Aims. The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. Methods. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. Results. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. Conclusion. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions. Cite this article: Bone Jt Open 2023;4(2):110–119

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. Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?. Methods. A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on PROMs, ROM, and complications. PROMs and ROM results were reported descriptively and a meta-analysis of complications was conducted. Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42021228329). Results. A total of 29 studies met the inclusion and exclusion criteria. The mean Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score was 19.6 (SD 7.5) for HA and 38 (SD 11.9) for TEA and the mean abbreviated version of DASH was 17.2 (SD 13.2) for HA and 24.9 (SD 4.8) for TEA. The Mayo Elbow Performance Score was the most commonly reported PROM across included studies, with a mean of 87 (SD 5.3) in HA and 88.3 (SD 5) in TEA. High complication rates were seen in both HA (22% (95% confidence interval (CI) 5 to 44)) and TEA (21% (95% CI 13 to 30), but no statistically significant difference identified. Conclusion. This systematic review has indicated PROMs and ROM mostly favouring HA, but with a similarly high complication rate in the two procedures. However, due to the small sample size and heterogeneity between studies, strength of evidence for these findings is low. We propose further research in the form of a national randomized controlled trial. Cite this article: Bone Joint J 2022;104-B(5):559–566

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. Methods. We searched PubMed, MEDLINE, Cochrane Reviews, and Embase from between January 2003 and March 2019. The primary aim was to determine the implant failure rate, the mode of failure, and risk factors predisposing to failure. A secondary aim was to identify the overall complication rate, associated risk factors, and clinical performance. A meta-regression analysis was completed to identify the association between each parameter with the outcome. Results. A total of 38 studies including 2,118 TEAs were included in the study. The mean follow-up was 80.9 months (8.2 to 156). The implant failure and complication rates were 16.1% (95% confidence interval (CI) 0.128 to 0.200) and 24.5% (95% CI 0.203 to 0.293), respectively. Aseptic loosening was the most common mode of failure (9.5%; 95% CI 0.071 to 0.124). The mean postoperative ranges of motion (ROMs) were: flexion 131.5° (124.2° to 138.8°), extension 29.3° (26.8° to 31.9°), pronation 74.0° (67.8° to 80.2°), and supination 72.5° (69.5° to 75.5°), and the mean postoperative Mayo Elbow Performance Score (MEPS) was 89.3 (95% CI 86.9 to 91.6). The meta-regression analysis identified that younger patients and implants with an unlinked design correlated with higher failure rates. Younger patients were associated with increased complications, while female patients and an unlinked prosthesis were associated with aseptic loosening. Conclusion. TEA continues to provide satisfactory results for patients with RA. However, it is associated with a substantially higher implant failure and complication rates compared with hip and knee arthroplasties. The patient’s age, sex, and whether cemented fixation and unlinked prosthesis were used can influence the outcome. Level of Evidence: Therapeutic Level IV. Cite this article: Bone Joint J 2020;102-B(8):967–980

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

Aims

The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA).

To prevent insufficiency of the triceps after total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar approach. This study evaluates the clinical results and post-operative alignment of the prosthesis using this approach.

We reviewed 25 elbows in 23 patients. There were five men and 18 women with a mean age of 69 years (54 to 83). There were 18 elbows with rheumatoid arthritis, six with a fracture or pseudoarthrosis and one elbow with osteoarthritis.

Post-operative complications included one intra-operative fracture, one elbow with heterotopic ossification, one transient ulnar nerve palsy, and one elbow with skin necrosis, but no elbow was affected by insufficiency of the triceps.

Patients were followed for a mean of 42 months (24 to 77). The mean post-operative Japanese Orthopaedic Association Elbow Score was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8 (65 to 100). The mean post-operative flexion/extension of the elbow was 135°/-8°. The Manual Muscle Testing score of the triceps was 5 in 23 elbows and 2 in two elbows (one patient). The mean alignment of the implants examined by 3D-CT was 2.8° pronation (standard deviation (sd) 5.5), 0.3° valgus (sd 2.7), and 0.7° extension (sd 3.2) for the humeral component, and 9.3° pronation (sd 9.7), 0.3° valgus (sd 4.0), and 8.6° extension (sd 3.1) for the ulnar component. There was no radiolucent line or loosening of the implants on the final radiographs.

The triceps-sparing ulnar approach allows satisfactory alignment of the implants, is effective in preventing post-operative triceps insufficiency, and gives satisfactory short-term results.

Cite this article: 2015;97-B:1096–1101.

Aims. The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA). Methods. Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used. Results. A total of 19 studies met the inclusion criteria, investigating 28 possible prognostic factors. Most QUIPS domains (84%) were rated as moderate to high risk of bias. The quality of the evidence was low or very low for all prognostic factors. In low-quality evidence, prognostic factors with consistent associations with failure of TEA in more than one study were: the sequelae of trauma leading to TEA, either independently or combined with acute trauma, and male sex. Several other studies investigating sex reported no association. The evidence for other factors was of very low quality and mostly involved exploratory studies. Conclusion. The current evidence investigating the prognostic factors associated with failure of TEA is of low or very low quality, and studies generally have a moderate to high risk of bias. Prognostic factors are subject to uncertainty, should be interpreted with caution, and are of little clinical value. Higher-quality evidence is required to determine robust prognostic factors for failure of TEA. Cite this article: Bone Joint Res 2024;13(5):201–213

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 – 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 - 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

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

Between 1993 and 2002, 58 GSB III total elbow replacements were implanted in 45 patients with rheumatoid arthritis by the same surgeon. At the most recent follow-up, five patients had died (five elbows) and six (nine elbows) had been lost to follow-up, leaving 44 total elbow replacements in 34 patients available for clinical and radiological review at a mean follow-up of 74 months (25 to 143). There were 26 women and eight men with a mean age at operation of 55.7 years (24 to 77). At the latest follow-up, 31 excellent (70%), six good (14%), three fair (7%) and four poor (9%) results were noted according to the Mayo elbow performance score. Five humeral (11%) and one ulnar (2%) component were loose according to radiological criteria (type III or type IV). Of the 44 prostheses, two (5%) had been revised, one for type-IV humeral loosening after follow-up for ten years and one for fracture of the ulnar component. Seven elbows had post-operative dysfunction of the ulnar nerve, which was transient in five and permanent in two. Despite an increased incidence of loosening with time, the GSB III prosthesis has given favourable mid-term results in patients with rheumatoid arthritis

Between September 1993 and September 1996, we performed 34 Kudo 5 total elbow replacements in 31 rheumatoid patients. All 22 surviving patients were reviewed at a mean of 11.9 years (10 to 14). Their mean age was 56 years (37 to 78) at the time of operation. All had Larsen grade IV or V rheumatoid changes on X-ray. Nine (three bilateral replacements and six unilateral) had died from unrelated causes. One who had died before ten years underwent revision for dislocation. Of the 22 total elbow replacements reviewed six had required revision, four for aseptic loosening (one humeral and three ulnar) and two for infection. Post-operatively, one patient had neuropraxia of the ulnar nerve and one of the radial nerve. Two patients had valgus tilting of the ulnar component. With revision as the endpoint, the mean survival time for the prosthesis was 11.3 years (95% confidence interval (10 to 13) and the estimated survival of the prosthesis at 12 years according to Kaplan-Meier survival analysis was 74% (95% confidence interval 0.53 to 0.91). Of the 16 surviving implants, ten were free from pain, four had mild pain and two moderate. The mean arc of flexion/extension of the elbow was 106° (65° to 130°) with pronation/supination of 90° (30° to 150°) with the joint at 90° of flexion. The mean Mayo elbow performance score was 82 (60 to 100) with five excellent, ten good and one fair result. Good long-term results can be expected using the Kudo 5 total elbow replacement in patients with rheumatoid disease, with a low incidence of loosening of the components

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem. Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement

Total Elbow Replacements are indicated for pain and disability in patients with rheumatoid and osteoarthritis of the elbow. The quality of the cementation has been specifically studied and shown to be directly related to the clinical outcome and implant survival. Aim. The aim of our study is to radiologically assess and grade the cementation around the components following total elbow replacement (GSB 3 or Coonrad Morrey) in two groups of patients. Materials and methods. Group I underwent total elbow replacement using Heraeus cement gun with medium palacos viscosity cement and group 2 using Zimmer cement gun with simplex medium viscosity cement. Average age in Group 1 was 72.3 (range 67–88 yrs) and group 2 was 69 years (range 52–87 yrs). 3 Coonrad Morrey and 13 GSB 3 total elbow replacement were used in Group 1 and 2 Coonrad Morrey and 14 GSB 3 in group 2. The primary indication for surgery was osteoarthritis, rheumatoid arthritis, post traumatic arthritis and seronegative arthritis in both groups. The cementation was assessed radiologically using three grading system (Morrey, Gerber & Bristol). Results. In Group I (Heraeus) 14 had adequete cementation in both AP and lateral radiographs, 1 humeral and 1 ulna components on AP radiograph revealed marginal cementing. In Group 2 (Zimmer) 11 had adequete cementation in both AP and lateral radiographs, 1 humeral and 1 ulna on AP and 1 humerus and 3 ulna on lateral radiograph were 4 marginal. Conclusion. Precise application of cement during total elbow arthroplasty is an important factor in achieving good implant fixation. To achieve this, a proper ergonomic design of the cement gun is mandatory. From our study we conclude that there was a difference in quality of cementation between the two groups

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern

Aim. Infections after total elbow arthroplasty are more frequent than after other joint arthroplasties. Therapeutic management varies depending of the patient status, the time of diagnosis of the infection, the status of the implant as well as the remaining bone stock around the implants. Method. Between 1997 and 2017, 180 total elbow arthroplasties were performed in our department. Eleven (6%) sustained a deep infection and were revised. Infection occurred after prosthesis of first intention in 4 and after a revision procedure in 7. Etiologies were: rheumatoid arthritis in 6, trauma sequela in 4 and osteosarcoma in 1. There were 7 women and 4 men of 59 years on average (22–87). Delay between the prosthesis and the diagnosis of infection was 66 months (0.5–300). The infection was stated as acute (<3week) in one, subacute (between 3 week and 3 months) in 1, and chronic (>3 months) in 9. Isolated bacteria were: Staphylococcus (10), Streptococcus (1), P. acnes (1), and Proteus mirabilis (1). Infection were poly microbial in 2 cases. A simple lavage with debridement was performed in 3 cases (Group 1), a 2-stage revision in 4 (Group 2), and a definitive removal of the prosthesis in 4 (Group 3). Adapted antibiotics were prescribed for all patients during at least 6 weeks. Results. All patients were reviewed with 59 months average follow-up. Eight patients were cured of their infection thanks to the initial therapeutic strategy. For 2 patients of Group 2, infection reccurrency required a new surgical procedure with one simple lavage/debridement for one, and 3 lavage/debridement for the other making it possible to cure the infection. For one patient of Group 1, a failure of lavage/debridement required removal of the implants. The MEPS reached 72 points: 67 points for patients of Group 1, 76 points for patients of Group 2, and 74 points for patients of Group 3. Complication rate was 36% (4): 2 ulnar nerve impairment with dysesthesia, one radial nerve palsy, and one humeral stem loosening. Conclusions. An adapted therapeutic strategy can allow suppression of the responsible bacteria after infection of total elbow arthroplasty. Sometimes, several procedures are necessary to obtain the cure. Better functional results were obtained when the prosthesis could be retained or replaced, but satisfactory results could also be obtained after resection arthroplasty when the humeral columns have been preserved to stabilize the joint

Aim. The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification. Patients and Methods. A total of 55 total elbow arthroplasties (TEAs) (52 patients) performed between June 2007 and December 2015 were eligible for inclusion in the study (29 TEAs for primary elective arthroplasty and 26 TEAs for trauma). At review, 15 patients (17 total elbow arthroplasties) had died from unrelated causes. There were 14 men and 38 women with a mean age of 70 years (42 to 90). The median clinical follow-up was 3.6 years (1.2 to 6) and the median radiological follow-up was 3.1 years (0.5 to 7.5). Results. The overall incidence of HO was 84% (46/55). This was higher in the trauma group (96%, 25/26) compared with the elective arthroplasty group (72%, 21/29) (p = 0.027, Fisher’s exact test). Patients in the trauma group had HO of higher Brooker class. The presence of HO did not significantly affect elbow range of movement within the trauma or elective groups (elective arthroplasty, Mann–Whitney U test, p = 0.070; trauma arthroplasty, p = 0.370, Mann–Whitney U test). Conclusion. HO after total elbow arthroplasty is seen more commonly than previously reported. We have reported a significantly higher rate of HO in TEAs performed for trauma than those performed electively. Cite this article: Bone Joint J 2018;100-B:767–71

