Aims

Despite numerous studies focusing on periprosthetic joint infections (PJIs), there are no robust data on the risk factors and timing of metachronous infections. Metachronous PJIs are PJIs that can arise in the same or other artificial joints after a period of time, in patients who have previously had PJI.

Aims. There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA). Methods. We retrospectively reviewed the records of 26 elbows of 21 patients with RA who were aged less than 50 years who underwent primary TEA with an unlinked elbow prosthesis. The mean patient age was 46 years (35 to 49), and the mean follow-up period was 13.6 years (6 to 27). Outcome measures included pain, range of motion, Mayo Elbow Performance Score (MEPS), radiological evaluation for radiolucent line and loosening, complications, and revision surgery with or without implant removal. Results. The mean MEPS significantly improved from 47 (15 to 70) points preoperatively to 95 (70 to 100) points at final follow-up (p < 0.001). Complications were noted in six elbows (23%) in six patients, and of these, four with an ulnar neuropathy and one elbow with postoperative traumatic fracture required additional surgeries. There was no revision with implant removal, and there was no radiological evidence of loosening around the components. With any revision surgery as the endpoint, the survival rates up to 25 years were 78.1% (95% confidence interval 52.8 to 90.6) as determined by Kaplan-Meier analysis. Conclusion. The clinical outcome of primary unlinked TEA for young patients with RA was satisfactory and comparable with that for elderly patients. A favourable survival rate without implant removal might support the use of unlinked devices for young patients with this disease entity, with a caution of a relatively high complication rate regarding ulnar neuropathy. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Jt Open 2023;4(1):19–26

Aims

Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research.

Aims

The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection.

Aims

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

Introduction. Total Elbow Arthroplasty (TEA) is recognized as an effective treatment solution for patients with rheumatoid arthritis or for traumatic conditions. Current total elbow devices can be divided into linked or unlinked design. The first design usually presents a linking element (i.e. an axle) to link together the ulnar and humeral components to stabilize the joint; the second one does not present any linkage and the stability is provided by both intrinsic design constraints and the soft tissues. Convertible modular solutions allow for an intraoperative decision to link or unlink the prosthesis; the modular connections introduce however additional risks in terms of both mechanical strength and potential fatigue and fretting phenomena that may arise not only due to low demand activities loads, but also high demand (HD) ones that could be even more detrimental. The aim of this study was to assess the strength of the modular connection between the axle and the ulnar component in a novel convertible elbow prosthesis design under simulated HD and activities of daily living (ADLs) loading. Methods. A novel convertible total elbow prosthesis (LimaCorporate, IT) comprising both ulnar and humeral components that can be linked together by means of an axle, was used. Both typical ADLs and HD torques to be applied to the axle were determined based on finite element analysis (FEA); the boundary load conditions for the FEA were determined based on kinematics analysis on real patients in previous studies. The FEA resultant moment acting on the axle junction during typical ADLs (i.e. feeding with 7.2lbs weight in hand) was 3.2Nm while for HD loads (i.e. sit to stand) was 5.7 Nm. In the experimental setup, 5 axle specimens coupled with 5 ulnar bodies through a tapered connection (5 Nm assembly torque) were fixed to a torque actuator (MTS Bionix) and submerged in a saline solution (9g/l). A moment of 3.2 Nm was applied to the axle for 5M cycles through a fixture to test it under ADLs loading. After 5M cycles, the axles were analyzed with regards to fretting behavior and then re-assembled to test them against HD loading by applying 5.7 Nm for 200K cycles (corresponding to 20 years function). Results. All 5 samples withstood all 5.2M loading cycles without any mechanical failure. At the end of 5M cycles, each axle was still stable as the measured disassembly torque was 3.96 +/−0.18 Nm. Slight signs of fretting were detected on the tapered connection after 5M cycles, however they did not compromise the mechanical connection nor the stability. Discussion and Conclusions. Currently there are no reference standards that properly define protocols for biomechanical testing of elbow prostheses. In the present study, a test to mechanically assess the strength of an axle connection under both typical ADLs and HD loads was set. The connection was able to withstand the imposed conditions. In general, testing of TEA devices should include not only standard ADLs loads but also HD loads, which could be more detrimental for the long-term survivorship. For any figures or tables, please contact authors directly

