012 to 2015 regarding elbow arthroplasty to determine the event date and the type of each adverse event.

RESULTS

Among 179 total elbow adverse event reports, the most common modes of failure were implant dissociation (23%), loosening (22%), and infection (16%). The most common modes of failure among 58 radial head replacement reports were component dissociation (19%) and linkage screw failure (19%). The percentage distribution of adverse event types differed among different arthroplasty systems and from that reported in published reviews of elbow arthroplasty. Three implant recalls were implemented 2, 5, and 9 years after the first adverse event report in the MAUDE database. For 2 of the recalls, the first reports of the device failures were published 2 and 5 years after the first MAUDE reports.

CONCLUSIONS

The MAUDE database is a publicly funded and publicly available means by which surgeons can identify adverse events for the prostheses they use before such information becomes available through journal publication or recall notification. In this study, MAUDE data revealed a higher relative frequency of mechanical dissociation of elbow implants than what has been represented in the literature. Early identification of these adverse events may help surgeons by informing their implant selection and surgical technique.

Treatment of periprosthetic joint infection of the elbow: 15-year experience at a single institution

BACKGROUND

Total elbow arthroplasty (TEA) can be complicated by periprosthetic joint infection (PJI) with potentially catastrophic failure. The purpose of this study was to describe the results of elbow PJI treatment at a tertiary-care referral center.

METHODS

An institutional TEA database was queried for infection and reoperation after TEA. Patients who underwent irrigation and débridement (I&D) with component retention were compared with those who underwent component explantation, antibiotic spacer placement, and reimplantation of a revision TEA.

RESULTS

A total of 26 patients (10 men; mean age, 64.3 years) were treated for PJI of TEA. There were 3 polymicrobial infections (11.5%) and 13 Staphylococcus aureus infections (50%) (4 methicillin resistant); 6 patients (23.1%) had negative culture results. Ten patients (38.5%) underwent I&D and component retention, with 5 of those patients (5 of 10, 50%) having recurrent infection at an average of 3.1 years (range, 0.25-7.8 years) after I&D. Of 16 patients who underwent antibiotic spacer placement, 12 (75%) underwent 2-stage reimplantation of a TEA. Among those with reimplantation, 4 of 12 (33.3%) required reoperation. In 3 of 12 (25.0%), reoperation was required for infection, whereas 1 of 12 (8.3%) required surgery for mechanical complications.

CONCLUSION

Two-stage revision results in a decreased rate of recurrent PJI. Certain patients (those with poor health or well-fixed components) may be more suitable for I&D and component retention, with a demonstrated 50% success rate over a period of 3 years. Longer-term follow-up may result in higher reinfection rates in both groups.

A survivorship study of 838 total elbow replacements: a report from the Norwegian Arthroplasty Register 1994-2016

BACKGROUND

The aim of this study was to present the long-term survivorship (20 years) of total elbow arthroplasty (TEA) for a relatively large population and to compare different prosthesis brands and patient subgroups.

METHODS

Between 1994 and 2017, a total of 838 primary TEAs were reported to the Norwegian Arthroplasty Register. Implant survival was calculated using the Kaplan-Meier method. Risk differences were examined using Cox regression analyses and exact Cox regression for rare events. We compared the survivorship of the 8 most frequently used implant brands, the different diagnoses leading to TEA, and the influence of the fixation technique.

RESULTS

The overall 5-, 10-, 15-, and 20-year survival rates for all elbow arthroplasties were 92%, 81%, 71%, and 61%, respectively. Risk factors for revision were a diagnosis of sequelae after trauma and cementless fixation of the ulna component. There were some differences between the implant brands. The Norway prostheses had higher survival compared with the Kudo after 15 years of follow-up (78% and 66%, respectively; P < .001). Among the implants with shorter follow-up, the IBP and NES had inferior survivorship compared with the Norway. The frequently used Discovery had promising survivorship up to 5 years. The most frequent reason for revision surgery was aseptic loosening, followed by defective polyethylene, infection, and dislocation. The revision causes were to some degree implant specific.