Aims: To review the results from a series of GSB III total elbow arthroplasties performed at an independent centre. Between 1996 and 2004 the senior author performed 58 total elbow arthroplasties in 44 patients (10 males, 34 females) using the GSB III implant. These were reviewed and the outcome assessed through the use of a patient-answered questionnaire and clinical and radiological review. Mean age was 65 (49 to 84 years). Indications for surgery included rheumatoid arthritis (46 elbows) and post-traumatic osteoarthritis (11 elbows). Mean F/up was 4.1 years (0.8 to 8.5 years). 4 patients had died (6 elbows) and 4 patients (4 elbows) were unavailable for review. 2 of the implants had been revised (1x aseptic loosening, 1x deep infection), leaving a total of 46 elbows available for review. The survival rate at a mean of 4 years was 98% with aseptic loosening as the endpoint. Complications included 1 case of intraoperative fracture and 1 persistent ulnar neuritis. Overall patient satisfaction was high. The mean Mayo Elbow Performance Score was 83 out of 100 (range, 34 to 100) and mean Liverpool Elbow Score was 8 out of 10 (range, 1 to 10). Conclusion: Previous studies of outcome following total elbow arthroplasty using the GSB III elbow prosthesis at independent centres have shown satisfactory results, but have looked at small groups of patients. Our results offer more robust data to show that the medium term outcome following total elbow arthroplasty using the GSB III prosthesis is satisfactory

Aims: To review the results from a series of GSB III total elbow arthroplasties performed at an independent centre. Between 1996 and 2004, the senior author performed 58 total elbow arthroplasties in 44 patients (10 males, 34 females) using the GSB III implant. These were reviewed and the outcome assessed through the use of a patient-answered questionnaire and clinical and radiological review. Mean age was 65 (49 to 84 years). Indications for surgery included rheumatoid arthritis (46 elbows) and post-traumatic osteoarthritis (11 elbows). Mean F/up was 4.1 years (0.8 to 8.5 years). Four patients had died (six elbows) and four patients (four elbows) were unavailable for review. Two of the implants had been revised (1x aseptic loosening, 1x deep infection), leaving a total of 46 elbows available for review. The survival rate at a mean of four years was 98% with aseptic loosening as the endpoint. Complications included one case of intraoperative fracture and one persistent ulnar neuritis. Overall patient satisfaction was high. The mean Mayo Elbow Performance Score was 83 out of 100 (range, 34 to 100) and mean Liverpool Elbow Score was 8 out of 10 (range, 1 to 10). Conclusion: Previous studies of outcome following total elbow arthroplasty using the GSB III elbow prosthesis at independent centres have shown satisfactory results, but have looked at small groups of patients. Our results offer more robust data to show that the medium term outcome following total elbow arthroplasty using the GSB III prosthesis is satisfactory

Reconstruction of deficient bone stock during total elbow arthroplasty in rheumatoid arthritis represents a challenge for the surgeon. Fracture and osteolysis of the olecranon process is a very rare condition in rheumatoid arthritis. The consequence of a deficient olecranon is an instable and painful elbow. We report a case of successful olecranon reconstruction with bone graft associated to total elbow arthroplasty with a 8 years follow up and discuss surgical aspects. This case concerns a 44 years old woman with a very severe rheumatoid arthritis. She complains of pain and instability of her right elbow. X-rays show fracture and major osteolysis of the olecranon process with only some persistent bone at the insertion of the triceps tendon. The humeral condyles were subluxated posteriorly. We performed a total elbow replacement with a GSB3 implant and reconstruction of the olecranon with two cancellous iliac bone strut fixed by 2.7 diameter screws to the proximal ulna. The triceps tendon with remnant olecranon bone chips was secured to the bone graft by tension band wiring. Postoperatively, the elbow was immobilized for 3 weeks. With a follow up of more than 8 years the elbow is pain free with excellent function. The active range of motion of flexion – extension is 140° / −20°. The elbow is stable and triceps function is very satisfying authorizing the use of crutches. X-rays show good bony integration of the reconstructed olecranon process and no signs of loosening of the GSB3 implant. The literature concerning olecranon reconstruction during total elbow arthroplasty in rheumatoid patients is very poor. Kamineni and Morrey reported on one case of olecranon reconstruction with strut allograft in revision total elbow arthroplasty with an unsatisfying result. Their fixation technique was different. We prefer an autograft whenever it is possible and we recommend our fixation technique using screws and tension band wiring

The purpose of this study was to assess the long-term results (more than ten years) of two types of cemented ulnar component with type-5 Kudo total elbow arthroplasty in a consecutive series of 56 patients (60 elbows) with rheumatoid arthritis, and to compare the results in elbows above and below a Larsen grade IV. There was no radiolucency around the humeral component. Patients in whom a metal-backed ulnar component and a porous-coated stem were used had better clinical results and significantly less progression of radiolucent line formation around the ulnar component. They also had a significantly better long-term survival than patients with an all-polyethylene ulnar component. The clinical results of arthroplasty using all-polyethylene ulnar components were inferior, regardless of the degree of joint destruction. We conclude that the type-5 Kudo total elbow arthroplasty with cementless fixation of the porous-coated humeral component and cemented fixation of a metal-backed ulnar component is acceptable and well-tolerated by rheumatoid patients

Heterotopic Ossification (HO) is a known complication that can arise after total elbow arthroplasty (TEA). In most cases it is asymptomatic, however, in some patients it can limit range of motion and lead to poor outcomes. The objective of this review was to assess and report incidence, risk factors, prophylaxis, and management of HO after TEA. A systematic search was conducted using MEDLINE, EMBASE, and PubMed to retrieve all relevant studies evaluating occurrence of HO after TEA. The search was performed in duplicate and a quality assessment was performed of all included studies. A total of 1907 studies were retrieved of which 45 studies were included involving 2256 TEA patients. HO was radiographically present in 10% of patients and was symptomatic in 3%. Less than 1% of patients went on to surgical excision of HO, with outcomes following surgery reported as good or excellent as assessed by range of motion and Mayo Elbow Performance Scores (MEPS). TEA due to ankylosis, primary osteoarthritis, and posttraumatic arthritis are more likely to develop symptomatic HO. HO is an uncommon complication following TEA with the majority of patients developing HO being asymptomatic and requiring no surgical management. Routine HO prophylaxis for TEA is not supported by the literature. The effectiveness of prophylaxis in high risk patients is uncertain and future studies are required to clarify its usefulness. The strength of these conclusions are limited by inconsistent reporting in the available literature

The purpose of this study is to report our experience with revision of total elbow arthroplasty by exchange cementation. Between 1982 and 2004 at our institution, forty six elbows were treated with exchange cementation of a total elbow arthroplasty into the existing cement mantle or debrided bone interface, without the use of an osteotomy, bone graft or prosthetic augmentation. Indications for the procedure were aseptic loosening (17), second stage after septic loosening (14), instability (7), prosthetic fracture (4), periprosthetic fracture (2), failed hemiarthroplasty (1) and ulnar component wear (1). Both components were exchanged in 18 elbows, the humerus alone in 25 and the ulna in 3. Mean follow up was 90.5 months (10 to 266 months);18 patients had died with the prosthesis in situ. Complications were noted in 22 elbows; periprosthetic fracture of ulna (6) and humerus (2), humeral component fracture (1), aseptic loosening (4), non-union (1), heterotrophic ossification (2), soft tissue contracture (2) and soft tissue failure (2), delayed wound healing (1) and bushing failure (1). Reoperation was required in 10 elbows for revision of both components (2), ulna (3), humerus (1), bushing revision (2), soft tissue debridement (1) and soft tissue repair (1). There were no septic recurrences in previously infected elbows; however the reoperation rate in this group was 29% versus 19% after re-cementation for other causes. Revision of total elbow arthroplasty by exchange cementation is a reasonable treatment for those elbows with adequate bone stock for secure prosthetic fixation; however careful consideration should be given to augmentation of the ulna due to the high rate of periprosthetic fracture in this series. Re-cementation following débridement for infection is effective despite having a higher rate of revision operation compared to re-cementation in the aseptic elbow

We present the early results of 36 primary total elbow arthroplasties using the Acclaim prosthesis. The Acclaim prosthesis was used in 46 primary total elbow arthroplasties between July 2000 and August 2002. All operations were performed or directly supervised by the two senior authors (IAT and JKS). There were 32 females and 14 males. The mean age at surgery was 64 years (range, 34–93). The underlying pathology was rheumatoid arthritis in 39, osteoarthritis in five and post-traumatic arthritis in two. The early results of 36 cases are presented at a minimum follow-up of two years. Patients were assessed using the American Shoulder and Elbow Surgeons patient self assessment form and the range of movement of the elbow measured. The Wrightington method was used for radiographic analysis of lucencies. There was good relief of pain and range of movement improved. The mean preoperative pain score was 8.1 and decreased to 2.1 at latest follow up. The mean disability score increased from 34.2 to 66.1. The mean overall satisfaction rating following surgery was 9.3 on a visual analogue scale from zero to ten. The mean range of flexion increased from 83. o. to105. o. The mean flexion gain was just over 10. o. and the mean extension gain was just over 12. o. There were 11 cases of intraoperative fracture of the humeral condyle. One of these fractures failed to unite and required revision to a linked prosthesis because of persistent instability. There was one case of deep infection. There were three cases of ulnar neuropathy, one of which resolved. There was no evidence of loosening. The Acclaim total elbow arthroplasty gives good symptomatic relief and improvement in function according to the American Shoulder and Elbow Surgeons patient self assessment form. These early results are encouraging but the frequency of intra-operative fractures is of some concern

We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total score (maximum 100) before the operation was 47.21 and improved to 79.92 (p < 0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p < 0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p < 0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124° to 136° was noted (p < 0.001). Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing relief from pain and functional improvement in rheumatoid patients

There have been few reports in the literature of total elbow arthroplasty extending beyond 10 to 15 years. We reviewed 40 patients (41 elbows) with a mean age of 56 years (19 to 83) who had undergone a Coonrad/Coonrad-Morrey elbow arthroplasty by one surgeon for various diagnoses between 1974 and 1994. Surgical selection excluded patients with previous elbow infection or who refused to accept a sedentary level of elbow activity postoperatively. Objective data were collected from charts, radiographs, clinical photographs and supplemented by the referring orthopaedic surgeons’ records and radiographs if health or distance prevented a patient from returning for final review. Subjective outcome was defined by patient satisfaction. Of the 41 elbows, 21 were functional between 10 and 14 years after operation, ten between 15 and 19 years and ten between 20 and 31 years. There were 14 complications and 13 revisions, but no cases of acute infection, or permanent removal of any implant

Aim: To study the role of total elbow replacement in the management of distal humeral fractures in elderly patients. Patients and methods: Between 1995 and 2003, 25 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. All surgeries were performed by one of the senior authors in two centers in South Wales. There were 18 females and 7 males and none of them had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 78 years (68–84). According to the AO classification, 16 patients had suffered a C3 injury, five type B3 and three type A3. One fracture was unclassified. The mean time to follow-up was 4 years (1–9 years). Results: At follow-up 19 patients (76%) reported no pain, five (20%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 28 degrees to 105 degrees. The mean supination was 69 degrees (50–90) and pronation 70 degrees (50–80). No elbow was unstable. Mean Mayo elbow performance score was 71.5(25–100). Four patients (16%) developed ulnar neuropraxia following surgery that improved with time, 2 patients developed superficial wound infection (staphylococcus aureus), which was treated with antibiotics only. None of the above elbows required revision to date. Radiological evaluation revealed only one patient with a radio-lucent line at the cement -bone interface. It was between 1 and 2mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up. Conclusion: Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult

Although it is generally accepted that revision total elbow replacement may be necessary for loosening, instability, peri-prosthetic fracture and infection there is less agreement as to whether surgery should be performed as a one or two stage procedure. This can be of vital importance since the soft tissues around the elbow are often relatively poor making a single operation desirable. However, a one stage procedure in the presence of undetected low grade infection will result in joint failure with early loosening. In our unit we have found the use of a preliminary aspiration/drill biopsy prior to revision surgery helpful in evaluating whether a one or two stage procedure should be performed. Over an 8 year period 18 revision total elbow replacements have been undertaken. 9 patients were revised for aseptic loosening, 4 for proven infection, 3 for instability of an unlinked implant and 2 for peri-prosthetic fracture. With this experience we have devised the following management plan: Early instability of an unlinked implant is due to either poor implant positioning or soft tissue balancing and is suitable for a one stage revision without the need for aspiration/drill biopsy. Late instability is due to implant wear or low grade infection. In this situation we regard an aspiration/drill biopsy as necessary. A negative result allows a one stage revision whereas a positive aspiration indicates the need for a two stage revision. In a peri-prosthetic fracture if the bone cement mantle is intact a one stage revision without aspiration/ drill biopsy can be performed. If however, there is bone cement lucency we would advise an aspiration/ drill biopsy. We have found the aspiration/drill biopsy helpful prior to revision total elbow replacement and we have used it to guide us as to whether a one or two stage procedure should be performed

Although it is generally accepted that revision total elbow replacement may be necessary for loosening, instability, peri-prosthetic fracture and infection there is less agreement as to whether surgery should be performed as a one or two stage procedure. This can be of vital importance since the soft tissues around the elbow are often relatively poor making a single operation desirable. However, a one stage procedure in the presence of undetected low grade infection will result in joint failure with early loosening. In our unit we have found the use of a preliminary aspiration/drill biopsy prior to revision surgery helpful in evaluating whether a one or two stage procedure should be performed. Over an 8 year period 18 revision total elbow replacements have been undertaken. 9 patients were revised for aseptic loosening, 4 for proven infection, 3 for instability of an unlinked implant and 2 for peri-prosthetic fracture. With this experience we have devised the following management plan. Early instability of an unlinked implant is due to either poor implant positioning or soft tissue balancing and is suitable for a one stage revision without the need for aspiration/drill biopsy. Late instability is due to implant wear or low grade infection. In this situation we regard an aspiration/drill biopsy as necessary. A negative result allow a one stage revision whereas a positive aspiration indicates the need for a two stage revision. In a peri-prosthetic fracture if the bone cement mantle is intact a one stage revision without aspiration/ drill biopsy can be performed. If, however, there is bone cement lucency we would advise an aspiration/ drill biopsy. We have found the aspiration/drill biopsy helpful prior to revision total elbow replacement and we have used it to guide us as to whether a one or two stage procedure should be performed

