Elbow Replacement Research Articles

Does an Internal Joint Stabilizer and Standardized Protocol Prevent Recurrent Instability in Complex Persistent Elbow Instability?

Does an Internal Joint Stabilizer and Standardized Protocol Prevent Recurrent Instability in Complex Persistent Elbow Instability?

Testing of Novel Total Elbow Prostheses Using Active Motion Experimental Setup

The goal of this study was to test a novel uncemented and unconstrained total elbow arthroplasty (Kaufmann total elbow) design that is stabilized through a ligament reconstruction. We quantified the implant stability after 25,000 cycles, which represents the time between implantation and when ligament and bone healing has occurred. We used an active motion experimental setup that applies tendon loads via pneumatic cylinders and reproduces the forearm-originating dynamic stabilizers of the elbow. The novel total elbow arthroplasty was actuated for 5,000 full flexion-extension cycles at 5 different shoulder positions. Four Sawbones and 4 cadaver elbows were employed. Angular laxity and implant stability were recorded prior to testing and after each 5,000-loading cycle. Four Sawbones and 4 cadaver elbows were implanted with the uncemented total elbow arthroplasty and did not demonstrate fixation failure or substantial laxity after 25,000 cycles of loading imparted at different shoulder positions. Our findings demonstrate that the Kaufmann total elbow replacement implanted into cadaver and Sawbones specimens did not exhibit fixation failure or excessive laxity after 25,000 cycles. An uncemented, nonmechanically linked total elbow arthroplasty that gains component fixation using intramedullary screws and employs a ligament reconstruction to stabilize the elbow has the potential to be a valuable management option, particularly in younger patients.

1484 Tranexamic Acid Use to Decrease Blood Loss in Primary Shoulder and Elbow Replacement: A Systematic Review and Meta-Analysis

Abstract Tranexamic acid (TXA) is an inexpensive, commonly used antifibrinolytic agent that has been shown to significantly reduce perioperative blood loss and transfusion requirements after total hip and knee replacement. We conducted a systematic review and meta-analysis to synthesise the latest evidence regarding the effects of TXA on blood loss in total shoulder replacement (TSR) and total elbow replacement (TER). We systematically searched MEDLINE, EMBASE and CENTRAL from inception to 03 September 2020 for randomised controlled trial (RCTs) and observational studies. Our primary outcome was blood loss, and secondary outcomes included the need for blood transfusion and venous thromboembolic (VTE) complications. Four RCTs and five retrospective cohort studies (RCS) met eligibility criteria for TSRs, but none for TERs. RCT data determined that TXA administration significantly decreased estimated total blood loss, postoperative blood loss, change in haemoglobin (Hb) and total Hb loss when compared to placebo. RCS data demonstrated significant association between TXA administration and decreased in postoperative blood loss, change in Hb, change in Hct and length of stay. This meta-analysis demonstrates that TXA administration in primary TSR significantly decreases blood loss compared with placebo and is associated with lower blood loss and shorter length of stay compared with no treatment with no increase in VTE complications. TXA administration should be part of a wider blood management strategy to minimise perioperative blood loss and blood transfusion requirements in patients undergoing TSR. Further research is needed to demonstrate if a similar treatment benefit exists in patients undergoing TER.

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

Epicondyle involvement in capitellar and trochlear fractures is often considered a simple associated lesion that does not substantially change treatment or prognosis. Although theoretically predicted in reviews, case series almost never report elbow prosthesis use in comminuted coronal shear injuries associated with epicondylar fracture in the elderly. The purpose of this study is to focus on this underestimated injury pattern that can be a negative risk factor for treatment and prognosis. We retrospectively reviewed all cases with coronal shear fracture of the distal humerus treated from 2016 to 2019. Fractures were classified according to Dubberley. Open reduction and internal fixation (ORIF) were performed when possible. Partial or total elbow replacement was used in severely comminuted fractures with epicondylar involvement in four elderly patients. Nineteen consecutive patients were selected (mean age: 62.4years), of which 10 had type 3A/3B fractures, and seven had both medial and lateral epicondylar involvement. The mean follow-up duration was 31.78months. The average Mayo Elbow Performance Index (MEPI) score was 81.05 points, with 7 excellent, 8 good, 1 fair, and 3 poor results. The average MEPI score of Dubberley's type 1 and type 2 was better than that of type 3 (mean: 92 vs. 72, p = 0.02). Further, the results of average range of motion were better in patients who had sustained Dubberley types 1 and 2 lesions than those with Dubberley type 3 lesion (mean: 133° vs. 85°, p = 0.002). Two patients out of three who required intra-operative conversion to total elbow arthroplasty had poor outcomes. The simultaneous presence of fracture of one or both epicondyles are usually associated with severe joint comminutions and makes ORIF more challenging, especially among elderly women. In these cases, primary total elbow prosthesis implantation could be a valid treatment option.

