Neglected Bicondylar Fracture of the Distal Humerus Treated With Total Elbow Arthroplasty.

A 69-year-old woman suffered a distal humerus fracture including the medial and lateral condyles. She received conservative treatment with a posterior arm splint at a local healthcare center where she was evaluated by a non-specialist physician. Eight months later, she presented to our department complaining about severe instability. An upper limb specialist examined the patient at the time, and after thoroughly explaining the condition, he suggested a surgical approach with total elbow arthroplasty (TEA), which was then performed. At the one-year follow-up, the patient had a full range of motion without any complications or pain complaints. TEA in neglected fractures of the distal humerus is a poorly researched topic in the field of upper limb surgery with only scarce literature available. In this case report, we present the excellent outcomes of the procedure performed on an elderly patient after non-union regaining her quality of life and suggest that TEA can be a viable solution in elderly patients with complicated or non-united elbow fractures.

Does timing of total elbow arthroplasty after distal humerus fracture affect 2-year complication rates?

BACKGROUND: Open reduction internal fixation (ORIF) remains the gold standard for adult distal humerus fractures (DHF). However, indications for total elbow arthroplasty (TEA) continue to expand and the incidence of primary and salvage TEA for DHF has increased. The objective of this study was to compare complication and reoperation rate for acute versus delayed primary and salvage TEA performed for DHF. METHODS: Patients who underwent TEA for DHF were identified in the PearlDiver database. Patients were sorted into three cohorts: (1) acute TEA (within 2 weeks of diagnosis), (2) delayed TEA (between 2 weeks and 6 months after diagnosis), and (3) salvage TEA (after failed ORIF, malunion, nonunion, delayed treatment between 6 months-1 year or post-traumatic arthritis). Multivariate analysis was utilized to assess for confounding variables and covariates when identify differences in complications between cohorts. RESULTS: 788 patients underwent acute TEA, 213 patients underwent delayed TEA, and 422 patients underwent salvage TEA after DHF. The incidence of PJI (8.5% vs. 3.4%, odds ratio (OR) 2.60, P=0.002) and triceps injury (2.4% vs. 0.4%, OR 6.29, P=0.012) were higher in the delayed compared to acute cohort. The incidence of revision (8.5% vs. 2.1%, OR 3.76, P< 0.001), periprosthetic fracture (4.3% vs. 1.1%, OR 3.64, P=0.002), PJI (14.7% vs 3.4%, OR 4.36, P< 0.001), triceps injury (2.6% vs. 0.4%, OR 5.70, P=0.008), and wound complications (6.9% vs 2.9%, OR 2.33, P=0.002) were higher in the salvage compared to acute cohort. There was an increased rate of revision (8.5% vs. 1.9%, OR 6.08, P=0.002) in the salvage compared to delayed cohort. CONCLUSION: Patients undergoing salvage TEA after DHF have increased rates of at 2 years postoperatively including revision, periprosthetic fracture, PJI, triceps injury, and wound complications. The salvage cohort also had an increased risk of revision when compared to the delayed cohort. However, other than revision rates, patients in the salvage and delayed cohorts have similar postoperative complication rates.

Total Elbow Arthroplasty Versus Open Reduction and Internal Fixation for Distal Humerus Fractures: A Propensity Score Matched Analysis of 30-Day Postoperative Complications.

Introduction: Open reduction and internal fixation (ORIF) is an established surgical procedure for distal humeral fractures; however, total elbow arthroplasty (TEA) has become an increasingly popular alternative for elderly patients with these injuries. Using a large sample of recent patient data, this study compares the rates of short-term complications between ORIF and TEA and evaluates complication risk factors. Methods: Patients who underwent primary TEA or ORIF from 2012 to 2021 were identified by Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching controlled for demographic and comorbid differences. The rates of 30-day postoperative complications were compared. Results: A total of 1539 patients were identified, with 1365 (88.7%) and 174 (11.3%) undergoing ORIF and TEA, respectively. Patients undergoing TEA were older on average (ORIF: 56.2 ± 19.8 years, TEA: 74.3 ± 11.0 years, P < .001). 348 patients were included in the matched analysis, with 174 patients in each group. TEA was associated with an increased risk for postoperative transfusion (OR = 6.808, 95% CI = 1.355 - 34.199, P = .020). There were no significant differences in any adverse event (AAE) between procedures (P = .259). A multivariate analysis indicated age was the only independent risk factor for the development of AAE across both groups (OR = 1.068, 95% CI = 1.011 - 1.128, P = .018). Conclusion: The risk of short-term complications within 30-days of ORIF or TEA procedures are similar when patient characteristics are controlled. TEA, however, was found to increase the risk of postoperative transfusions. Risks associated with increasing patient age should be considered prior to either procedure. These findings suggest that long-term functional outcomes can be prioritized in the management of distal humerus fractures.