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients

We reviewed 25 patients with rheumatoid arthritis who had failure of 26 primary total elbow arthroplasties causing pain and loss of function. Most revision cases required special custom implants to treat varying bone loss and soft-tissue disruption. Assessment showed satisfactory functional results in the patients treated by revision at a mean follow-up period of 35 months. Our review suggests that revision surgery produces short- to medium-term painfree function, and is the treatment of choice for a failed total elbow arthroplasty in the absence of infection

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

Between 1982 and 1997, 403 consecutive patients (522 elbows) with rheumatoid arthritis underwent Souter-Strathclyde total elbow replacement. By the end of 2007, there had been 66 revisions for aseptic loosening in 60 patients. The mean time of follow-up was 10.6 years (0 to 25) The survival rates at five-, ten, 15 and 19 years were 96% (95%, confidence interval (CI) 95 to 98), 89% (95% CI 86 to 92), 83% (95% CI 78 to 87), and 77% (95% CI 69 to 85), respectively. The small and medium-sized short-stemmed primary humeral components had a 5.6-fold and 3.6-fold risk of revision for aseptic loosening respectively, compared to the medium-sized long-stemmed component. The small and medium-sized all-polyethylene ulnar components had respectively a 28.2-fold and 8.4-fold risk of revision for aseptic loosening, compared to the metal-backed ulnar components. The use of retentive ulnar components was not associated with an increased risk of aseptic loosening compared to non-retentive implants

Implant designs for hip and knee arthroplasty have undergone a continual improvement process, but development of implants for total elbow arthroplasty (TEA) have lagged behind despite the marked mechanical burden placed on these implants. TEA is not as durable with failure rates approaching thirty percent at five years. The Coonrad-Morrey (Zimmer, Warsaw, IN), a linked design, remains the standard-bearer, employing polyethylene bushings through which a metal axle passes. A common failure mode is bushing wear and deformation, causing decreased joint function as the bushing-axle constraint decreases and osteolysis secondary to release of large volumes of wear debris. Improving upon this poor performance requires determining which factors most influence failure, so that failure can be avoided through design improvements. The approach integrates clinical observations of failed TEAs with implant retrieval analysis, followed by measurements of loads across the elbow for use in stress analyses to assess the performance of previous designs, and, finally, new design approaches to improve performance. Examination of the clinical failures of more than seventy Coonrad-Morrey TEAs revealed patterns of decreased constraint and stem loosening. Implant retrieval analysis from more than thirty of these cases showed excessive bushing deformation and wear and burnishing of the fixation stems consistent with varus moments across the joint. To determine loads across the elbow, motion analysis data were collected from eight TEA patients performing various activities of daily living. The kinematic data were input into a computational model to calculate contact forces on the total elbow replacement. The motion that produced the maximum contact force was a feeding motion with the humerus in 90° of abduction. For this motion, the joint reaction forces and moments at the point of maximum contact were determined from a computational model. We applied these loads to numerical models of the articulating bushings and axle of the Coonrad-Morrey to examine polyethylene strains as measures of damage and wear. Strain patterns in response to the large varus moment applied to the elbow during feeding activities showed extensive plastic deformation in the locations at which deformation and wear damage were observed in our retrieved implants (Fig. 1). Finally, we examined a new semi-constrained design concept intended to meet two goals: transfer contact loads away from the center of the joint, thus allowing contact to provide a larger internal moment to resist the large external varus moment; and reduce polyethylene strains by utilizing curved contacting surfaces on both the axle and the bushings (Fig. 2). After a sensitivity analysis to determine optimal dimensional choices (e.g., bushing and axle radii), we compared the resulting polyethylene strains between the Coonrad-Morrey and new design at locations that experienced the largest strains (Fig. 3). Substantial decreases were achieved, suggesting far less deformation and wear, which should relate to marked improvements in performance. Currently, we are incorporating this new design concept, along with alterations in stem design achieved from examination of load transfer at the fixation interfaces based on the same loading conditions, to achieve an implant system intended to improve the performance of TEA

Total Elbow arthroplasty can be a valuable treatment option in the painful or stiff elbow but outcomes have been disappointing previously. The history of total elbow arthroplasty has been disappointing in the past. Implants initially were a coupled articulation and were a rigid hinge. There was then a move to resurfacing type of designs although there was an issue with instability postoperatively with these implants. The semiconstrained coupled implant was developed in the mid 1970s by Coonrad. The idea behind the implant was that the loose polyethylene coupling provides inherent stability while decreasing the amount of loosening that was seen with the rigid hinge implants previously. We are reporting our results of our experience with a single type of semiconstrained implant that has been used in our unit since 1999. A semiconstrained total elbow arthroplasty was performed in thirteen patients over a period of 7 years period in our unit. Mean age at time of surgery was 60 years (44–70) M:F ratio 11:2. The aetiology of the joint pathology was Rheumatoid Arthritis (n= 10), psoriatic arthritis (n= 2) & posttraumatic (n =1). The patients were followed up for a mean duration of 4.5 years. They were assessed for range of motion, Mayo elbow function scores and radiographic evaluation and complication rate. 9 of the 13 elbows had a good to excellent result. There were 5 complications overall. There was two ulnar neuropathies that eventually resolved and one ulnar component that had to be revised 2 weeks after initial insertion. 3 had condylar fractures none of which required further operation. One patient had evidence of radiographic loosening but was asymptomatic. In our experience the semiconstrained total elbow replacement is a valuable option in the treatment of painful stiff the elbow

This study reviews the predisposing features, the clinical, and laboratory findings at the time of diagnosis and the results of single-stage revision of prosthetic replacement of the elbow for infection. Deep infection occurred in six of 305 (1.9%) primary total elbow replacements. The mean follow-up after revision was 6.8 years (6 months to 16 years) and the mean age at the time of revision was 62.7 years (56 to 74). All six cases with infection had rheumatoid arthritis and had received steroid therapy. The infective organism was Staphylococcus aureus. Four of the six elbows had a developed radiolucency around one component or the other. Successful single-stage exchange arthroplasty was carried out with antibiotic-loaded cement in five of the six cases. In one, the revision prosthesis had to be removed following recurrence of the infection. The functional result was good in three elbows, fair in one, poor in one and fair in the resection arthroplasty

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No significant difference was found between the two groups

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis. Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group

To show the role and effectiveness of semi-constrained total elbow arthroplasty in restoring elbow function in severe, irreversible post-traumatic osseous and chondral injuries. Eighteen patients, aged 19–80, 11 male and 7 female, suffering from serious, irreversible anatomical and functional lesions of the elbow joint due to previous severe untreated or inadequately treated fractures (T-type transcondylar, trochlear-condylar, open fxs with large bony defects, severe osteochondral, heterotopic ossification in ICU fracture patients). Postop follow up was 9–57 months. All patients were treated with modular, cemented, semi-constrained linked total elbow arthroplasty. A functional brace was used post-operatively, and motion was permitted on the 3rd post-op day. The patients were allowed a full range of motion at 1 week post-op and they were subjected to vigorous physiotherapy. Post-op results were evaluated by using Mayo, DASH, quick-DASH scores and measuring grip strength and range of motion. Our results ranged from satisfactory to excellent in 16 patiens, with good strength and wide motion arc (with up to 15o extension-flexion deficit). One old female patient suffered a severe cerebral stroke with a bad outcome. In another young male patient the motion arc reached only 40% of the normal (spasticity, ICU patient with brain injury). Semi-constrained linked total elbow arthroplasty proves to be an effective method of treatment in severe, irreversible, intraarticular post-traumatic elbow injuries with chondral destruction and grave functional deficit, provided the proper technique is employed and a vigorous rehabilitation program is followed

Aim:. To investigate the incidence of post-operative ulna nerve symptoms in total elbow arthroplasty after full in-situ release. Methods:. A retrospective review was completed of the medical records of eighty-three consecutive primary total elbow arthroplasties (TEA) performed between 2003 and 2012. Data analysed included the presence of pre-operative ulnar nerve (UN) symptoms, history of prior UN transposition, intra-operative management of the UN and presence of post-operative symptoms. Results:. One patient had a prior UN transposition. The nerve was transposed at time of TEA in 4 of the 83 elbows (4.8%). The indication for transposition in all 4 cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. The remaining 78 TEA's all received a full in-situ release of the nerve. The incidence of post-operative UN symptoms in this group was 7.7% (6/78). Four neuropraxias resolved in the early post-operative period, whilst two patients (2.6%) continued to experience significant UN symptoms requiring subsequent transposition, at 6 weeks and 12 months post TEA. Conclusion:. A 2.6% incidence of significant post-operative UN symptoms compares favourably with systematic reviews in the literature (3–11% incidence of UN complications). We do not believe routine transposition, which adds to the handling of the nerve and increases total surgical time, is necessary, and should be reserved for cases where intra-operative assessment by the surgeon deems it necessary

Total elbow arthroplasty (TEA) usage is increasing owing to expanded surgical indications, better implant designs, and improved long-term survival. Correct humeral implant positioning has been shown to diminish stem loading in vitro, and radiographic loosening in in the long-term. Replication of the native elbow centre of rotation is thought to restore normal muscle moment arms and has been suggested to improve elbow strength and function. While much of the focus has been on humeral component positioning, little is known about the effect of positioning of the ulnar stem on post-operative range of motion and clinical outcomes. The purpose of this study is to determine the effect of the sagittal alignment and positioning of the humeral and ulnar components on the functional outcomes after TEA. Between 2003 and 2016, 173 semi-constrained TEAs (Wright-Tornier Latitude/Latitude EV, Memphis, TN, USA) were performed at our institution, and our preliminary analysis includes 46 elbows in 41 patients (39 female, 7 male). Patients were excluded if they had severe elbow deformity precluding reliable measurement, experienced a major complication related to an ipsilateral upper limb procedure, or underwent revision TEA. For each elbow, saggital alignment was compared pre- and post-operatively. A best fit circle of the trochlea and capitellum was drawn, with its centre representing the rotation axis. Ninety degree tangent lines from the intramedullary axes of the ulna and humerus, and from the olecranon tip to the centre of rotation were drawn and measured relative to the rotation axis, representing the ulna posterior offset, humerus offset, and ulna proximal offset, respectively. In addition, we measured the ulna stem angle (angle subtended by the implant and the intramedullary axis of the ulna), as well as radial neck offset (the length of a 90o tangent line from the intramedullary axis of the radial neck and the centre of rotation) in patients with retained or replaced radial heads. Our primary outcome measure was the quickDASH score recorded at the latest follow-up for each patient. Our secondary outcome measures were postoperative flexion, extension, pronation and supination measured at the same timepoints. Each variable was tested for linear correlation with the primary and secondary outcome measures using the Pearson two-tailed test. At an average follow-up of 6.8 years (range 2–14 years), there was a strong positive correlation between anterior radial neck offset and the quickDASH (r=0.60, p=0.001). There was also a weak negative correlation between the posterior offset of the ulnar component and the qDASH (r=0.39, p=0.031), and a moderate positive correlation between the change in humeral offset and elbow supination (r=0.41, p=0.044). The ulna proximal offset and ulna stem angle were not correlated with either the primary, or secondary outcome measures. When performing primary TEA with radial head retention, or replacement, care should be taken to ensure that the ulnar component is correctly positioned such that intramedullary axis of the radial neck lines up with the centre of elbow rotation, as this strongly correlates with better function and less pain after surgery

Distal humeral fractures are difficult fractures to treat. In the elderly population the problems are compounded by gross comminution and osteoporosis. Concurrent presence of rheumatoid arthritis makes the problem more difficult. Open reduction and internal fixation of such fractures have been shown to give poor results. Total elbow replacement has been recommended as an alternative solution to this difficult problem. We present the results of a retrospective review of a small group of elderly patients who underwent total elbow arthroplasty in our unit for comminuted fractures of the distal end of the humerus. We have followed up seven patients (seven elbows) with a mean age of 81. 7 years (range 74. 1 to 87. 8) at the time of injury. The presence of rheumatoid arthritis in three of them influenced the choice of treatment. All replacements were performed using the semiconstrained Coonrad-Morrey elbow replacement prosthesis. The duration of follow up at present is between two and four years. None of the patients have been lost to follow up. At the latest follow up the mean arc of flexion was 20 to 130 degrees. 6 of the patients had no pain while 1 complained of mild pain. All elbows were stable. The Mayo Elbow Performance Score (MEPS) for five elbows was excellent, two scored good. The mean MEPS for all the elbows was 92/100. There were 2 cases of superficial wound infection and no cases of deep infection, ulnar nerve neuritis or component failure. These results suggest that a semiconstrained total elbow replacement has a role to play in the treatment of carefully selected distal humeral fractures, which cannot be treated by internal fixation due to extensive intraarticular comminution and gross osteopenia. Although these are short-term follow up results they are encouraging outcomes for treatment of one of the most challenging fractures