Non-oncologic indication for elbow megaprothesis replacement: 2 cases report.

IntroductionTreatment of elbow bone defects is still a huge challenge in orthopaedic in order to restore the shape and function of the elbow joint. Bone defect reconstruction is very difficult due to biomechanical complexity of the elbow joint and the poor coverage tissue of this area, so mega-prothesis can be considered the most optimal solution in these cases.Case reportWe present two clinical cases of megaprosthesis elbow replacement for treatment of bone defects caused by sequelae of trauma. There is one case of 3 cm bone defect at proximal ulna and one case of 3 cm bone defect at distal humerus. In the 1st case, the elbow joint is fusioned and the second case, the elbow joint is degenerated totally after 3 previous surgery. We performed total elbow replacement with a customized megaprosthesis for them. The Mayo elbow function assessment scale [1] pre-surgery was poor at 50 points. The average age is 35 years old. The mean post-operative follow-up time was 14 months. Range of elbow flexed motion was 135 degrees, both patients were maximally extension, the forearm pronation and supination were 90 and 75 degrees, respectively. The Mayo score is very good with 97,5 points. Both patients were completely satisfied with the postoperative results.ConclusionOur results show that megaprosthesis elbow replacement is a very effective option for cases large elbow bone defects due to trauma sequelae. However, careful preoperative preparation is required for the best outcome.

Joint replacement surgery for elbow tumours: a systematic review of outcomes

Tumour resection followed by joint reconstruction is a surgical option in the appropriate patient. The evidence for such reconstructive surgery of the elbow joint is limited. The aim of this study is to review the literature to evaluate the outcomes of joint replacement surgery in tumours of the elbow. A systematic review of PUBMED and EMBASE databases was conducted. Case series and comparative studies reporting results after total elbow arthroplasty, modular endo-prosthetic replacement and custom prosthesis were eligible for inclusion. Eleven eligible studies were identified (n = 134). At mean follow-up of 44 months, the overall revision rate was 14% and complication rate was 28%. The mean Mayo Elbow Performance Score was 75, with 56% of patients reporting good or excellent outcomes. The mean post-operative range of motion was 97°. Elbow prosthesis reconstruction after tumour resection can provide good functional outcomes at mid-term follow-up. The complication and revision rates are comparable to other indications for elbow replacement surgery. Further prospective studies are required to compare outcomes between different elbow arthroplasty options after tumour resection.

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

IntroductionConstrain of a total elbow replacement and elbow arthrodesis are too much for the working population to bear. As such interpositional elbow arthroplasty using fascia lata autologous graft to reconstruct the elbow joint is a viable option in this age group. Materials and method8 patients were operated for arthritic stiff elbow, and joint reconstruction was done using fascia lata autologous graft, with out the use of any hinged external fixator. Pre-operative and post-operative functional assessment was done using Mayo Elbow Performance Score (MEPS) and statistically measured using a paired t-test. ResultThere was significant improvement in range of motion in coronal (flexion-extension) and axial (supination-protonation) with p-value of <0.001. The mean pre-operative MEPI increased from 40.6 points to 91.9 points (p < 0.0001). All parameters of MEPI had statistically significant improvement with exception of stability (p-value = 0.0824).

