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

AIMS: The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. MATERIALS AND METHODS: We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). RESULTS: This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. CONCLUSION: The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489-1497.

Indications and Clinical Results of Radial Head Replacement: Has Anything Changed?

Radial head fractures are common injuries comprising 1/3 of the fractures about the elbow. As a secondary valgus stabilizer of the elbow, radial head fractures can compromise elbow stability leading to long-term pain, dysfunction, and degenerative change. Furthermore, radial head fractures can be accompanied by associated injuries including ligamentous lesions that can further exacerbate elbow instability, leading to long-term sequelae. As fixation principles and technology have evolved, so has the ability to render surgical treatment for these fractures. In general, minimally displaced and some displaced fractures may be treated nonoperatively with early motion. Fractures with a block to rotation and displaced fragments with 3 or fewer fragments may be treated with open reduction and internal fixation. Comminuted fractures or those with greater than 3 fragments may be successfully treated with radial head replacement. Associated elbow instability will also influence treatment decisions.

Activities after total elbow arthroplasty.

BACKGROUND: Knowledge of patient activities after total elbow arthroplasty may help delineate the true functional gains obtained after replacement. Experience suggests that some patients may perform activities excessively demanding on elbow implants, but compliance with activity restrictions recommended after elbow arthroplasty is largely unknown. MATERIALS AND METHODS: All patients who underwent a primary or revision total elbow arthroplasty at a single institution from 2005 to 2007 were surveyed regarding their activity level. The University of California, Los Angeles (UCLA) activity score and Mayo Elbow Performance Score were assessed. Patients were also questioned about whether they recalled which activities were not recommended by their surgeon. RESULTS: One hundred thirteen completed surveys were analyzed. There were 29 men and 84 women with a mean age of 65 years. Of the patients, 64 had primary and 49 had revision operations. The mean Mayo Elbow Performance Score was 77 points (range, 15-100 points). The mean University of California, Los Angeles activity score was 5 points (range, 1-10 points). Moderate-demand activities were performed by 94% of patients, and high-demand activities were performed by 40% of patients. Male gender and a diagnosis of fracture/nonunion was associated with increased performance of high-demand activities (P < .05). Eighty percent of patients remembered receiving postoperative restrictions, and of these patients, 83% interpreted that they were compliant with their restrictions. CONCLUSION: Ninety-four percent of patients engaged in moderate-demand activities after total elbow arthroplasty. Forty percent engaged in high-demand activities. Factors correlated with more demanding activities included male gender and diagnosis of fracture/nonunion. The vast majority of patients remembered receiving postoperative restrictions.

Revision total elbow arthroplasty with the linked Coonrad-Morrey total elbow arthroplasty: a retrospective study of twenty procedures.

PURPOSE: In this retrospective study we evaluated the short- to medium-term results after 20 Coonrad-Morrey revision total elbow arthroplasties (TEAs). METHODS: We included a consecutive series of revision TEAs performed at our institution from 2004 to 2010. At a mean follow-up of 4.4 years, patients were evaluated using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES) and standard radiographs. RESULTS: The mean age at revision TEA was 65.8 years. The median time of implant survival for primary prosthesis was 9.5 years. The mean post-operative MEPS was 79. The mean OES was 58, 66 and 53 for function, pain and social-psychological dimensions, respectively. At follow-up the range of motion had improved significantly. There were two cases of radiolucent lines and two cases of minor bushing wear; however, none of the implants were clinically loose. In one case deep infection led to a further revision. Two patients had post-operative ulnar nerve paraesthesia. CONCLUSIONS: Results after revision TEA using the Coonrad-Morrey prosthesis are acceptable with a low short- to midterm failure rate. Revision improves range of motion and provides pain relief. One case of deep infection with recurrent revision is of concern. The treatment can be used as an option for failed TEA.

Humeral fracture between a total elbow and total shoulder arthroplasty.

This article presents a case of a 71-year-old woman with a humeral fracture between a cementless reverse total shoulder arthroplasty and a cemented total elbow arthroplasty and discusses our treatment plan. Surgical treatment was performed after the patient was informed of possible complications and the benefits of surgery including: early, complete restoration of arm anatomy, greater functional improvement of the adjacent joints, and increased risk of nonunion with nonoperative treatment.The fracture was comminuted and extended proximally around the shoulder prosthesis. Through the posterior approach, the radial nerve was identified and protected. Both prostheses were found firmly fixed to bone. The fracture around the shoulder prosthesis was reduced first using a strut allograft and reduction clamps. Next, arm alignment restoration and distal humerus reduction were performed. The construct was neutralized with a 3.5-mm locking plate spanning the whole length of the humerus. The locking plate was positioned posterolaterally and the strut medially in a 90° to 90° configuration secured with wires and cables.A hinged elbow brace was applied for 6 weeks postoperatively. Active range of motion exercises of the wrist and hand and passive motion of the elbow and shoulder were started at 4 to 5 days postoperatively. At 2 weeks postoperatively, passive motion of the elbow and shoulder progressed to strengthening exercises. Thereafter, the patient underwent several weeks of physical therapy to restore motion, strength, and function of the upper extremity with instructions not to overload the arm and avoid heavy work and sports for as long as 1 year. At 10 months postoperatively, radiographs of the arm showed a stable construct; the patient had resumed full activities of daily living.

Unlinked and convertible total elbow arthroplasty.

Total elbow arthroplasty (TEA) is still in its infancy if we compare it with other arthroplasties such as knee or hip. TEA designs have been evolving with experience; however, long-term outcome data remain limited. The designs of total elbow prostheses can be subdivided into 3 general categories: unlinked, linked, and convertible devices. This article focuses on unlinked and convertible prostheses.