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%)

Aims. Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA. Patients and Methods. Between 2006 and 2010 we used the Latitude TEA for revision in 18 consecutive elbows (17 patients); mean age 53 years (28 to 80); 14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde TEA in three. Stability, range of movement (ROM), visual analogue score (VAS) for pain and functional scores, Elbow Functional Assessment Scale (EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM) and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed pre-operatively and at each post-operative follow-up visit (six, 12 months and biennially thereafter). Radiographs were analysed for loosening, fractures and dislocation. The mean follow-up was 59 months (26 to 89). Results. The ROM of the elbow did not improve significantly. The mean EFAS and MAESS scores improved significantly six months post-operatively (18.6 points, standard deviation (. sd. ) 7.7; p = 0.03 and 28.8 points, . sd . 8.6; p = 0.006, respectively) and continued to improve slightly or reached a plateau. The mean pain scores at rest (Z = -3.2, p = 0.001) and during activity (Z = -3.2, p = 0.001), and stability (Z = -3.0, p = 0.003) improved significantly six months post-operatively. Thereafter scores continued to improve slightly or a plateau was reached. There were no signs of loosening. Conclusion. Revision surgery using the Latitude TEA results in improvement of functionality, reduced pain and better stability of the elbow. Improvement of ROM of the elbow should not be expected. Cite this article: Bone Joint J 2016;98-B:1086–92

We report our experience of staged revision surgery for the treatment of infected total elbow arthroplasty (TEA). Between 1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent a first-stage procedure with the intention to proceed to second-stage procedure when the infection had been controlled. A single first-stage procedure with removal of the components and cement was undertaken for 29 TEAs (85%), followed by the insertion of antibiotic-impregnated cement beads, and five (15%) required two or more first-stage procedures. The most common organism isolated was coagulase-negative Staphylococcus in 21 TEAs (62%). A second-stage procedure was performed for 26 TEAs (76%); seven patients (seven TEAs, 21%) had a functional resection arthroplasty with antibiotic beads in situ and had no further surgery, one had a persistent discharge preventing further surgery. There were three recurrent infections (11.5%) in those patients who underwent a second-stage procedure. The infection presented at a mean of eight months (5 to 10) post-operatively. The mean Mayo Elbow Performance Score (MEPS) in those who underwent a second stage revision without recurrent infection was 81.1 (65 to 95). Staged revision surgery is successful in the treatment of patients with an infected TEA and is associated with a low rate of recurrent infection. However, when infection does occur, this study would suggest that it becomes apparent within ten months of the second stage procedure. Cite this article: Bone Joint J 2013;95-B:1681–6

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

40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67. 3 years, (range 48 to 87 years) and the mean follow up 50 months (range 8 to 134 months). Each patient had undergone at least 1 operation prior to the index arthroplasty (range 1 to 10). 27 elbows were flail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2. A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a snap-fit Souter Strath-clyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. At review 38 elbows had no or mild pain, 2 moderate, and no patient had severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant. Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in one and curettage and bone grafting of a cement granuloma in one. One patient with a Charcot joint developed a non-union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition six had delayed wound healing, two ulnar nerve symptoms and two triceps weakness. In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a flail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients

This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4). Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved. This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals. Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors. 16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component. Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant

Introduction. Primary Total Elbow Replacement (TER) is gaining popularity as a primary treatment option for osteoporotic fractures of the elbow, particularly in patients with low demand. The aim of this study was to assess the clinical and functional efficacy of TER as a primary treatment for comminuted distal humerus fractures in the elderly. Methods. We retrospectively reviewed twenty-three patients (22 females and 1 male) who were treated with primary total elbow replacement for complex, intra-articular fractures of the distal humerus in the elderly between March 2000 and January 2010. The average age of the patients was seventy-five years (ranging from 66 to 94 years). Postoperative elbow function was assessed using the Mayo Elbow Performance Score. The radiological assessment was performed using antero-posterior and lateral radiographs done at follow-up appointments. Results. The average duration of follow up was 6 years. Overall, the mean Mayo elbow performance score was 93 points out of 100. The arc of flexion averaged at 94.3degrees. One patient developed blisters at her arm postoperatively but resolved with dressings. Two patients (8.6%) had mild pain at two years post surgery but there was no evidence of implant loosening or evidence of infection. One patient developed superficial infection which was treated with antibiotics. Nineteen (82%) of the twenty-three elbows had neither a complication nor further surgery from the time of TER to the recent follow up. Conclusions. Our review suggests that total elbow replacement as a primary treatment for comminuted distal humerus fractures in the elderly can give good to excellent results both in the short and the long term basis. When osteosynthesis is not a feasible option, especially in older patients who place lower demands on the joint, total elbow replacement can be considered a the primary treatment

We have carried out a retrospective review of 11 Souter-Strathclyde primary total elbow arthroplasties in ten patients with osteoarthritis, over a period of nine years. The diagnosis was primary osteoarthritis in nine elbows and post-traumatic arthritis in two. The mean follow-up was 68 months (15 to 117). Although no patient was symptomatic, radiological review revealed evidence of loosening affecting three humeral and two ulnar components, one of which subsequently failed and was revised at 97 months. There were no dislocations, deep infections or mechanical failures. Complications included two superficial wound infections and two neurapraxias of the ulnar nerve which resolved. This study shows that the unlinked Souter-Strathclyde total elbow arthroplasty can be considered for patients with osteoarthritis and gives good symptomatic relief and improvement in function

Aim: 40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67.3 (48–87) years and the mean follow up 50 (8–134) months. Each patient had undergone at least 1 operation prior to the index arthroplasty (1–10). 27 elbows were ßail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2. Methods: A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a Snap þt Souter Strathclyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. Results: At review 38 elbows had no or mild pain, 2 moderate, and no patient with severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant. Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in 1 and curettage and bone grafting of a cement granuloma in 1. One patient with a Charcot joint developed a non- union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition 6 had delayed wound healing, 2 ulnar nerve symptoms and 2 triceps weakness. Conclusions: In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a ßail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients

Purpose: Aseptic loosening is one of the leading causes of failure in total elbow arthroplasty. It is logical to postulate that incorrect implant positioning and alignment may lead to excessive loading and wear which can induce the loosening cascade. However, the effect of implant malalignment on wear inducing loads in the elbow is not yet known. This in-vitro study determined the effect of anterior malpositioning, and varus-valgus (VV) and internal-external (IE) malrotations on humeral stem loading in total elbow arthroplasty. Method: The humeral, ulnar, and radial components of a linked total elbow arthroplasty were optimally positioned using computer navigation in eight cadaveric elbows, mounted in a load/motion control elbow simulator (age 75yrs, range 42–93; 5 male). A modular, humeral component was employed to generate implant malpositioning errors of ±6° VV, ±8° IE, and 5mm anterior. The implant was instrumented with strain gauges to quantify VV and IE bending loads during elbow flexion with the forearm in supination. Load output was combined using a sum-of-squares technique. Passive flexion was performed with the arm in the varus and valgus orientations; passive and active flexion were performed with the arm in the vertical orientation. Results: With the arm (humerus) in the vertical orientation, bending loads increased between 418Nmm and 1618Nmm for all malaligned implant positions (p< 0.05). Passive flexion (1354±859Nmm) produced higher resultant loads for the optimally positioned implant than active (819±891Nmm) flexion (p< 0.05). Although it varied during flexion, loading with the arm in varus (2928±1273Nmm) or valgus (2494±743Nmm) orientations resulted in up to a three-fold increase in loading when compared to the vertical orientation (p< 0.01). Conclusion: These data demonstrate that humeral component malpositioning increases loading in the implant, however further studies are required to determine the long term effect on polyethylene wear and component loosening. Prosthesis designs that replicate the native flexion-extension axis and make use of sophisticated instrumentation or computer assistance to achieve precise positioning during implantation should lead to improved arthroplasty durability. Also, loading was higher with the arm in varus or valgus orientations, suggesting that patients should avoid activities post-operatively that require their elbow to be positioned in this way

We determined the short-term clinical outcome and migration within the bone of the humeral cementless component of the Instrumented Bone Preserving (IBP) total elbow replacement in a series of 16 patients. There were four men and 12 women with a mean age at operation of 63 years (40 to 81). Migration was calculated using radiostereometric analysis. There were no intra-operative complications and no revisions. At two-year follow-up, all patients showed a significant reduction in pain and functional improvement of the elbow (both p < 0.001). Although ten components (63%) showed movement or micromovement during the first six weeks, 14 (88%) were stable at one year post-operatively. Translation was primarily found in the proximal direction (median 0.3 mm (interquartile range (IQR) -0.09 to 0.8); the major rotational movement was an anterior tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component continued to migrate during the second year, and one component could not be followed beyond three months because migration had caused the markers to break off the prosthesis. This study shows promising early results for the cementless humeral component of the IBP total elbow replacement. All patients had a good clinical outcome, and most components stabilised within six months of the operation. . Cite this article: Bone Joint J 2014;96-B:229–36

Aim. To compare radiological and clinical outcomes between triceps-detaching and triceps-sparing approaches in total elbow arthroplasty, with specific focus on cementing technique and post-operative range of motion. Methods. A retrospective review was completed of medical records and radiographs of 56 consecutively managed patients who underwent a primary total elbow arthroplasty between 2000 and 2012 at a tertiary hospital. Rheumatoid Arthritis was the predominant pathology (47/56). Data analysed included patient demographics, range of motion pre-operatively and at various stages post-operatively, approach utilized, operative time and complications. Cementing technique was graded as adequate, marginal or inadequate according to Morrey's criteria. Results. 12 patients were lost to follow-up or had incomplete records, leaving 44 patients for analysis. 15 patients had a triceps-sparing approach, and 29 had a variation of a triceps-detaching approach. Average follow-up was 56.1 months. Flexion range of motion in the triceps-sparing group improved from 25°–122° (±19.6°) pre-op to 10°–140° (±22.5°) at final follow-up, and in the triceps-detaching group from 41°–104° (± 22.2°) pre-op to 27°–129° (±35.0°) at final follow-up. Tourniquet time averaged 85.4 (±17.0) minutes for the triceps-sparing group and 96.1 (±22.6) minutes for the triceps-detaching group. The complication rate in the triceps-sparing group was 13.3%, and included one olecranon fracture and one case of superficial wound sepsis. The complication rate for the triceps-detaching group was 24.1%, and included one patient with persistent ulnar nerve symptoms requiring transposition, one medial condyle fracture and five triceps ruptures. Three patients who had attempted repairs of the rupture developed deep infections requiring multiple further surgeries. Cementing technique was adequate in 91.7% in the triceps-sparing group and in 70.6% in the triceps-detaching group and marginal in the remainder of the cohort. Conclusion. A triceps-sparing approach results in a predictable improvement in range of motion with no compromise of the cement mantle. NO DISCLOSURES

Aim. The aim of this study was to report the long-term outcome and implant survival of the lateral resurfacing elbow (LRE) arthroplasty in the treatment of elbow arthritis. Patients and Methods. We reviewed a consecutive series of 27 patients (30 elbows) who underwent LRE arthroplasty between December 2005 and January 2008. There were 15 women and 12 men, with a mean age of 61 years (25 to 82). The diagnosis was primary hypotrophic osteoarthritis (OA) in 12 patients (14 elbows), post-traumatic osteoarthritis (PTOA) in five (five elbows) and rheumatoid arthritis (RA) in ten patients (11 elbows). The mean clinical outcome scores including the Mayo Elbow Performance Score (MEPS), the American Shoulder and Elbow Surgeons elbow score (ASES-e), the mean range of movement and the radiological outcome were recorded at three, six and 12 months and at a mean final follow-up of 8.3 years (7.3 to 9.4). A one sample t-test comparing pre and postoperative values, and survival analysis using the Kaplan–Meier method were undertaken. Results. A statistically significantly increased outcome score was noted for the whole group at each time interval. This was also significantly increased at each time in each of the subgroups (OA, RA, and PTOA). Implant survivorship was 100%. Conclusion. We found that the LRE arthroplasty, which was initially developed for younger patients with osteoarthritis, is an effective form of surgical treatment for a wider range of patients with more severe degenerative changes, irrespective of their cause. It is therefore a satisfactory alternative to total elbow arthroplasty (TEA) and has lower rates of complications in the subgroups of patients we have studied. It does not require activities to be restricted to the same extent as following TEA. Based on this experience, we now recommend LRE arthroplasty rather than TEA as the primary form of implant for the treatment of patients with OA of the elbow. Cite this article: Bone Joint J 2018;100-B:338–45

We analysed the outcome of the Coonrad-Morrey total elbow replacement used for fracture of the distal humerus in elderly patients with no evidence of inflammatory arthritis and compared the results for early versus delayed treatment. We studied a total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group. The mean follow-up was 56.1 months (18 to 88). The percentage of excellent to good results based on the Mayo elbow performance score was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. One patient in the early group developed chronic regional pain syndrome and another type 4 aseptic loosening. Two elbows in the early group also showed type 1 radiological loosening. Two patients in the delayed group had an infection, two an ulnar nerve palsy, one developed heterotopic ossification and one type 4 aseptic loosening. Two elbows in this group also showed type 1 radiological loosening. The complication rates in the early and delayed treatment group were 13% and 29% respectively. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No statistically significant difference was found between the two groups. We conclude that total elbow replacement provides a preditable and reproducible outcome in terms of pain relief and functional range of movement in elderly osteoporotic patients with difficult distal humerus fractures