A quantitative analysis of two cementing techniques in total elbow replacement: A cadaveric study.

One of the reasons for failure of total elbow replacement is loosening of the ulnar component. Cementing techniques are often outdated. A special small nozzle is needed for the ulnar component, when a cement gun is used. This may not always be available, or surgeons may prefer to use a syringe. We postulated that the use of a cement gun and smaller nozzle would result in improved filling of the ulnar canal. A cadaveric study was performed in which the ulnas of paired specimens were cemented with a cement gun or with a syringe. A 3D printed ulnar component was inserted and computed tomography scanning was performed on all specimens. Filling of the ulnar intramedullary canal was analysed using 3D reconstructions of the specimens. A greater degree of filling was seen by the use of the cement gun in 85.7%. Filling was 52.7% in the syringe group (25.1-78.7%), compared to 63.3% for the cement gun group (p < 0.05). The use of a small nozzle cement gun provided a significantly higher filling degree of the ulnar canal. We recommend to always use a cement gun with a specific small nozzle to cement the ulnar component in total elbow arthroplasty.

How Long Does an Elbow Replacement Last? A Systematic Review and Meta-Analysis of Case-Series and National Registry Reports With More Than 10 Years of Follow-Up

How Long Does an Elbow Replacement Last? A Systematic Review and Meta-Analysis of Case-Series and National Registry Reports With More Than 10 Years of Follow-Up

Clinical and pathological perspectives on elbow arthritis and arthroplasty

: The basic design of replacement arthroplasty components for treating arthritis in the hip, knee and shoulder had been established by the end of the 1970s/early 1980s. Replacement arthroplasty components for elbow arthritis were being developed at the same time, but a wide variety of designs were manufactured, and the basic design characteristics required for a successful elbow joint arthroplasty remain a matter of debate today. Whereas the number of total elbow joint replacements (TERs) performed for elbow fractures has increased steadily over recent years, the reverse is true in arthritis surgery where there has been a steady decline. We explain this in terms of how our understanding of the pathology and evolution of degenerative changes in the elbow over the past 40 years have influenced our perspectives on the design of elbow arthroplasty components for arthritis and the predilection of the degenerative changes for the lateral (radiocapitellar) compartment of the elbow joint. This has led to the concept of unicompartmental elbow replacement and development of components to resurface the lateral compartment of the elbow [lateral resurfacing elbow (LRE) arthroplasty]. We now believe that the future direction of elbow arthroplasty lies in the further development of components to resurface specifically only those areas of articular cartilage destroyed by the disease process in an individual elbow joint and the development of ‘anatomical designs’ of TER with replaceable bearing surfaces for those joints in which the areas of cartilage destruction are more widespread.

Treatment of a High Titer Anti-Factor-VIII Antibody by Continuous Factor VIII Administration: Report of a Case

Daily administration of large doses of factor VIII concentrate in a hemophiliac with a high titer factor VIII inhibitor resulted in marked reduction in the titer and response of the inhibitor to factor VIII administration and made possible elbow and bilateral knee replacements under conventional factor VIII coverage. Studies performed during the course of treatment indicated that the reduction in the inhibitor was the result of specific tolerance to factor VIII.

General Principles of the Surgical Management of Juvenile Inflammatory Arthritis

Surgical management of Juvenile Inflammatory Arthritis (JIA) presents many challenges for the patient, healthcare team and especially the orthopedic surgeon. Collaborative care efforts must be endorsed early on in order to facilitate maximal postoperative functional ability. Developmental levels, both physically and emotionally must be established preoperatively. It is important to determine bone age and growth plate closure to establish the best surgical intervention and avoid leg-length discrepancies later in life. Emotional maturity may impede the ability of the patient to manage pain or follow directions throughout the recuperative process. Surgical challenges require a team approach that includes rheumatologists who can manage disease modifying agents and the effects of discontinuing medications or planning surgery around dosing regimens in order to decrease immunosuppression. Managing multiple joint issues will require an expert team of occupational and physical therapists to prepare adaptive devices and rehabilitate patients who have significant functional limitations and decreased muscular strength. Because of an anticipated longer and more difficult recovery for JIA patients, case managers must engage in support systems and plan for postoperative care prior to surgery. Implant specific devices need to accommodate small bone structure, bone loss and complex deformities along with diaphyseal or epiphyseal dysplasia. Neurologic assessments will avoid cervical spine compromise during anesthesia administration. Bilateral procedures in the lower extremities should be considered whenever flexion contractures are present and should take place prior to upper extremity joint replacements. Restoring function to the hand and wrist takes priority over elbow and shoulder replacement, respectively. The key factors of appropriate surgical management in JIA patients are to decrease pain, restore function and avoid loss of ambulation at a young age. Extensive preoperative planning and communication with the patient, support system and healthcare team are warranted to address the complexities in this patient population.