Restoring Functionality: Humeroradial Total Elbow Revision for Salvaging Total Elbow Arthroplasty Failure and Ulnar Bone Loss.

As the number of total elbow arthroplasty (TEA) continues to increase worldwide, one might predict the number of revision TEA would rise as well. The most common indications for revision TEA include (a) loosening, (b) infection, and (c) periprosthetic fracture. Although the rate of revision TEA procedures continues to rise due to the infrequency in which they are performed compared to other arthroplasty surgeries, no gold standard algorithm or procedure for managing severe ulnar bone loss in revision TEA has been determined. Various surgical techniques and strategies including allograft-prosthesis composite, custom long prosthesis with or without allograft, and resection arthroplasty have all been employed in attempting to address severe ulnar bone loss in revision TEA. Though the reported outcomes are mixed at best between each treatment strategy with similar complication rates. Another option is implanting the ulnar component into the radius. In those patients with severe ulnar bone loss, a humeroradial TEA revision can provide stability, restore range of motion, and provide pain relief.

Recent advances in unlinked total elbow arthroplasty in Japan.

Background: Total elbow arthroplasty (TEA) is a valuable therapeutic approach for improving function and relieving pain in severely deformed elbow joints. However, TEA is associated with a high incidence of complications. In Japan, the use of unlinked TEA has a long history, with the development of the Kudo prosthesis marking a significant milestone. Subsequently, various unlinked implant designs have been developed. Although favorable long-term clinical results have been reported, complications remain a concern. To further improve the outcome of unlinked TEA, attempts have been made in recent years to develop various surgical approaches and intraoperative support devices. This review focuses on the clinical outcomes and recent advances in unlinked TEA in Japan. Methods: A comprehensive review of clinical results and advancements in unlinked TEA in Japan was conducted. The analysis included trends in the number of TEA, medium-term and long-term results for unlinked TEA, surgical approaches, or preoperative planning techniques. Results: Several implant designs have been developed in Japan. Clinical studies have reported satisfactory long-term outcomes with these implants, but complications, such as infection, fractures, and dislocation, have been observed. In order to enhance the outcomes of unlinked TEA, various triceps-on approaches have been developed as alternatives to the triceps-detaching approach, which compromises the continuity between the triceps tendon and ulna, leading to inevitable complications related to the triceps tendon. Preservation or repair of the surrounding soft tissues is considered critical for preventing postoperative instability due to the absence of a radial head in the current unlinked TEA design. Computed tomography-based 3-dimensional preoperative planning has been pioneered in Japan, demonstrating its effectiveness in predicting implant size and achieving appropriate implant placement. Additionally, augmented reality-assisted surgery is being explored to accurately translate preoperative planning into the surgical procedure. Conclusion: Unlinked TEA for inflammatory arthritis has exhibited promising long-term results in Japan, with ongoing efforts to improve surgical techniques and preoperative planning. Further advancements are anticipated to prevent complications such as dislocation and peri-implant fractures.

Outcomes of total elbow arthroplasty in the treatment of distal humeral fractures in the elderly: A retrospective cohort comparison between primary arthroplasty and arthroplasty secondary to failed internal fixation.