CONCLUSION

Fairly good results in terms of prosthesis survival were obtained with TEA, although results were poorer than for knee and hip arthroplasties.

Risk factors for reoperation after total elbow arthroplasty

BACKGROUND

Total elbow arthroplasty (TEA) is a treatment option for arthritic conditions of the elbow and for complex distal humerus fractures in the elderly. Complications are common, however, and rates of survivorship vary. The goal of this study was to describe the factors associated with reoperation and revision after TEA.

METHODS

We retrospectively reviewed primary TEAs performed at 2 tertiary academic medical centers. We identified 102 primary TEAs in 82 patients by 9 surgeons. The average age of the patients was 61 years. Female patients represented 81% of TEAs performed. The mean follow-up was 6.1 years. The principal diagnosis was inflammatory arthritis in 63 patients (62%), acute trauma or post-trauma in 28 (27%), and primary osteoarthritis in 9 (8.8%).

RESULTS

The rate of reoperation was 41% (42 of 102). The median time to the first reoperation was 1.8 years. The percentage of elbows that had 1 or both components revised was 30% (31 of 102). The most common indication for reoperation was component loosening (17). Six elbows were treated definitively with resection arthroplasty, and 1 was revised to an elbow fusion. The rate of implant revision was 27% for inflammatory arthritis, 11% for osteoarthritis, and 57% after trauma. Trauma-related TEA was more likely to undergo additional reoperation (odds ratio, 4.3; P = .008) and implant revision (odds ratio, 3.4; P = .031).

CONCLUSION

Revision surgery with implant revision after primary TEA is common. Trauma-related TEA often leads to additional procedures.

Radiocapitellar prosthetic arthroplasty in traumatic and post-traumatic complex lesions of the elbow

Radiocapitellar prosthetic arthroplasty is a fascinating new option in the treatment of complex lesions of the elbow. The device has been developed in order to treat primitive and post-traumatic radiocapitellar degenerative arthritis, while preserving the ulnohumeral joint of the elbow. Compared to a radial head resection, it avoids valgus and axial instability of the elbow and forearm preventing ulnohumeral degeneration. Seven patients have been reviewed with a mean of follow-up of 40 months. Two of them presented with an acute trauma and five of them with a post-traumatic degenerative arthritis involving the radial compartment of the elbow. The patients' evaluation was performed using DASH and Mayo elbow performance score (MEPS). Implant overstuffing, loosening and degenerative changes of the ulnohumeral joint have been monitored with X-ray controls. All patients presented with a marked improvement in elbow function, no signs of overstuffing or ulnohumeral degeneration were observed. Two patients developed a clinically asymptomatic aseptic loosening of the radial press-fit stem. The radiocapitellar prosthetic arthroplasty shows convincing results in the treatment of symptomatic radiocapitellar degenerative arthritis. It has also been effective in acute trauma scenarios in the presence of major osteoarticular wearing or loss of the entire radiocapitellar joint.

Distal humerus fractures: a review of current therapy concepts

Fractures of the distal humerus in the adult comprise approximately one third of all humeral fractures. Successful management of distal humerus fractures depends on correct reduction of the fracture, reconstruction of the articular surface if needed, stability and rigidity of the fixation, and appropriate rehabilitation. In this review, we evaluated the available literature and highlighted current therapy concepts. We assessed the evolution of internal fixation and elbow arthroplasty focusing on the established surgical approaches against the background of a growing incidence of distal humeral fractures in an aging patient population. Therefore evaluating the aspect and influence of age-dependent comorbidities like osteoporosis on successful treatment.

The effect of using a cement gun with a narrow nozzle on cement penetration for total elbow arthroplasty: a cadaveric study

PURPOSE

To compare the cement mantle characteristics associated with use of a narrow nozzle cement gun versus the use of a 60-mL catheter tip syringe.