Aims. We assessed the long-term (more than ten-year) outcomes of the Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis (RA). Materials and Methods. We reviewed 41 elbows (Larsen Grade IV, n = 21; Grade V, n = 20) in 31 patients with RA who had undergone a Kudo type-5 total elbow arthroplasty (TEA) between 1994 and 2003, and had been followed up for more than ten years. The humeral component was cementless and the all-polyethylene ulnar component cemented in every patient. Clinical outcome was assessed using the Mayo elbow performance score. We calculated the revision rate and evaluated potential risk factors for revision. The duration of follow-up was a mean 141 months (120 to 203). Results. Aseptic loosening of the ulnar component occurred in 11 elbows. There was no radiolucency around any humeral component. There was one deep infection. The survival rate according to Kaplan-Meier survivorship analysis was 87.8% after five years and 70.7% after ten years. The range of extension/flexion was a mean -38° (-80° to 0°)/105° (30° to 150°) before surgery and -40° (-70° to -20°)/132° (100° to 150°) at the final follow-up, while the mean Mayo elbow performance score was 43 before surgery and 80 at final follow-up. Disease duration of RA up to the TEA of < 15 years and a pre-operative range of movement (ROM) of > 85° were significant risk factors for revision or aseptic loosening. Conclusion. Although Kudo type-5 prostheses gave satisfactory results in the short-term, aseptic loosening increased after five years. In most cases, elbow function was maintained in the long-term without loosening of the implant. A short duration from the onset of RA to TEA and a large pre-operative ROM were significant risk factors for revision or aseptic loosening. Cite this article: Bone Joint J 2017;99-B:818–23

Aims

The diagnosis of periprosthetic joint infection (PJI) remains demanding due to limitations of all the available diagnostic tests. The synovial fluid marker, α-defensin, is a promising adjunct for the assessment of potential PJI. The purpose of this study was to investigate the qualitative assessment of α-defensin, using Synovasure to detect or exclude periprosthetic infection in total joint arthroplasty.

The aim of this study was to assess the long-term results of the Kudo type-5 total elbow prosthesis and compare the results of two types of cemented ulnar components. The Kudo type-5 unlinked total elbow prosthesis (Biomet UK Ltd, Bridgend Wales) was developed in 1993. The stem of humeral component is porous-coated with a plasma spray of titanium alloy for cementless use. The ulnar component may be metal-backed with a porous-coated stem or polyethylene alone; the latter designed mainly for cement use. A metal-backed type without a porous-coated stem designed for cement use also came into being after 2003. Between 1993 and 2010, the Kudo type-5 total elbow arthroplasty was performed on 364 elbows in 274 consecutive patients with rheumatoid arthritis. The mean age of the patients at the time of the operation was 60.7 (27–86) years. Twenty elbows had Larsen grade III, 224 had grade IV, and 120 had grade V changes pre-operatively. Before the operation, 346 elbows had severe or moderate pain, 95 had gross valgus-varus instability. Clinical symptoms and revision rates were assessed 4 to 20 years (mean, 9 years) postoperatively. The mean Mayo elbow performance scores were all poor except for three initially (mean overall score, 39.5 points). The overall score had improved substantially both at the early follow-up (1 to 3 years after the operation) and the latest follow-up (4 to 20 years after the operation), with 89.5 and 84.7 points, respectively. At the latest follow-up the overall result was excellent for 185 elbows, good for 103, fair for 11 and poor for 30, with almost complete relief from pain for 298. The arc of movement had increased from a mean of 85.7 °pre-operatively to 95.1 ° post-operatively, and to 98.1 °at the latest follow-up. Spot welds around the humeral stem suggesting solid osseous integration were often seen in the elbows with cementless fixation of the porous humeral stem. At the latest follow-up, implants were removed due to infection in 3 elbows. Twenty-five elbows required ulnar component revision due to loosening of the all-polyethylene component. Two elbows required ulnar component revision due to loosening of the metal-backed component. Seven elbows required humeral component revision due to loosening of the humeral components. One elbow required revision due to dislocation. A survival analysis with revision or removal of one or both components as the end point was performed according to the Kaplan and Meier method. The overall survival rate of the prosthesis was 75.2% at 19 years. The survival of 87.0% in the metal-backed group was higher than the 74.3% in the all-polyethylene group. Loosening of the all-polyethylene ulnar component was the main reason for deterioration in the long-term outcome. We conclude that the long-term results of the Kudo type-5 total elbow arthroplasty is acceptable and cemented fixation of metal-backed ulnar component had better long-term survival than the all-polyethylene component