BACKGROUND: The primary objective of this study was to compare the clinical outcomes of total elbow arthroplasty as the index procedure in the treatment of traumatic distal humerus fractures, with secondary total elbow arthroplasty following failed internal fixation. The secondary objectives were to compare the complication rates and the radiographic results in the two groups. Our hypothesis was that the clinical results of total elbow arthroplasty performed secondarily to failed internal fixation were comparable to primary total elbow arthroplasty in the treatment of distal humerus fractures in the elderly population. METHODS: We conducted a retrospective cohort comparison study, including 60 patients with a median age of 80 years (71-85), who either underwent a primary total elbow arthroplasty (group 1; 45 patients), or secondary total elbow arthroplasty following failed internal fixation (group 2; 15 patients), in the treatment of a post-traumatic supra and intercondylar fracture of the distal humerus, between January 2004 and January 2021. The clinical examination, including MEPS score and triceps proficiency test, complication rates and the need for re-operation were noted. The average clinical and radiographic follow-up was 40.8 months (24-120). RESULTS: The clinical results of the two groups were comparable when looking at the MEPS score (90.00 [85.00, 100.00] p= 0.486). With regards to complications, there were 2 surgical site infections in group 1 and 3 in group 2 (p=0.099), 1 case of mechanical loosening of the humeral component in group 1 and 1 in group 2 (p= 0.448), and 1 patient with triceps insufficiency in group 1. CONCLUSION: Secondary total elbow arthroplasty following failed internal fixation has shown good functional results, and a complication rate comparable to that of index total elbow arthroplasty in the treatment of articular fractures of the distal humerus in the elderly.

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

BACKGROUND: Total elbow arthroplasty (TEA) is an appropriate surgical treatment option for a variety of conditions ranging from inflammatory arthritis to trauma. Due to a high complication profile, implant companies have attempted to improve patient outcomes with evolving design mechanics and philosophy. However, the Nexel TEA prosthesis has been criticized for its unacceptably high revision rate by other research groups in the literature. The purpose of this study was to evaluate the survivorship and revision rates of the Nexel and Coonrad-Morrey total elbow arthroplasty implant systems in New Zealand. METHODS: Prospectively collected national joint registry data was used to compare the survival rates of these prostheses. Underlying diagnoses, reasons for revision, and patient demographics were all recorded. Statistical analysis included survival analysis using Kaplan-Meier curves and comparison between groups using independent t-tests. RESULTS: Over the 23-year study interval, the Nexel and Coonrad-Morrey prostheses showed similar survivorship and revision rates. The revision rates at 5 years were 7.3% for ZN and 4.5% for the Coonrad-Morrey cohorts. The average time to revision for those who are revised was 3.13 ± 1.74 years in the Nexel group and 4.93 ± 4.13 years in the Coonrad-Morrey population. CONCLUSION: Our study confirms a lower revision rate of the Nexel TEA compared to other studies in the literature. Additionally, the Nexel TEA implant performs comparably to its predecessor, the Coonrad-Morrey prosthesis in New Zealand. While it is difficult to explain the discrepancy in results with the study by Morrey et. al, future studies should focus on investigating postoperative radiographs and a deep analysis of the specific surgical technique used for this implant.

A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options.

Background: Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management. Methods: A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates. Results: Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)). Discussion: Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Mid-Term Follow Up of the Nexel Total Elbow Arthroplasty.

INTRODUCTION: Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at mid-term follow-up. METHODS: Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3 year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via Wrightington method by three independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Dash (QDASH), Patient Rated Elbow Evaluation (PREE), and EuroQoL (EQ5D). RESULTS: 38 consecutive patients (22 female, 16 male) with mean age of 67 underwent TEA via triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with one patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across three observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QDASH, PREE, and EQ5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs. CONCLUSION: At mid-term follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preop to final postop follow-up. Although promising, these results should be interpreted with some caution as long term data regarding this prosthesis are still lacking.

High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience.

BACKGROUND: Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. METHODS: We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined. RESULTS: Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179). CONCLUSION: Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.

Do ChatGPT and Google differ in answers to commonly asked patient questions regarding total shoulder and total elbow arthroplasty?