METHODS

Twelve cadaveric distal humeri were cemented with either a cement gun or a syringe without canal occlusion. The humeri were sectioned and photographed. The corticocancellous junction and the outer margin of the cement mantle were analyzed digitally. The corticocancellous junction defined the available area for cement penetration. The outline of the cement mantle defined the actual area of penetration. The ratio of penetration to the available area was recorded for each slice. The mean ratio for each humerus was multiplied by the number of slices in that sample containing cement to calculate a cement index.

RESULTS

The cement penetration ratios observed in cross-sections at the same level and the cement index were significantly greater with the use of the cement gun than with the use of the syringe. There was no difference in the number of slices that contained cement.

CONCLUSIONS

The use of a cement gun with a narrow nozzle improved cement mantle characteristics compared with the use of a syringe when measured in a cadaveric model in the absence of canal occlusion.

CLINICAL RELEVANCE

Improving cement mantle characteristics may decrease the incidence of aseptic loosening after total elbow arythroplasty.

Distal humeral hemiarthroplasty: indications, results, and complications. A systematic review

BACKGROUND

Distal humeral hemiarthroplasty (DHH) is a treatment option for unreconstructable intra-articular distal humerus fractures. DHH may also be used in the setting of rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis. DHH has specific advantages over other, more common, treatment modalities: total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF). DHH is especially a reasonable option in younger patients to preserve bone stock, avoid significant weight restrictions, and limit loosening.

METHODS

The literature was reviewed for all cases of DHH for fracture and non-fracture indications between 1947 and 2014. Two hundred thirty-six papers were identified; 4 studies including 17 patients met criteria for non-fracture indications and 13 studies including 116 patients were identified for fracture indications. A systematic review was generated; patient indications, outcomes, and complications were recorded.

RESULTS

For non-fracture indications, good to excellent results were achieved in 76.5 % of patients with a mean arc of motion of 62° at mean follow up of 46.3 months. Half of the patients experienced a complication, most commonly stiffness. Loosening of the prosthesis was not noted in any patient. For fractures, good to excellent results were achieved in 67.4 % of patients with a mean arc of motion of 98.3° at a mean follow up of 42.2 months. One third of the patients experienced a complication but only 1.7 % experienced loosening of the prosthesis.

CONCLUSION

Here, we present the first review of the indications for DHH. DHH is a reasonable treatment option for older patients with unreconstructable intra-articular fractures of the distal humerus as well as younger patients with rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis.

Primary total elbow arthroplasty in complex fractures of the distal humerus

AIM: To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus.

METHODS: A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo.

RESULTS: Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt.

CONCLUSION: Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.

Factors affecting choice of open surgical techniques in elbow stiffness

BACKGROUND

We analyzed the clinical outcomes of stiff elbow open treatment to assess factors affecting the choice of surgical procedures in a consecutive series of patients followed up prospectively.

MATERIALS AND METHODS

Forty-one patients, mean aged 48 years, were evaluated. Elbow stiffness was caused by post-traumatic osteoarthritis in 32 patients, primary osteoarthritis in seven and rheumatoid arthritis in two. Stiffness was classified as mixed and extrinsic in 28 and 13 cases, respectively. Seventeen ulno-humeral arthroplasties (UHA), seven UHA with radiocapitellar replacement, six UHA with radial head replacement, ten total elbow replacement and one UHA with anconeus interposition were performed. Mayo Elbow Performance Score (MEPS), modified-American Shoulder and Elbow Surgeons (m-ASES) and Q-DASH scores were used for the pre- and post-operative evaluation.

RESULTS

Mean follow-up was 25 months. The average increase in MEPS and m-ASES was 45 and 41, respectively. The average decrease in Q-DASH and the average increase in m-ASES pain were 43 and 21, respectively. The mean increase in flection, extension, pronation and supination was 29°, 25°, 18° and 17°, respectively. All the differences were statistically significant.

CONCLUSIONS

Strictly customized open surgery of elbow stiffness, by taking into account the clinical value of each patient's pathoanatomical conditions, yields satisfactory functional results in majority of cases. In particular, the degree and site of elbow cartilage wear proved to be the factors affecting the choice of treatment most. Treatment should be aimed at removing the causes of pain and at recovering range of motion.