Aims. We describe the use of a protocol of irrigation and debridement (I& D) with retention of the implant for the treatment of periprosthetic infection of a total elbow arthroplasty (TEA). This may be an attractive alternative to staged re-implantation. . Patients and Methods. Between 1990 and 2010, 23 consecutive patients were treated in this way. Three were lost to follow-up leaving 20 patients (21 TEAs) in the study. There were six men and 14 women. Their mean age was 58 years (23 to 76). The protocol involved: component unlinking, irrigation and debridement (I& D), and the introduction of antibiotic laden cement beads; organism-specific intravenous antibiotics; repeat I& D and re-linkage of the implant if appropriate; long-term oral antibiotic therapy. . Results. The mean follow-up was 7.1 years (2 to 16). The infecting micro-organisms were Staphylococcus aureus in nine, coagulase-negative Staphylococcus in 13, Corynebacterium in three and other in six cases. Re-operations included three repeat staged I& Ds, two repeat superficial I& Ds and one fasciocutaneous forearm flap. One patient required removal of the implant due to persistent infection. All except three patients rated their pain as absent or mild. Outcome was rated as good or excellent in 15 patients (mean Mayo Elbow Performance Score 78 points, (5 to 100) with a mean flexion-extension arc of 103° (40° to 150°)). . Conclusion. A staged protocol can be successful in retaining stable components of an infected TEA. Function of the elbow may compare unfavourably to that after an uncomplicated TEA. Cite this article: Bone Joint J 2016;98-B:976–83

This study investigated the effect of the articulation position on joint load transfer in total elbow arthroplasty. To quantify loading, an adjustable humeral component, instrumented with a load cell, was developed to measure ulnohumeral loads in-vitro. Computer guidance was implemented to accurately place the linked articulation into eight cadaveric elbows. Axial compression and bending about the flexion axis produced the greatest loads during simulated active elbow flexion. An anteriorly malpositioned flexion-extension axis resulted in increased joint loads during flexion. Translational positional errors were more influential than rotational position on articular loading. To quantify the relationship between total elbow arthroplasty position and elbow joint loading. Eight cadaveric upper extremities were tested using a motion-controlled testing device, which simulated muscle activity. Computer guidance was employed to accurately position a linked implant consisting of a custom-designed adjustable humeral component and commercial ulnar component. The testing apparatus was instrumented with a six-degree-of-freedom load cell to measure axial and bending loads. Seven implant positions were tested including anterior-posterior translation (−5.0, −2.5, 0.0, 2.5, 5.0 mm) and internal-external rotation (−5, 0, 5°) during supinated and pronated flexion. The resultant joint force decreased for all prosthetic hinge positions as elbow flexion increased (p< 0.001). Anterior hinge positions produced greater ulnohumeral loads (p< 0.001) and moments (p< 0.001) than posterior hinge positions during simulated elbow flexion. The greatest bending moment occurred about the flexion axis which reached maximum magnitudes during mid-flexion. Implant hinge malrotation did not have a significant effect on axial (p=0.07) or bending (p=0.6) forces experienced at the joint. The distance between the flexion (hinge) axis and the muscular line-of-action of flexors is reduced with anterior hinge placement, likely increasing the force necessary to produce flexion. An anteriorly malpositioned flexion-extension axis resulted in an increase in joint loading during flexion and should be avoided during elbow arthroplasty. This is the first reported study to measure the effect of elbow prosthesis positioning on joint loading. The knowledge gained about joint loads should improve future prosthetic designs and treatment options. Funding: Canadian Institute for Health Research. Please contact author for graphs and/or diagrams

Total Elbow Arthroplasty (TEA) is a procedure to treat a number of conditions including rheumatoid arthritis (RA), post-traumatic arthritis, and osteoarthritis. To date, there has been minimal literature published on the Latitude since its release in 2001. There is one study reporting outcomes from the Latitude, a German study published in 2010. The purpose of this study was to analyse outcomes from primary Latitude TEAs. We performed a retrospective case series of 23 TEAs performed on 20 patients. 6 patients required revision surgery and were not included in the analysis. One patient was lost to follow up, resulting in 17 patients included for ROM analysis. All patients received Latitude TEA through a posterior approach and underwent a standard rehab protocol. 11 Patients were recalled at least two years post-op and were administered DASH and MAYO questionnaires. Complications such as triceps insufficiency, ulnar nerve dysfunction, infection, and aseptic loosening were recorded. Outcomes were compared using the Wilcoxon Signed-Rank test in STATA. Immediate post-op radiographs and patients most recent radiographs were analysed by a blinded upper-extremity surgeon not involved in the initial operation and analysed for loosening and implant malpostioning. Mean follow up was 4.8 years (range 2.6–7.5 years). Analysis of 17 TEAs in 16 patients revealed no difference in pre-operative ROM and post-operative ROM for flexion (121°±20 vs 129°±16, p=0.13) extension (40°±27 vs 27°±15, p=0.19), pronation (73°±13 vs 75°±24, p=0.55) or supination (64°±22 vs 68°±14, p=0.52). Patients who underwent TEA for RA had a significant improvement in flexion (121°±15 vs 135°±10, p<0.02). There was a statistically significant improvement in flexion-extension arc post-operatively (101°±28) compared to pre-operative scores (83±23 degrees, p<0.02). DASH and MAYO scores were calculated from 11elbows in 11 non-revision patients able to return for examination. The average MAYO score was 87.9 with nine patients in the “excellent” category, two patients in the “good” category, one patient in the “fair” category, and one in the “poor” category. The average DASH score was 32.9. Two patients underwent revision for periprosthetic fractures, two patients underwent revision for infection, one underwent revision for aseptic loosening and two for radial head dissociation (rate of 30%). This is one of the first studies examining the outcomes of the Latitude TEA. This retrospective case series demonstrates that the Latitude TEA has promising outcomes with respect to improving patient pain and functioning as assessed by the MAYO. Treatment using the Latitude TEA results in favorable functional outcomes for a majority of patients and offers an improvement in flexion-extension arc. Furthermore, our results are comparable to the MAYO scores reported by other studies analysing different prosthesis designs. The complication rate in our series was comparable to published rates of 20–40%

We used 11 cadaver elbows and a three-dimensional electromagnetic tracking device to record elbow movements before and after implantation of a 'loose-hinged' elbow prosthesis (modified Coonrad). During simulated active motion there was a maximum of 2.7 degrees (+/- 1.5 degrees) varus/valgus laxity in the cadaver joints. This increased slightly after total elbow arthroplasty to 3.8 degrees (+/- 1.4 degrees). These values are lower than those recorded for the cadaver joints and for the prostheses at the limits of their varus/valgus displacements, indicating that both behave as 'semi-constrained' joints under physiological conditions. They suggest that the muscles absorb some of the forces and moments that in a constrained prosthesis would be transferred to the prosthesis-bone interface

Although total elbow arthroplasty is undertaken in far smaller numbers than total hip and knee arthroplasty a recent review of the world literature indicated that aseptic loosening radiologically occurred in 17.2% whilst clinical loosening was present in 6.4%. In addition, infections were noted in 8.1%. With both aseptic and septic loosening bone loss can be a major problem and must be addressed if revision surgery is contemplated Options for treating bone loss include:. Revision with standard implant. Revision with customised implant. Revision with impaction bone grafting and standard or customised implant. Revision with allograft and standard or customised implant. When considering revision surgery it is essential to ascertain whether or not implant loosening is aseptic or septic. To this end screening blood tests including white blood count, ESR and CRP should be performed. A bone scan may also be helpful. In addition, it is my practice to perform an aspiration biopsy prior to revision surgery. A sample of fluid from the elbow joint is looked at microscopically and cultured for organism sensitivity. If infection is present surgery is undertaken as a two-stage procedure. The first stage involves removal of the implant and bone cement together with the insertion of antibiotic beads specially prepared with added antibiotics appropriate to the sensitivity of the infectiong organism. If infection is not present then a one-stage revision is performed

We compared the outcome of peri-operative humeral condylar fractures in patients undergoing a Coonrad-Morrey semiconstrained total elbow replacement with that of patients with rheumatoid arthritis undergoing the same procedure without fractures. In a consecutive series of 40 elbows in 33 patients, 13 elbows had a fracture in either condyle peri-operatively, and 27 elbows were intact. The fractured condyle was either fixed internally or excised. We found no statistical difference in the patients’ background, such as age, length of follow-up, immobilisation period, Larsen’s radiological grade, or Steinbrocker’s stage and functional class. There was also no statistical difference between the groups in relation to the Mayo Elbow Performance Score, muscle strength, range of movement, or radiolucency around the implants at a mean of 4.8 years (1.1 to 8.0) follow-up. We conclude that fractured condyles can be successfully treated with either internal fixation or excision, and cause no harmful effect

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients. The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years

The Souter-Strathclyde prosthesis was used in 52 revisions of total elbow replacements (TERs) between August 1986 and May 1997. Of these, 50, carried out in 45 patients, were prospectively followed for a mean of 53 months (14 to 139). The procedure produced reliable relief of pain, and the range of movement was preserved. There was a considerable incidence of adverse events associated with revision (30%), and 12 further procedures have been required. Nonetheless, a revision is the preferred salvage procedure for failed primary arthroplasty in the absence of sepsis

Introduction. Recently, computer-aided orthopaedic surgery has enabled three dimensional (3D) preoperative planning, navigation systems and patient matched instrument, and they provide good clinical results in total knee arthroplasty. However, the preoperative planning methods and the criteria in total elbow arthroplasty (TEA) still have not sufficiently established due to the uncertainty of 3D anatomical geometry of the elbow joints. In order to clarify the 3D anatomical geometry, this study measured 3D bone models of the normal elbow joints. Additionally this study attempted to apply the 3D preoperative planning to ordinary surgery. Then the postoperative position of implant has evaluated as compared with the position in 3D preoperative planning. Methods. Three dimensional bone measurements on 4 normal cases were performed. Three dimensional bone models were constructed with CT image using Bone Viewer®(ORTHREE Co., Ltd.). TEA was performed with FINE® Total Elbow System (Nakashima Medical Co., Ltd.) for 3 rheumatoid arthritis (RA) cases (Fig. 1). Three dimensional preoperative planning was based on this bone measurement, and postoperative position of implant were evaluated. The postoperative assessments were evaluated by superimposing preoperative planning image on postoperative CT image using Bone Simulator® (ORTHREE Co., Ltd.). This study only covers humeral part. Results. The results of 3D bone measurements on 4 normal cases shows the average internal rotation angle between the flexion-extension axis and the epicondyles axis in the distal humerus was 2.2 degrees. The average valgus tilt of the distal humerus was 3.7 degrees. Postoperative position of humeral component for 3 RA cases was installed at proximal and valgus position compared to the preoperative planning. Discussion. This study indicates that ordinary two dimensional criteria and 3D anatomical one in the elbow joint may be different in several bony landmarks such as rotation, varus and valgus. Additionally these results show the differences between postoperative position of implant and preoperative position in 3D planning. More studies need to be conducted to validate postoperative evaluation and preoperative planning

Between 1993 and 1996, we undertook 35 Kudo 5 total elbow replacements in a consecutive series of 31 rheumatoid patients. A total of 25 patients (29 procedures) was evaluated at a mean follow-up of six years (5 to 7.5) using the Mayo Clinic performance index. In addition, all patients were assessed for loosening using standard anteroposterior and lateral radiographs. At review, 19 elbows (65%) had either no pain or mild pain, ten (35%) had moderate pain and none had severe pain. The mean arc of flexion/extension was 94° (35 to 130) and supination/pronation was 128° (30 to 165). A fracture of the medial epicondyle occurred during surgery in one patient. This was successfully treated with a single AO screw and a standard Kudo 5 implant was inserted. Postoperatively, there were no infections. One patient had a dislocation which was treated by closed reduction and five had neurapraxia of the ulnar nerve. Radiologically, there was no evidence of loosening of the humeral component, but two ulnar components had progressive radiolucent lines suggestive of loosening. Two other ulnar components had incomplete and non-progressive radiolucent lines. With definite radiological loosening as the endpoint, the probability of survival of the Kudo 5 prosthesis at five years using the Kaplan-Meier method was 89%

The treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125° (110 to 140) and loss of extension was 23.5° (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly

To assess the outcome of semi-constrained total elbow arthroplasty (TEA) in osteoarthritis and compare it to the rheumatoid group. Two groups of patients assessed. In group-one with the diagnosis of rheumatoid arthritis 40 replaced elbows in 31 patients (25 female and 1 male), with average age of 67 (49–82) were reviewed. Group-two consisted of 14 elbows in 14 patients (9 female and 5 male) with post-traumatic osteoarthritis. Average age in this group was 71 (54–84). Mayo elbow performance (MEPS) and Liverpool elbow scores (LES) were used as the outcome measure. The average follow up for group-one was 53 (20–90) and group-two 60 months (21–103). According to the MEPS 87.1% of patients in group 1 and 63.6% in group 2 had excellent or good outcome (p=0.09). Only one patient from group one and none in group two had the joint revised. No difference was observed in MEPS of group-one (86 ± 17) and group-two (77 ± 24), (p=0.25). Also the LES in the two groups were not different (p=0.85). The outcome of TEA is satisfactory in both groups. No statistically significant difference was noted in the two groups. The recommendation of TEA in patients with osteoarthritis is supported by this study