BACKGROUND: Artificial intelligence (AI) and large language models (LLMs) offer a new potential resource for patient education. The answers by Chat Generative Pre-Trained Transformer (ChatGPT), a LLM AI text bot, to frequently asked questions (FAQs) were compared to answers provided by a contemporary Google search to determine the reliability of information provided by these sources for patient education in upper extremity arthroplasty. METHODS: "Total shoulder arthroplasty" (TSA) and "total elbow arthroplasty" (TEA) were entered into Google Search and ChatGPT 3.0 to determine the ten most FAQs. On Google, the FAQs were obtained through the "people also ask" section, while ChatGPT was asked to provide the ten most FAQs. Each question, answer, and reference(s) cited were recorded. A modified version of the Rothwell system was used to categorize questions into 10 subtopics: special activities, timeline of recovery, restrictions, technical details, cost, indications/management, risks and complications, pain, longevity, and evaluation of surgery. Each reference was categorized into the following groups: commercial, academic, medical practice, single surgeon personal, or social media. Questions for TSA and TEA were combined for analysis and compared between Google and ChatGPT with a 2 sample Z-test for proportions. RESULTS: Overall, most questions were related to procedural indications or management (17.5%). There were no significant differences between Google and ChatGPT between question categories. The majority of references were from academic websites (65%). ChatGPT produced a greater number of academic references compared to Google (80% vs. 50%; P = .047), while Google more commonly provided medical practice references (25% vs. 0%; P = .017). CONCLUSION: In conjunction with patient-physician discussions, AI LLMs may provide a reliable resource for patients. By providing information based on academic references, these tools have the potential to improve health literacy and improved shared decision making for patients searching for information about TSA and TEA. CLINICAL SIGNIFICANCE: With the rising prevalence of AI programs, it is essential to understand how these applications affect patient education in medicine.

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

PURPOSE: Linked component of total elbow arthroplasty (TEA) consisted of bushing and locking pins. Failure of linked components is a rare complication of TEA. This study aims to investigate the mechanism and consequence of failure of the linkage mechanism in TEA surgeries. METHODS: Between 2010 and 2021, five patients received revision operation due to linked component failure. Besides, two patients underwent primary operation at another institute were also analyzed due to failure of the linkage mechanism. RESULTS: All seven patients underwent primary TEA and mean age for primary TEA was 48 (range, 27-62). Two patients had TEA for post-traumatic arthritis, three patients for rheumatoid arthritis, and two patients for comminuted distal humerus fracture. The average time between primary TEA and revision TEA for linked component failure was 13.6 years. Three bushing wear and four locking pin dissociation were diagnosed according to pre-operative radiography. Elbow pain and swelling are the most common clinical symptoms. Severe osteolysis, periprosthetic fracture, and stem loosening were noted in three bushing wear cases. In four dissociation of locking pin cases, breakage of male locking pin phalanges was demonstrated in two patients. For revision procedures, both the locking pins and bushings were replaced. No patients in the study required additional surgery after the revision operation for linked component failure. CONCLUSION: Osteolysis, component loosening, periprosthetic fracture may be expected after linked component failure. Patients should be regularly followed up from short-term to long-term with radiography. Early diagnosis and intervention with linked component exchange can prevent extensive revision surgery.

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

BACKGROUND: Total elbow arthroplasty (TEA) has been used for various conditions including rheumatoid arthritis (RA). While the Kudo TEA has been associated with favorable short-term outcomes, there is limited information on the longer term outcomes of this device. The aim of this study was to investigate the average 15-year outcome of Kudo type-5 TEA in patients with RA. METHODS: For this retrospective cohort study, we reviewed 29 elbows in 28 patients (Larsen grade III, n = 8; IV, n = 19; V, n = 2) with RA who underwent Kudo type-5 TEA between 1999 and 2010. The patients were followed up for a mean of 15 (range: 10-21) years. We investigated the survival with setting revision/removal as the endpoints. The risk factors for revision/loosening were assessed. RESULTS: There was a significant improvement in elbow flexion after Kudo TEA. Preoperative and postoperative Mayo Elbow Performance Score improved significantly from 60.3 to 94.7. Complications included intraoperative medial humeral epicondyle fracture (n = 2), postoperative dislocations (n = 4), deep infections (n = 1), and persistent ulnar nerve neuropathy (n = 1). Aseptic loosening was observed in 7 elbows (24.1%; humerus, n = 3; ulna, n = 3; both sides, n = 1). The causes of the 5 revisions were postoperative dislocation (n = 1), deep infection (n = 1), aseptic loosening of the humerus (n = 2), and aseptic loosening of the ulna (n = 1). All 5 elbows underwent revision of the ulnar component (n = 2) or the linked TEA (n = 3). The survival rate was 81% at 15 years after surgery with setting revision/removal as the endpoints. A deviation of ulnar component insertion angle of over 5° in any plane was associated with more revision compared to those with accurately placed implants. CONCLUSION: The Kudo type-5 elbow showed good results for up to 15 years of follow-up. However, excessive deviation of insertion angle of the ulnar component (over 5°) was associated with more revision. Due to the small sample size, robust statistical analysis of risk factors for postoperative complications or revision could not be performed, and further research is warranted to resolve this limitation.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial.