Determining and accurately restoring the flexion-extension axis of the elbow is essential for functional recovery after total elbow arthroplasty (TEA). We evaluated the effect of morphological features of the elbow on variations of alignment of the components at TEA. Morphological and positioning variables were compared by systematic CT scans of 22 elbows in 21 patients after TEA.

There were five men and 16 women, and the mean age was 63 years (38 to 80). The mean follow-up was 22 months (11 to 44).

The anterior offset and version of the humeral components were significantly affected by the anterior angulation of the humerus (p = 0.052 and p = 0.004, respectively). The anterior offset and version of the ulnar components were strongly significantly affected by the anterior angulation of the ulna (p < 0.001 and p < 0.001).

The closer the anterior angulation of the ulna was to the joint, the lower the ulnar anterior offset (p = 0.030) and version of the ulnar component (p = 0.010). The distance from the joint to the varus angulation also affected the lateral offset of the ulnar component (p = 0.046).

Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. This is explained by abutment of the stems of the components and is particularly severe when there are substantial deformities or the deformities are close to the joint.

Cite this article: Bone Joint J 2015;97-B:1539–45.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients.

A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation.

The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients.

Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Cite this article: Bone Joint J 2015;97-B:1377–84.

Summary Statement. Discovery system produced effective functional improvement in both primary and revision total elbow replacement. The incidence of major complications was in an acceptable range. Introduction. The search for the ideal elbow prosthesis continues as instability and loosening remain the prime reasons for total elbow replacement (TER) failure. The Discovery Elbow System (Biomet) is one of the latest generations of linked prosthesis and has been used in UK since 2003. We report outcome of TER using this system. Methods. A total of 100 TERs (75 primary, 25 revisions) were performed between 2003 and 2010. The main primary underlying pathologies for TER were advanced rheumatoid arthritis (N=58), osteoarthritis (N=35), acute fractures (N=7). There were 60 female and 40 male patients with an average age of 62 years. The outcome assessment included pain, patient satisfaction, Liverpool Elbow Score (LES), range of movement, and imaging during a mean follow-up period of 48.5 months. Major complications are also reported. Results. For the whole patient group (primary + revision), the LES was significantly (p<0.001) improved from 3.79+/−1.71 to 6.36+/−1.85There were significant improvements in elbow flexion from 100°+/−24 to 118°+17, supination from 38°+/−26 to 50°+/−25 and pronation from 48°+/−22 to 61°+/−21. Mean improvement in flexion-extension and pronation-supination arc was 20° and 25°, respectively. 64% of cases were completely pain-free and at the final follow-up (compared to 7% preoperatively). Only 6% of patients scored “Not Satisfied” at the final follow-up. LES improvement was significantly higher in the primary TER compared to revision TER (p<0.05). Imaging reviewed for 60 cases showed loosening in 4% of patients. Other main complications included deep infection (N=2), ulnar neuropathy (N=3), pre-prosthetic fracture (N=2), and prosthetic failure (N=1). Discussion. TER using the Discovery Elbow System is an effective arthroplasty in terms of functional improvement, pain relief and range of motion in both primary and revision patients. TER resulted in no/mild pain in 78% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 20° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSBIII (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 25° in pronation-supination arc in our series is also comparable to that of 21–28° reported the Coonrad-Morrey and 27–33° for Discovery prostheses. An infection rate of 2% is lower than several other reports for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy (3%) was lower compared to GSBIII TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%)