Purpose of study:. Total elbow replacement (TER) is one of the surgical options for treatment of severe haemophilic arthropathy of the elbow. There are only a few small series described in the literature. The goal of our study was to evaluate our cases and add these data to the known literature. Methods:. A retrospective analysis of a series of 8 TER's (5 patients) was performed. Patients were seen in clinic and evaluated by physical examination, a VAS score for pain, the Mayo Elbow Performance Score (MEPS, 100 points=excellent) and X-rays of the affected elbow. Mean follow-up was 91 (4–236) months, and 103 months when we excluded a patient with only 4 months follow-up. Primary diagnosis was Hemophilia type A in 4 and von Willebrand disease in 1 patient. 2 patients were positive for Hepatitis C and 3 for HIV. Mean age at primary surgery was 46.7 (31.8–63.1) years. Results:. The mean VAS score for pain improved from 7.9 to 0.5 and the mean Mayo Elbow Performance Score from 36 to 93. The arc for flexion/extension improved from 68° to 91° and from to 75° to 153° for pro- and supination. Revision surgery was performed in 3 out of 8 TER's; 1 because of loosening of the humeral component (18.7 years postop), 1 for loosening of the ulnar component (9.9 years postoperatively) and 1 due to a late deep infection, 4 years postoperatively. The last case was treated with an excision arthroplasty, the others with a revision. No replacement currently shows signs of loosening. Conclusion:. This is a small retrospective study, as are the other studies on TER in haemophilic patients. It demonstrated excellent clinical outcome and an acceptable survival rate of a TER, with a mean follow-up of 7.6 years even in this young patient population

The aim of this study was to review the outcome of semi-constrained total elbow arthroplasty (TEA) in osteoarthritis and compare it to the rheumatoid group. This was performed on a single-surgeon, single-prosthesis (GSB III) series of patients. Two groups of patients assessed. In the first group with the diagnosis of rheumatoid arthritis 40 replaced elbows in 31 patients (25 female and 1 male), with average age of 67 (range 49–82) were reviewed. The second group consisted of 14 elbows in 14 patients (9 female and 5 male) with post-traumatic osteoarthritis. Average age in this group was 71 (range 54–84). All patients were recalled for clinical review. Fresh radiographs obtained and compared to the immediate postoperative images. Mayo elbow performance (MEPS) and Liverpool elbow scores (LES) were used as the outcome measure. Kaplan-Meier survival analysis for the two groups was performed. The average follow up for the first group was 53 (range 20–90) and second group 60 months (range 21–103). According to the MEPS 87.1% of patients in group 1 and 63.6% in group 2 had excellent or good outcome. This different was not statistically significant (p=0.09). Only one patient from group one and none in group two had the joint revised. No significant difference was observed in MEPS of group one (86 ± 17) and group two (77 ± 24), (p=0.25). Also the LES in the two groups were not different (p=0.85) (group one 8 ± 1 vs. group two 8 ± 2). The outcome of TEA is satisfactory in both groups. No statistically significant difference was noted in the two groups. The recommendation of TEA in patients with osteoarthritis is supported by this study

Background. Previously, the Coonrad-Morrey elbow system has typically been performed using linked-type total elbow arthroplasty (TEA) implants. However, this implant have been reported to be associated with some problems, such as wearing down, loosening, the complexity of the necessary surgical techniques and inappropriate implant size for Asian people. The Discovery elbow system (Biomet Inc., Warsaw, US) has recently been developed and it has many advantages when compared to Coonrad-Morrey implant, but the treatment outcome for this system is unclear in patients with rheumatoid arthritis (RA). Objectives. The aim of this study was to clarify the outcome of TEA using the Discovery elbow system. Methods. Eleven RA patients (13 elbows) who underwent TEA using the Discovery elbow system were investigated in this study. Two patients (3 elbows) were males, and 9 patients (10 elbows) were females. Ten were right elbows, and 3 were left elbows. Two elbows has Larsen grade “disease, 7 had grade” disease and 4 elbows underwent revision surgery. The surgical approach used for all cases was Campbell's posterior approach. The Discovery elbow system was installed using cemented fixation. Two weeks after the operation, ROM exercise was started. The elbow ROM, Mayo elbow performance score (MEPS), and any complications observed at baseline, 6 months and 24 months after surgery were assessed. Results. The preoperative elbow ROM (mean±SD) was −33.4±4.4° in extension, 133.5±3.4° in flexion, 48.5±8.4° pronation and 67.7±5.7° in supination. The postoperative elbow ROM (mean±SD) was −18.5±6.2° in extension, 112.7±6.1° in flexion, 70.0±3.4° in pronation and 73.7±1.6° in supination. As a result, a significant improvement was observed in extension, flexion and pronation. The MEPS improved significantly at 6 months and 24 months after surgery. In addition, no implant loosening was found or revision surgery was required at 24 months after surgery. Conclusions. In this study, the elbow function was observed to significantly improve by TEA using the Discovery elbow system based on the short-time outcome. However, further study is still needed to clarify the long-term outcome of this implant in RA patients

Between 1993 and 1996, 35 Kudo unlinked total elbow replacements were performed in a consecutive series of 33 rheumatoid patients. All patients had radiological changes of Larsen grade IV or grade V and met the diagnostic criteria of the American Rheumatism Association. The indication for surgery was intractable pain leading to loss of function. There were 6 men and 27 women with a mean age of 60 years (37 to 79) at the time of surgery. A total of 23 patients were reviewed at a mean follow up of 12 years (10 to 13). Ten patients (11 replacements) had died from unrelated causes prior to the review period. Function was assessed with regards to activities of daily living with the Mayo Clinic Performance Index and DASH scoring. Seven patients had undergone revision surgery after the index procedure with conversion of the Kudo replacement to a Coonrad-Morrey prosthesis. The mean time to revision was 6 years (1 to 11). The indications for revision were periprosthetic fracture (n=1), infection (n=2) and aseptic loosening (n=5). This review represents the longest follow up of the Kudo implant outside of the design unit and includes a detailed assessment of the failed arthroplasties

Our study examines a group of patients less than fifty years of age who underwent Total Elbow Arthroplasty with the Souter Strathclyde Elbow Replacement and compares their survivorship with a dataset of older group of patients. 309 patients were who underwent standard long stemmed Souter Implants as a primary procedure for rheumatoid arthritis over the last 16 years were included in this study. Patients were divided into two groups according to the their age at the time of surgery. In the first group of older patients greater than or equal to 50 years of age (Mean Age =64.4 years) there were 263 patients with a mean follow up of 7.3 years. The second group consisted of patients less than 50 years of age (Mean Age 42.04 years) who had a longer mean follow up period of 9.3 years. The survivorship of the implants for three different failure events was compared for both groups. The radiographs were evaluated using the Kaplan-Meir survival analyses, to produce survival curves for revision, revision due to aseptic loosening of the humeral component and finally gross loosening of the humeral implant (Hidex> 1). For each terminal event there were two curves and the age group analyses were all non-significant when log rank tested. The rates of loosening/revision were comparable in all curves. We set out to determine the role of age as predictive factor for loosening. Our conclusions were that Total Elbow Arthroplasty is suitable for younger patients with rheumatoid elbow. Using survivorship data there does not appear to be any difference in loosening when compared to patients of an older age group. As previously published the position of the humeral component within the humerus is crucial for long-term survivorship. Thus age alone should not be the sole discretionary factor for withholding the benefits of elbow Arthroplasty in younger patients

A 55-year-old woman who was diagnosed as RA (stage, class ) in 1995 had undergone right total elbow arthroplasty (TEA) in October 2006. We implanted her prosthesis FINE ELBOW. ®. (Nakashima Medical, Japan). Prosthesis of the humerus side is made of Co-Cr-Mo, and the ulna side is of polyethylene. Radius side is metal back system which inserts a polyethylene joint part in metal holder made by Co-Cr-Mo. All components were fixed by cement. She complained her right elbow uncomfortable gradually from January 2008. X-ray radiograph showed loosening of the ulnar component. So we performed revision surgery using ulnar revision sack in May 2008. This ulnar component had only a product made in polyethylene and we inserted the component of the product made in the polyethylene in a metal sack. The operation was successed and now she does housework. We think that strength is not worthy of the ulnar component made by polyethylene in TEA for the patient with terrible joint destruction and high daily activity patient of rheumatoid arthritis

INTRODUCTION. Aseptic loosening is the most common failure mode for Total Elbow Arthroplasty (TEA) and is considered to be associated with accelerated polyethylene bearing wear [1, 2]. This study aimed to evaluate three commercially available implant designs under loads associated with daily living. The hypothesis was that more recent designs (Discovery and Nexel) provide greater articular contact areas resulting in lower polyethylene stresses compared to the Coonrad/Morrey (CM). METHODS. Motion tracking was performed on a healthy volunteer during elbow flexion at 0, 45, and 90° shoulder abduction because most daily activities occur with some shoulder abduction [3] resulting in varus stress about the elbow. This kinematic data was used in an OpenSim upper extremity musculoskeletal model [4] to estimate muscle and joint reaction loads with 5lb in hand, consistent with the common clinical restrictions following TEA. Computer aided assemblies of the smallest size implants for each system were imported to ANSYS for finite element analysis. Metallic components were treated as rigid and polyethylene components were modeled using a nonlinear elastoplastic constitutive model calibrated to material data. Articular contacts were frictional. Physiologic joint reaction forces and moments quantified in OpenSim were applied and the resulting peak articular contact area and peak bearing von Mises stresses were assessed. RESULTS. Simulated deformation patterns of CM bearings corresponded well to those reported in retrievals studies [1, 2] supporting the clinical relevance of the modeling approach. Peak stresses for CM and Nexel were consistently found in the central and side bearings respectively. The central bearing stresses remained 2–2.6 times lower in Nexel compared to CM. Peak stress for all three TEA systems increased with shoulder abduction (Fig.1, 2). Highest peak stresses (Fig.2) were obtained in CM and consistently exceeded the polyethylene yield limit; CM showed the lowest contact area (Fig.3). Nexel and Discovery experienced peak polyethylene stresses 26–34% and 17–39% lower than CM respectively (Fig.2). DISCUSSION. Our results support the hypothesis that newer TEA systems provide increased articular contact area and reduced bearing stresses during physiological loading. The cylindrical CM central bearing carries both the joint reaction force and moment leading to edge loading and high stresses (Fig.1). The design of the Nexel central bearing provides limited resistance to varus-valgus moment, thus transferring the moment to the side bearings and reducing central bearing stresses. The hemispherical Discovery bearing design was confirmed to offer a large articular contact area. However, non-concentricity of the contact spheres can lead to edge loading and high polyethylene stresses under off-axis forces. CM and Discovery utilize conventional polyethylene, whereas Nexel utilizes highly cross-linked Vitamin-E polyethylene. This study does not account for the increased wear resistance of Vitamin-E as compared to conventional polyethylene [5]. Long term clinical data are needed to demonstrate how these wear properties, as well as the geometric design which has been shown to impact stresses and contact patterns, translate to in vivo performance. For figures, please contact authors directly

Objective. Computed tomography based three-dimensional surgical preoperative planning (3D-planning) has been expanded to achieve more precise placement of knee and hip arthroplasties. However, few reports have addressed the utility of 3D-planning for the total elbow arthroplasty (TEA). The purpose of this study was to assess the reliability and precision of 3D planning in unlinked TEA. Methods. Between April 2012 and April 2014, 17 joints in 17 patients (male 4, female 13) were included in this study. Sixteen patients were rheumatoid arthritis and one was osteoarthritis and the average age at the time of the procedure was 61 years (range 28–88). Unlinked K-NOW total elbow system (Teijin-Nakashima Medical. Co. Ltd.) was used in all cases and 3D planning was performed by Zed View (Lexi.Co.). After the appropriate size and position of the prosthesis were decided on the 3D images [Figure 1], the position of the bone tunnel made for the insertion of humeral and ulnar stem was recorded on axial, sagittal, and coronal plane (4 point measurements for humerus, and 6 points for ulna, See Figure 2). After the elbow was exposed via a posterior approach, bone resection and reaming was performed according to the 3D planning. The surgeon took an appropriate adjustment to align the prosthesis properly during the surgery. The final position of the stem insertion was recorded immediately prior to set the prostheses. We analyzed the accuracy of stem size prediction, the correlation between preoperative and final measurements, and postoperative complications. Results. The sizes of humeral stems and ulnar stems were estimated exactly in 70% (12/17) and 94 % (16/17) of all cases, respectively. All of the stem sizes were estimated accurately within one size. There was a strong correlation between the preoperative measurements around stem insertion and final position of the humerus with the correlation coefficient of 0.96–0.99, whereas the correlation was varied widely 0.48–0.97 for the ulna stem. The mean error in 3D orientation of the stem position was 0.56 mm for the humeral stem and 1.03 mm for the ulnar stem. There were no technical difficulties related to use of 3D-planning and the prostheses were properly placed in 16 cases, however posterior penetration of the ulnar stem occurred in 1 case. Conclusion. This study demonstrated the reliability and precision of preoperative 3D planning for unlinked TEA. Proper positioning of the prosthesis is extremely important to prevent maltracking and instability since postoperative instability has been a major complication of the unlinked TEA. This technique will potentially reduce the postoperative complications