BACKGROUND: Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients. MATERIAL AND METHODS: This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength. RESULTS: Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group. CONCLUSION: In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

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.

Non-cefazolin antibiotic prophylaxis is associated with higher rates of elbow periprosthetic joint infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a common source of failure following elbow arthroplasty. Perioperative prophylactic antibiotics are considered standard of care. However, there are no data regarding the comparative efficacy of various antibiotics in the prevention of PJI for elbow arthroplasty. Previous studies in shoulder, hip, and knee arthroplasty have demonstrated higher rates of PJI with administration of non-cefazolin antibiotics. The elbow has higher rates of PJI than other joints. Therefore, this study evaluated whether perioperative antibiotic choice affects rates of PJI in elbow arthroplasty. MATERIALS AND METHODS: A single-institution, prospectively collected total joint registry database was queried to identify patients who underwent primary elbow arthroplasty between 2003 and 2021. Elbows with known infection prior to arthroplasty (25) and procedures with incomplete perioperative antibiotic data (7) were excluded, for a final sample size of 603 total elbow arthroplasties and 19 distal humerus hemiarthroplasties. Cefazolin was administered in 561 elbows (90%) and non-cefazolin antibiotics including vancomycin (32 elbows, 5%), clindamycin (27 elbows, 4%), and piperacillin/tazobactam (2 elbows, 0.3%) were administered in the remaining 61 elbows (10%). Univariate and multivariate analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Infection-free survivorship was estimated using the Kaplan-Meier method. RESULTS: Deep infection occurred in 47 elbows (7.5%), and 16 elbows (2.5%) were diagnosed with superficial infections. Univariate analysis demonstrated that patients receiving non-cefazolin alternatives were at significantly higher risk for any infection (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.4-5.0; P < .01) and deep infection (HR 2.7, 95% CI 1.3-5.5; P < .01) compared with cefazolin administration. Multivariable analysis, controlling for several independent predictors of PJI (tobacco use, male sex, surgical indication other than osteoarthritis, and American Society of Anesthesiologists score), showed that non-cefazolin administration had a higher risk for any infection (HR 2.8, 95% CI 1.4-5.3; P < .01) and deep infection (HR 2.9, 95% CI 1.3-6.3; P < .01). Survivorship free of infection was significantly higher at all time points for the cefazolin cohort. DISCUSSION: In primary elbow arthroplasty, cefazolin administration was associated with significantly lower rates of PJI compared to non-cefazolin antibiotics, even in patients with a greater number of prior surgeries, which is known to increase the risk of PJI. For patients with penicillin or cephalosporin allergies, preoperative allergy testing or a cefazolin test dose should be considered before administering non-cefazolin alternatives.

Total elbow arthroplasty for hemophilic osteoproliferative elbow arthritis with severe flexion contracture: A case report.

Total elbow arthroplasty is effective for pain relief and the functional improvement of severe symptomatic hemophilic osteoproliferative arthropathy. Nevertheless, high complication rates have been reported. This report describes clinical results obtained at 30-month follow-up of total elbow arthroplasty in a hemophilic patient with severe flexion contracture. A 50-year-old patient with advanced left elbow hemophilic arthropathy underwent unlinked total elbow arthroplasty. He had sustained an intraoperative fracture of the medial part of a supracondylar humerus complication. To control perioperative bleeding, strict factor VIII replacement therapy was performed under the guidance of hematologists. The total elbow range of motion was 35° preoperatively, but it had improved to 110° postoperatively. The Patient-Rated Elbow Evaluation Japanese version score, which was 53.7 preoperatively, improved to 10.7 postoperatively. During the 30 months after operation, no complication occurred. Good clinical results have been obtained under close collaboration with hematologists and close patient adherence following treatment.