Background. The quest for the perfectly designed elbow prosthesis continues as instability and loosening remain the foremost reasons for the failure of total elbow replacement (TER). The Discovery® Elbow System (Biomet, UK) (Figure 1), which has been used in UK since 2003, is one of the latest generations of linked prosthesis. This system was designed to decrease polyethylene-bushing wear, improve anatomic stem design, restore elbow joint biomechanics, and produce a hinge that could be easily revised. This report describes the short term outcome of TER using the Discovery® Elbow System. Patients and Methods. A total of 60 TERs including 48 primary and 12 revisions were performed between 2003 and 2008. Patients included 21 males (37%) and 36 females (63%) with a mean age of 63 years. The indications for primary TER were advanced rheumatoid arthritis (n=19), osteoarthritis (n=16), post traumatic osteoarthritis (n=9), acute fractures (n=3), and haemophilic arthropathy (n=1). The outcome was assessed using pain score, Liverpool Elbow Score (LES), and range of movement during a mean follow-up of 26 months. Associated complications were documented. Radiological assessment included evaluation for loosening, instability and periprosthetic fractures. Results. The mean LES was significantly (p<0.001) improved from 3.8 (±1) pre-operatively to 6.9 (±2) at the final follow- up. Significant improvements were noted in elbow flexion from 100° (±22) to 120° (±15), supination from 41° (±28) to 65° (±20) and pronation from 52° (±22) to 72° (±18). There was no significant change in elbow extension. Mean improvement in flexion-extension and pronation-supination arc was 22° and 44°, respectively. 46 cases (77%) were completely pain-free at the final follow-up. The main complications included deep infection (4 cases – treated with staged revision TER), postoperative ulnar neuropathy (3 cases–treated with decompression), intra-operative fractures of medial condyle (3 cases – treated non-operatively with brace), and elbow haemarthrosis (1 case). Discussion. TER with Discovery® Elbow System resulted in either no pain or mild pain in 87% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 22° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSB III (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 44° in pronation-supination arc in our series is also comparable to that of 31–67° reported for GSB III and higher than the Coonrad-Morrey prosthesis (21–28°). In terms of complications, an infection rate of 6.7% is consistent with those reported for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy was lower compared to GSB III TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%). While the survival of Discovery TER was 93%, the survival of GSB III (5–6 years) and Coonrad-Morrey (5 years) has been reported as 71–85% and 72–90%. The results indicate that Discovery® Elbow System is an effective device for total elbow arthroplasty in terms of functional improvement, pain relief and range of motion at short-term follow-up

In rheumatoid arthritis (RA), non constrained or semi-constrained prostheses can be used. The authors used the Kudo III, IV or V or iBP prostheses 54 times from 1994 to 2003. After initial satisfactory results, they had to change one or both implants for several reasons: humeral stem fracture (5 cases), unipolar humeral loosening (1 case), ulnar loosening without laxity (8 cases), polyethylene wear (11 cases), due to progressive ulnar collateral ligament lengthening and progressive valgus deformity, without or with metallosis, due to contact between Cr-Co humeral component and titanium alloy ulnar component, chronic infection (1 case). When the local conditions were satisfactory (bone stock, ligament balance), the fractured or loosened component was changed. When the conditions were bad (poor bone stock, ligament misbalance, metallosis), both implants were removed; posterior humeral and/or medial or lateral ulnar window were used to removed the uncemented stems still osteointegrated. All the bipolar operations used the Coonrad-Morrey prosthesis, but the last case a Discovery prosthesis. The operative tricks are described, the management of the extensor apparatus is discussed, the clinical outcomes (especially the extensor apparatus function, most often weak) and the radiographic outcomes are presented.