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. All had a minimum of 5 years follow-up. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed for at least 5 years

A primary mode of failure for total elbow arthroplasty is osteolysis caused by wear debris. Loading of the polyethylene components by off-axis bearing loads is the likely cause of this debris. Load transfer at the elbow is affected by many factors, including the state of the radial head. New implant designs provide the option to use the intact, resected, or implant reconstructed radial head. However, the effect of the radial head state on stability and loading has not yet been investigated in these new implant designs. We postulated that the presence of the native or prosthetic radial head would reduce the wear-inducing loading patterns experienced by the humeral component and improve joint stability compared to when the radial head is resected. Seven cadaveric upper extremities, amputated at the mid humerus, were tested in a joint motion simulator equipped with an electromagnetic tracking system to quantify motion. Simulated active flexion was tested with the arm in the dependent position. Passive elbow flexion was conducted with the arm in the varus and valgus gravity-loaded orientations. After testing the intact elbow, the collateral ligaments were sectioned and a linked Latitude ulno-humeral joint replacement was performed (Tornier, Stafford, TX). The humeral component was instrumented with strain gauges for measuring varus-valgus bending and internal-external torsion. Ulno-humeral kinematics and humeral component loading were measured when the radial head was intact, resected, and following radial head arthroplasty. An increase in varus-valgus laxity was noted following replacement of the ulno-humeral joint with the prosthesis (p< 0.05). There was no difference in joint laxity between the intact radial head, radial head excision or radial head arthroplasty (p> 0.05). Torsion moments increased, while bending loads decreased in the humeral component following radial head excision and were restored following radial head arthroplasty (p< 0.05). No significant effect of radial head state on varus-valgus joint laxity was observed for the linked ulno-humeral prosthesis. In the absence of collateral ligaments, the observed post-operative increase in varus-valgus laxity can be attributed to the difference in laxity between the native joint and the articular components of the linked implant. Load transfer was altered by radial head excision, which may affect the magnitude of bearing wear and the incidence of aseptic loosening. Further studies are required to determine whether these changes in load transfer influence wear of the polyethylene components or implant loosening

Correct placement of the total elbow endoprosthesis is a critical factor for the long-term success of an artificial joint. Correct restoration of the centre of rotation is essential for optimal outcome. To evaluate whether surgical navigation has the potential to improve accuracy during Total Elbow Arthroplasty (TEA), an existing CAS system was applied on one plastic model and three patients. The spine module of the SurgiGATE™ navigation system (Medivision, Oberdorf, Switzerland) was used. To apply it during TEA, a standard 3.5-mm drill guide was instrumented with infrared LEDs and calibrated. A dynamic reference base (DRB) was developed. Its base consisted of an X-shaped, scissors-like construct that could be clamped rigidly onto the distal humerus after exposure. On a plastic model, the DRB design was evaluated, and three landmarks suitable for intraoperative matching were identified. Subsequently, the Spine system was applied during three TEA surgeries. For the first surgery no pre-operative CT scan was acquired, but the design of the DRB, its camera visibility, and the accessibility of the landmarks were verified. For the other cases, the elbows were CT-scanned preoperatively. Planning consisted of 3-D segmentation as well as the definition of matching landmarks and a trajectory representing the position of a Steinmann pin, with which the humeral implant position is defined. Intraoperatively, the DRB was fixated, and matching was performed. Using the navigation system, the drill guide could then be aligned with the planned trajectory. For the second patient, no accurate matching was achieved, hence surgery was completed conventionally. The last patient could be registered precisely, and the Steinmann pin was placed as planned. Preliminary results show that CT-based navigation can be applied during TEA. Given a positive output of an ongoing clinical study, the development of a special TEA navigation system is planned

To date there has been only one published series of elbow arthroplasty in patients with Juvenile Idiopathic arthritis. These patients pose particular problems because of the size and variable shape of the humerus and ulna together with the soft tissue contractures and bony erosion which can sometimes be severe. We have reviewed the results of elbow arthroplasty using the unlinked Kudo 5 and the linked Coonrad-Morrey implants which in our practice have different indications dependent upon bone stock and stability. Methods 19 total elbow replacements in 13 patients with juvenile idiopathic arthritis were performed by 1 specialist elbow surgeon, the senior author. 13 of these are Kudo 5 and 6 are Coonrad-Morrey implants. The mean age at operation was 39 years. 6 of the elbow replacements had undergone previous surgery, 4 had an interposition arthroplasty and 2 a synovectomy and radial head excision. No patients were lost to follow up. All were evaluated at a mean follow up of 49 months [6–84 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results Preoperatively 7 had moderate pain and 12 had severe pain. Postoperatively the pain was rated as none by 13 and mild by 6. The average Mayo Elbow Score improved from 26 preoperatively to 81 postoperatively. The mean arc of flexion/extension improved from 85 to 108 degrees.12 elbow replacements had intra and post-operative complications and 2 elbows have been revised. Conclusions The medium-term results of Total Elbow Replacements in patients with Juvenile Chronic Arthritis are acceptable and comparable to the only other published series which also records a high complication rate

Background. Total elbow arthroplasty (TEA) has become an established procedure in the treatment of patients with rheumatoid arthritis (RA). However, there is little information on whether limited extension of the elbow affects clinical outcome scores after TEA and what causes the limited extension. Methods. We retrospectively analyzed fifty-four cases of primary TEA in patients with RA. There were seven men and thirty-nine women with a mean age of 63.6 years (range, thirty to eighty years). Thirty-seven of Coonrad-Morrey and seventeen of Discovery prostheses were used. The mean length of follow-up was 7.1 ± 4.0 years (range 2.0–14.6 years). Mayo Elbow Performing Score (MEPS) and radiological measurements were recorded. Anteroposterior and lateral radiographs were assessed before and after the operation and at the latest follow-up. Widening of the joint space was calculated by subtracting the length measured on the postoperative radiograph from that on the preoperative radiograph. Results. MEPS was significantly improved after surgery (51.2 to 91.1), especially in the domains of pain (18.6 to 43.1), stability (5.9 to 10) and daily function (10.7 to 21.0). Range of motion was significantly improved, in flexion (111.3° to 140.6°), pronation (62.1° to 72.3°), and supination (60.2° to 72.3°), but not in extension (30.0° to 28.8°). Simple and multivariate analyses showed that longer disease duration (p = 0.004), higher Larsen grade (p = 0.013), worse pronation/supination arc (p = 0.004) and worse postoperative extension (p = 0.033), but not postoperative flexion (p = 0.532), were significantly correlated with lower MEPS daily function. Conversely, simple and multivariate analyses showed that worse postoperative extension was correlated with lower MEPS daily function (p = 0.005) and worse preoperative extension (p < 0.001). Radiological analyses showed that, in the limited extension group (≧40°), the degree of extension was correlated with radiological widening of the joint. Conclusions. In linked TEA, perioperative widening of the elbow joint caused limited extension and worse daily function in patients with RA

Purpose of the study: to demonstrate a mechanism of loosening of the Souter-Strathclyde Total Elbow Replacement (TER) using evidence from revision surgery. Methods: nine Souter-Strathclyde humeral and ulnar components retrieved from revision surgery for aseptic loosening were examined macroscopically and then microscopically under low power magnification. The wear patterns were compared and photographed. Results and conclusion: inspection of the retrieved cobalt chrome steel humeral components revealed no evidence of surface wear. However on examination of the polyethylene ulnar components six of the nine exhibited macroscopic wear taking the form of deep linear grooves on either the medial or lateral articulating surface. Microscopic examination revealed wear exhibited as complete disruption of the polyethylene machining lines on the medial and lateral articular surfaces, but almost complete preservation on the central gliding ridge. The findings are best explained in the context of normal elbow kinematics and congruence of the Souter-Strathclyde components. The normal elbow joint is not a simple hinge joint. In addition to flexion/extension, axial rotation and abduction/adduction motion patterns occur. However articulating surfaces of the Souter-Strathclyde components are highly congruent and thus resist the elbow’s normal translational and rotational movements. Our wear patterns are the result of humeral component rocking during flexion and extension as a result of this resistance. The central gliding ridge is preserved because the humeral component is not always in contact with it as it rocks out of its articulation in the coronal plane. Furthermore as the humeral component rocks, the sharp edge of its articulating surface makes contact with the articulating surface of the ulna causing abrasion and in the extreme circumstance the deep linear grooves observed. The biomechanics eventually lead to component loosening

Purpose: This study evaluated the accuracy of humeral component alignment in total elbow arthroplasty. An image-based navigated approach was compared against a conventional non-navigated technique. We hypothesized that an image-based navigation system would improve humeral component positioning, with navigational errors less than or approaching 2.0mm and 2.0°. Method: Eleven cadaveric distal humeri were imaged using a CT scanner, from which 3D surface models were reconstructed. Non-navigated humeral component implantation was based on a visual estimation of the flexion-extension (FE) axis on the medial and lateral aspects of the distal humerus, followed by standard instrumentation and positioning of a commercial prosthesis by an experienced surgeon. Positioning was based on the estimated FE axis and surgeon judgment. The stem length was reduced by 75% to evaluate the navigation system independent of implant design constraints. For navigated alignment, the implant was aligned with the FE axis of the CT surface model, which was registered to landmarks of the physical humerus using the iterative closest point algorithm. Navigated implant positioning was based on aligning a 3D computer model calibrated to the implant with a 3D model registered to the distal humerus. Each alignment technique was repeated for a bone loss scenario where distal landmarks were not available for FE axis identification. Results: Implant alignment error was significantly lower using navigation (P< 0.001). Navigated implant alignment error was 1.2±0.3 mm in translation and 1.3±0.3° in rotation for the intact scenario, and 1.1±0.5 mm and 2.0±1.3° for the bone loss scenario. Non-navigated alignment error was 3.1±1.3 mm and 5.0±3.8° for the intact scenario, and 3.0±1.6 mm and 12.2±3.3° for the bone loss scenario. Without navigation, 5 implants were aligned outside 5° for intact bone while 9 were aligned outside 10° for the bone loss scenario. Conclusion: Image-based navigation improved the accuracy of humeral component placement to less than 2.0 mm and 2.0°. Further, outliers in implant positioning were reduced using image-based navigation, particularly in the presence of bone loss. Implant malalignment may well increase the likelihood of early implant wear, instability and loosening. It is likely that improved implant positioning will lead to fewer implant related complications and greater prosthesis longevity

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis

Introduction: Treatment and outcome of patients with rheumatoid arthritis and distal humerus fractures is not well established. Methods: Between 1982 and 2002 twenty-four elbows in twenty-two patients (eleven men, eleven women) treated for acute distal humerus fractures were retrospectively reviewed. The average age at time of the fracture was 64 years. Eleven elbows were immediately treated with a total elbow arthroplasty (TEA) type Coonrad-Morrey (CM), six elbows had underwent open reduction and internal fixation (ORIF), and seven elbows were referred to our institution after failed ORIF elsewhere and were revised with an TEA (CM). Results: At an average follow-up of 52 months the Mayo Elbow Performance Score (MEPS) averaged in the eleven elbows with an immediate TEA 96 points and in the six elbows with ORIF 93 points (p=0.79). In the seven elbows with TEA after failed ORIF there was a trend towards a less favorable outcome (MEPS: 86 points) but the differences was not significant compared to immediate TEA (p=0.31) and ORIF (p=0.53). Patients with failed ORIF and a subsequent TEA had an average of 3 operation per elbow with one patient ending in elbow resection after an infected TEA. Patients with immediate TEA had an average of 1.3 operations and patients with successful ORIF 1.2 interventions. Discussion and Conclusion: Distal humerus fractures in patients with rheumatoid arthritis can be treated successfully with an immediate TEA or ORIF. There is a trend towards a poorer clinical outcome in patients with TEA after failed ORIF

Background: To date there has been only one published series of elbow arthroplasty in patients with Juvenile Idiopathic arthritis. These patients pose particular problems because of the size and variable shape of the humerus and ulna together with the soft tissue contractures and bony erosion which can sometimes be severe. We have reviewed the results of elbow arthroplasty using the unlinked Kudo 5 and the linked Coonrad-Morrey implants which in our practice have different indications dependent upon bone stock and stability. Methods: 19 total elbow replacements in 13 patients with juvenile idiopathic arthritis were performed by 1 specialist elbow surgeon, the senior author. 13 of these are Kudo 5 and 6 are Coonrad-Morrey implants. The mean age at operation was 39 years. 6 of the elbow replacements had undergone previous surgery, 4 had an interposition arthroplasty and 2 a synovectomy and radial head excision. No patients were lost to follow up. All were evaluated at a mean follow up of 49 months [6–84 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results: Preoperatively 7 had moderate pain and 12 had severe pain. Postoperatively the pain was rated as none by 13 and mild by 6. The average Mayo Elbow Score improved from 26 preoperatively to 81 postoperatively. The mean arc of flexion/extension improved from 85 to 108 degrees.12 elbow replacements had intra and postoperative complications. 2 elbows have been revised, 1 for malalignment resulting in instability and 1 for aseptic loosening of the ulna component. 1 customised extra small implant has radiographic loosening of both components with minimal pain and a further aseptic loose implant awaits revision at 7 years. Conclusions: The medium-term results of Total Elbow Replacements in patients with Juvenile Chronic Arthritis are acceptable and comparable to the only other published series which also records a high complication rate similar to that reported by ourselves