We studied, ten patients (11 elbows) who had undergone 14 allograft-prosthesis composite reconstructions following failure of a previous total elbow replacement with massive structural bone loss. There were nine women and one man with a mean age of 64 years (40 to 84), who were reviewed at a mean of 75 months (24 to 213). One patient developed a deep infection after 26 months and had the allograft-prosthesis composite removed, and two patients had mild pain. The median flexion-extension arc was 100° (95% confidence interval (CI) 76° to 124°). With the exception of the patient who had the infected failure, all the patients could use their elbows comfortably without splints or braces for activities of daily living. The mean Mayo Elbow Performance Index improved from 9.5 (95% CI 4.4 to 14.7) pre-operatively to 74 (95% CI 62.4 to 84.9) at final review.

Radiologically, the rate of partial resorption was similar in the humeral and ulnar allografts (three of six and four of eight, respectively; p > 0.999). The patterns of resorption, however, were different. Union at the host-bone-allograft junction was also different between the humeral and ulnar allografts (one of six and seven of eight showing union, respectively; p = 0.03).

At medium-term follow-up, allograft-prosthesis composite reconstruction appears to be a useful salvage technique for failed elbow replacements with massive bone loss. The effects of allograft resorption and host-bone-allograft junctional union on the longevity of allograft-prosthesis composite reconstruction, however, remain unknown, and it is our view that these patients should remain under long-term regular review.

Background and purpose: The Souter-Strathclyde total elbow prosthesis is a well-studied replacement therapy for the destructed rheumatoid elbow joint. In the short-term results of a RSA-study we concluded that 8 out of 18 humeral components were at risk for loosening at two years of follow-up. Now we present the long-term results of this study to evaluate these predictions. Patients and Methods: Twenty-one elbows (18 patients) were included in the RSA-study. At risk for loosening was defined as increase of translation of more than 0.4 mm or increase of rotation of more than one degree during the second postoperative year. The average follow-up was 98 months (range: 12–134 months). RSA-measurements were performed post-operatively, at 3 months, 6 months, 12 months and at yearly intervals thereafter. Prosthetic position and radiolucent lines (RLLs) were examined on conventional radiographs. Results: Almost all humeral components, including the ones that were defined to be ‘at risk’ for loosening in our short-term study, showed increased and irregular migration in this long-term follow-up study. In contrast to this, the ulnar components were stable. Translations were most prominent in the posterior-anterior direction, the most prominent rotations took place about the transverse axis. No obvious influences of prosthetic alignment on micromotions were found. Four humeral components were clinically loose – three of them could be revised -, but only one of them was defined to be at risk for loosening in the short term study. Radiological assessment based on conventional radiographs showed that a prediction of humeral loosening can be made within four years after surgery. Interpretation: The RSA results clearly show that almost all humeral components migrate up to several millimeters and several degrees in an irregular manner, but often without clinical consequences

There is little information available at present regarding the mechanisms of failure of modern metallic radial head implants. Between 1998 and 2008, 44 consecutive patients (47 elbows) underwent removal of a failed metallic radial head replacement. In 13 patients (13 elbows) the initial operation had been undertaken within one week of a fracture of the radial head, at one to six weeks in seven patients (seven elbows) and more than six weeks (mean of 2.5 years (2 to 65 months)) in 22 patients (25 elbows). In the remaining two elbows the replacement was inserted for non-traumatic reasons. The most common indication for further surgery was painful loosening (31 elbows). Revision was undertaken for stiffness in 18 elbows, instability in nine, and deep infection in two. There were signs of over-lengthening of the radius in 11 elbows. Degenerative changes were found in all but one. Only three loose implants had been fixed with cement. Instability was not identified in any of the bipolar implants.