Purpose: While computer-assisted techniques can improve the alignment of the implant articulation with the native structure, stem abutment in the intramedullary canal may impede achievement of this alignment. In the current study, the effect of a fixed valgus (6 degree) stemmed humeral component on the alignment of navigated total elbow arthroplasty was investigated. Our hypothesis was that implantation of a humeral component with a reduced stem length would be more accurate than implantation of the humeral component with a standard length stem. Method: Thirteen cadaveric distal humeri were imaged using a CT scanner, and a 3D surface model was reconstructed from each scan. Implantation was performed using two implant configurations. The first set was unmodified (Regular) while the second set was modified by reducing the length of the humeral stem to 25% of the original stem (Reduced). A surface model of the humeral component was aligned with the flexion-extension (FE) axis of the CT-based surface model, which was registered to the landmarks of the physical humerus using the iterative closest point algorithm. Navigated implant positioning was based on aligning a 3D computer model calibrated to the implant with a 3D model registered to the distal humerus. Results: Implant alignment error was significantly lower for the Reduced implant, averaging 1.3±0.5 mm in translation and 1.2±0.4° in rotation, compared with 1.9±1.1 mm and 3.6±2.1° for the Regular implant. Abutment of the implant stem with the medullary canal of the humerus prevented optimal alignment of the Regular humeral component as only four of the 13 implantations were aligned to within 2.0° using navigation. Conclusion: These results demonstrate that a humeral component with a fixed valgus angulation cannot be accurately positioned in a consistent fashion within the medullary canal of the distal humerus without sacrificing alignment of the FE axis due to stem abutment. Improved accuracy of implant placement can be achieved by introducing a family of humeral components, with three valgus angulations of 0°, 4° and 8°. Based on humeral morphology for these specimens, 12 of the 13 implants may be positioned to within 2° of the native FE axis using one of these 3 valgus angulations

Total elbow arthroplasty is usually performed through a posterior approach. The management of the triceps tendon insertion include; Triceps division (V-Y Triceps turn down), Detachment of the Triceps insertion either by triceps splitting (Gschwind approach) or triceps reflecting (Bryan-Morrey approach), or by leaving the Triceps insertion intact (Triceps On approach). The ideal approach needs to meet three broad criteria; firstly it should be quick and easy, secondly it should offer excellent exposure and thirdly it should have low morbidity to the Triceps tendon. An approach that is also versatile provides an additional advantage. The purpose of this study was to present and discuss the surgical technique of a “new” posterior approach to the elbow. To biomechanically evaluate and compare the strength of the Triceps tendon repair with the Bryan-Morrey approach (recently demonstrated in a cadaveric study to be the strongest of three methods of management of the Triceps tendon). The Bryan-Morrey and Oxford approach were each performed on fourteen pairs of cadaveric elbows with the two Triceps tendon repairs carried out. The contra-lateral elbow served as the control. The specimens were then mounted on a material testing system and a constant velocity elongation was applied. This new approach demonstrated a significant reduction in operative time as well as providing excellent exposure suitable for multiple indications. Final analysis of the data using % ultimate strength loss (%USL) compared to the control specimens as the ultimate end point showed this new approach is as strong as the Bryan-Morrey approach with %USL of −40% for both approaches

Cobb and Morrey (1997) reported the use of Total Elbow Replacement (TER) for patients with distal humerus fractures. In this paper, 48% of the patients had a previous history of inflammatory arthropathy. Our aim was to determine the role of TER as treatment for complex distal humeral fractures in elderly patients with no previous history of inflammatory arthropathy. These patients have greater functional demands. The complexity of the original injury was graded according to the AO Mullers’ classification of supracondylar humeral fractures. All patients were reviewed clinically and radiographically. Their daily activities and general post-operative quality of life was estimated with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The Mayo elbow performance score was used for functional evaluation. Implant survivorship was assessed. Fourteen patients (11 female and three male) underwent a Coonrad-Morrey TER via a standard posterior approach for humeral fractures. Their mean age was 73 years (range 61–84 years) at the time of injury. Ten patients had suffered a C3 injury, two a B3 and two an A3 according to the AO classification. The mean time to surgery after their injury was 8 days (range: 1–21 days). Complications: one myocardial infarct and one superficial wound infection. Mean time to follow-up was three years and two months (range: 9–66 months). Nine (64%) reported no pain, four (29%) had mild pain with activity and one had mild pain at rest. The mean arc of extension-flexion movement was 24°–125°. Supination: mean = 90° (range: 70°–100°). Pronation: mean = 70° (range: 50°–110°). No elbow was unstable. The mean DASH score was 22.6 (range: 0.92–63.3). Zero reflects no disability, 100 reflects most severe disability. The mean Mayo elbow performance score was 90 (range: 80–100). X-rays revealed that all implants were well fixed with no evidence of loosening. One patient had severe hypertrophic bone

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals. Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors. 16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component. Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant

We conducted a prospective randomised controlled trial to compare functional outcomes, complications and reoperation rates in elderly patients with displaced intra-articular distal humerus fractures treated with open reduction internal fixation (ORIF) or primary semi-constrained total elbow arthroplasty (TEA). Twenty-one patients were randomised to each treatment group. Two patients died prior to follow-up and were excluded from the study. Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were collected at six weeks, three months, six months, twelve months and two years. Complication type, duration, management, and treatment requiring reoperation were recorded. Five patients randomised to ORIF were converted to TEA intraoperatively because of extensive comminution and inability to obtain fixation stable enough to allow early ROM. This resulted in fifteen patients (three male, twelve female) with an average age of seventy-seven years in the ORIF group and twenty-five patients (two male, twenty-three female) with an average age of seventy-eight in the TEA group. MEPS was significantly improved at three months (82 vs 65, p=0.01), six months (86 vs 66, p=0.003), twelve months (87 vs 72, p=0.03) and two years (86 vs 73, p=0.04) in patients with TEA compared with ORIF. DASH scores showed a significant improvement for TEA compared with ORIF between six weeks (43 vs 77, p=0.02) and six months (31 vs 50, p=0.01) but not at twelve months (32 vs 47, p=0.1) and two years (34 vs 38, p=0.6). Reoperation rates for TEA (3/25) and ORIF (4/15) were not statistically different (p=0.2). TEA for the treatment of comminuted intra-articular distal humeral fractures provides improved functional outcome compared with ORIF

Purpose: Ligaments and osseous constraints are the only static stabilizers in a healthy elbow. Following arthroplasty, the use of semi-constrained, or linked, implants provides a potential third static stabilizer. However, this constraint may increase loading on the prosthesis, and hence accelerate polyethylene wear. The presence of competent collateral ligaments and the radial head would be expected to improve elbow stability and decrease loading on the ulnohumeral articulation. This in vitro study determined the effects of the collateral ligaments, radial head, and implant linkage on kinematics and wear-inducing loads in total elbow arthroplasty. Method: Eight cadaveric upper extremities (age 73.5yrs; 5 male), were tested using an elbow motion simulator. Humeral, ulnar, and radial components of an elbow arthroplasty were positioned using a computer-assisted technique. Varus-valgus and internal-external bending loads were measured during flexion using an instrumented humeral component. A tracking receiver attached to the ulna recorded its position during active and passive flexion in the vertical orientation, and passive flexion in the varus and valgus orientations. Kinematics and loading were measured with and without implant linkage, with an intact, resected and replaced radial head, and before and after sectioning of the collateral ligaments. Results: There were no differences in the bending loads with the arm in the vertical orientation regardless of the status of the ligaments, radial head or implant linkage (p> 0.2). Radial head excision produced an increase in valgus angulation of the ulna (6.7±6.4°) but did not influence bending loads in the vertical orientation (p< 0.05). Loading was lowest with the unlinked implant, and with ligaments and radial head intact, with the arm in the valgus (1065±466Nmm) (p< 0.01) and varus (1333±698Nmm) (p< 0.05) orientations. Conclusion: Our results show that the radial head is an important valgus stabilizer for the prosthesis employed in this investigation. Linkage of the articulation increases implant loading during passive flexion with the arm in the varus and valgus orientations, which may increase implant wear. This suggests that, when using prostheses of this design, linkage of the articulation may be unnecessary if adequate bone stock and ligaments are available, whilst preserving or repairing the collateral ligaments and preserving or replacing the radial head

Total elbow arthroplasty (TEA), as a primary procedure and open reduction and internal fixation (ORIF) have been used to treat complex intra-articular distal humeral fractures in elderly patients. The failure rate after ORIF is high and TEA has often been used as a salvage procedure. Although satisfactory results have been reported after TEA as a primary procedure, there are no publications reporting the results of TEA after failed internal fixation (FIF). In this study we compared the results of patients that had TEA after FIF with those that had had primary arthroplasty (PA). We reviewed the results of 9 consecutive patients who had FIF with 12 patients who had PA. All the operations were performed by one surgeon using the same technique and same prosthesis. Both groups of patients were similar with respect to ages, sex, co-morbidity and hand dominance. The mean follow-up for both groups of patients was 5 years. At final review, patients who had had FIF had a mean Mayo score of 68 and a range of flexion/extension of 90 degrees, there was 1 infection and 1 case of loosening. The PA group had a mean Mayo score of 88 and a range of flexion/extension of 96 degrees, there were no cases of infection or loosening. This study shows the results of TEA are satisfactory either as a PA or after FIF, however the results after PA are significantly better than after FIF

Aims

We review our experience of Coonrad-Morrey total elbow arthroplasty (TEA) for fractures of the distal humerus in non-rheumatoid patients with a minimum of ten years follow-up.

Introduction. Total elbow arthroplasty (TEA) is a widely accepted for the treatment for damaged rheumatoid elbows to achieve sufficient joint function. The current prospective study reports the long term follow-up of TEA with an unlinked stem type (Stemmed Kyocera type I, SKC-I) with a solid trochlea on patients who have rheumatoid arthritis (RA). SKC-1 is derived from an unlinked surface replacement prosthesis using polycrystalline alumina ceramics on high-density polyethylene (Kyocera type I), which was developed in 1979, based on the measurement study on the cadaveric elbows. Materials and Methods. 57 elbows (Larsen’s grade IV and V) from 45 RA patients replaced by SKC-1 were investigated. Cement fixation was used in all cases. The duration of follow-up ranged from 36 to 154 (average 73. 7) months. The clinical condition of each elbow before and after operation was assessed according to the scoring system of Japanese Orthopaedic Association (JOA) elbow scoring system (maximum 100 points), which is composed of scores for pain, activity of daily life, muscle strength, range of motion, instability, and deformity of the joint. On the basis of this system, the results are defined as excellent (90–100 points), good (75–89), fair (60–74), and poor (< 60). Radiographic loosening was defined as a progressive radiolucent line of more than two millimeters that completely surrounded the prosthesis. Results. The average postoperative JOA score improved from 43. 5±10. 2. °. to 81. 0±}10. 3. °. , with marked pain relief. The mean range of motion (ROM) of extension/flexion before the surgery was –35. 7±}22. 4/117. 1±}19. 1. °. and at last follow-up was −17 5±}12. 7/136. 3±}11. 4. °. The mean ROM of pronation /supination improved from 51. 1±}23. 4/56. 5±}28. 5. °. to 78. 3±}16. 8/82. 3±}16. 5. °. Of the 57 elbows, 9 elbows were judged to have excellent results, 37 had good results, 8 had fair results, and 3 had poor results. There were no instances of ulnar nerve palsy, triceps avulsion, or postoperative infection. Medial or lateral epicondylar fracture occurred in 2 cases during the operation, and union was achieved 3 months later. Massive instability with joint dislocation was seen in 3 cases of mutilans arthritis, resulting in poor results. Aseptic loosening was seen in 3 elbows. Revision surgery was performed in 1 case of accidental post-operative distal humerus fracture, and in another of olecranon fracture with the breakage of the ulnar component. With loosening defined as the end point, Kaplan-Meier curve of the cumulative probability of survivorship demonstrates the likelihood of survival of the prosthesis at 93. 8 percent for as long as 10 years. Discussion. The results of the current study showed a high reliability of the SKC-1 prosthesis with the novel alumina ceramic component over a long period when implanted with cement. However, the use of non-constrained devices is limited by the amount of bone and by the need for ligamentous stability. If soft tissues are damaged along with marked bone loss or inflammatory changes, the ligament should be repaired or a semiconstrained type of prosthesis is indicated. It is important to note that a high level of surgical technique is required for TEA in RA elbows to avoid typical postoperative complications

We studied 11 patients (14 elbows) with gross rheumatoid deformity of the elbow, treated by total arthroplasty using the Kudo type-5 unlinked prosthesis, and who were evaluated between five and 11 years after operation. Massive bone defects were augmented by autogenous bone grafts. There were no major complications such as infection, subluxation or loosening. In most elbows relief from pain and stability were achieved. The results, according to the Mayo Elbow Performance Score, were excellent in eight, good in five and fair in one. In most elbows there was minimal or no resorption of the grafted bone. There were no radiolucent lines around the stems of the cementless components. This study shows that even highly unstable rheumatoid elbows can be replaced successfully using an unlinked prosthesis, with augmentation by grafting for major defects of bone.