Mechanical loosening which begins with early-onset migration of the prosthesis is the major reason for failure of the Souter-Strathclyde elbow replacement. In a prospective study of 18 Souter-Strathclyde replacements we evaluated the patterns of migration using roentgen stereophotogrammetric analysis. We had previously reported the short-term results after a follow-up of two years which we have now extended to a mean follow-up of 8.2 years (1 to 11.3). Migration was assessed along the co-ordinal axes and overall micromovement was expressed as the maximum total point movement. The alignment of the prosthesis and the presence of radiolucent lines were examined on conventional standardised radiographs.

All the humeral components showed increased and variable patterns of migration at the extended follow-up and four humeral components were revised. The maximum total point movement at two years in the revised prostheses was 1.8 mm (sd 1.0) and in the non-revised 0.7 mm (sd 0.5, p = 0.01). Most humeral components migrated into external rotation resulting in an anterior and varus tilt. The ulnar components remained stable.

Purpose: To measure any observed migration and rotation of humeral and ulnar components using radiostereometric analysis. Methods: From 2002–2004 in a prospective study, twelve elbows in patients treated with either a linked(3) or unlinked(9) Acclaim total elbow prosthesis were included in a radiostereometry study. Six tantalum markers were introduced into the humerus another 3 markers were located on a humeral component. Four markers were placed in to ulna and three markers located on the ulnar component. RSA radiographs were taken postoperatively, six, twelve and twenty-four months. The radiographs were digitised and analysed using UmRSA software. The relative movement of the humeral and ulnar implants with respect to the bone was measured. Results: At twelve months, the largest rotation of the humeral component was anteversion/retroversion with a mean of 20, anterior tilt had a mean of 1.10 and varus/valgus tilt was minimal mean 0.60. Mean difference between twelve and 24 months segment rotation was no more than 0.50. Rotation in unlinked humeral implants reached a plateau at 12 months this did not occur in linked implants. Paired t-tests between twelve and 24 months segment translation data showed the mean differences to be no more than 0.04mm. In contrast, humeral tip motion produced a mean of 1.3mm at 12 months dominated by movement in the horizontal plane with a mean difference at 24 months of 0.2mm. Mean micro-motion of the ulna implant tip was 0.32mm at 12 months with a mean difference at 24 months of 0.1mm. Conclusions: Early micromotion of the Acclaim humeral implant occurs mostly by rotation about the vertical axis accompanied by anterior tilt. In unlinked implants this motion reaches a plateau at 12 months after operation but does occur in linked implants

This study reports our experience with total elbow replacement for fused elbows.

Between 1982 and 2004, 13 patients with spontaneously ankylosed elbows were treated with a linked semi-constrained non-custom total elbow implant. The mean age at operation was 54 years (24 to 80). The stiffness was a result of trauma in ten elbows, juvenile rheumatoid arthritis in one, and rheumatoid arthritis in two. The patients were followed for a mean of 12 years (2 to 26) and were evaluated clinically using the Mayo Elbow Performance Score, as well as radiologically.

A mean arc from 37° of extension to 118° of flexion was achieved. Outcomes were good or excellent for seven elbows at final review. Ten patients felt better or much better after total elbow replacement. However, there was a high complication rate and re-operation was required in over half of patients. Two developed peri-operative soft-tissue breakdown requiring debridement. A muscle flap with skin grafting was used for soft-tissue cover in one. Revision was undertaken in one elbow following fracture of the ulnar component. Three patients developed a deep infection. Three elbows were manipulated under anaesthesia for post-operative stiffness. Prophylactic measures for heterotopic ossification were unsuccessful.

Total elbow replacement for the ankylosed elbow should be performed with caution. However, the outcome can be reliable in the long term and have a markedly positive impact on patient function and satisfaction. The high potential for complications must be considered. We consider total elbow replacement to be an acceptable procedure in selected patients with reasonable expectations.