Distal humerus fracture in patients over 70\xa0years of age: results of open reduction and internal fixation

BackgroundDue to the complexity of distal humerusfractures and often poor bone quality in elderly patients, these entities remain a challenge. However, because of a high rate of complications related to total elbow prostheses, reconstruction of distal humerus fractures should still be considered a therapeutic option, also in the elderly patient. The purpose of the present study was to investigate the clinical outcomes after open reduction and internal fixation and to evaluate whether the results justify reconstruction even in elderly patients. We hypothesized that despite advanced age, reasonable clinical results can be achieved, using a standardized surgical technique and aftertreatment protocol for the treatment of distal humerus fractures in elderly patients.MethodsBetween 2004 and 2012, 30 patients with a mean age of 78 years at the time of injury with a recent distal humerus fracture were evaluated. All patients underwent the identical aftertreatment protocol with no weight bearing for 6 weeks and weekly increasing range of motion. Follow-up rate was 90%. 22 patients were treated with double plate, 4 with single plate, and 1 with screw fixation only. Patients were evaluated based on clinical criteria. Primary outcome measures were Mayo Elbow Performance Score, VAS and joint range of motion, secondary was radiological evaluation.ResultsAfter a mean follow-up period of 3.8 years (min. 1 year, max. 9 years, SD ± 2), the average range of motion was flexion of 127° (min. 100°; max. 150°; SD ± 16.5) and average loss of extension of 20.9° (min. 5°; max. 40°; SD ± 11). Average pronation and supination was 68.3° (min. 0°; max. 90°; SD ± 25.3) and 75.3° (min. 0°; max. 90°; SD ± 19.7), respectively. Average Mayo Elbow Performance (MEPS) score was 88.7 (min. 60; max. 100; SD ± 12.1). 6 patients developed heterotopic ossification without significant effect on the clinical outcome. 7 patients had radiological evidence of at least partial non-union with one requiring revision, 2 discrete hardware dislocations were treated conservatively. There were no infections in the presented cohort. Our results regarding the surgical approach showed significantly higher patient satisfaction scores in the osteotomy group, compared to the group with Triceps-On Approach (PTOA).ConclusionThe present data support indication for open reduction internal fixation (ORIF) even in the elderly patient. Advanced age should not be seen as a contraindication for ORIF of fractures of the distal humerus. Although the rate of complications is higher than in younger patients, complications such as non-union are often asymptomatic, patient satisfaction scores are high, and the possible devastating complications of failed elbow replacement can be evaded.Level of evidenceIV.

Reconstruction of Elbow Joint and Soft Tissue Defect with Anterolateral Thigh Flap and Total Elbow Replacement: A Case Report

Soft tissue and bone defect due to the machinery penetrating injury of elbow joint are a rare and challenging problem for reconstructive surgeons. After reconstructing soft tissue with anterolateral thigh (ALT) flap and external fixator, the authors planned restoration of elbow function using total elbow replacement (TER). Finally, the patient regained the soft tissue reconstruction and the motion of the elbow using TER, and satisfied with the clinical results. Therefore, the authors present the successful case of ALT flap and TER to treat the machinery penetrating the injury of the elbow.

Intramedullary fibula strut bone allograft in a periprosthetic humeral shaft fracture with implant loosening after total elbow arthroplasty.

Periprosthetic fracture after total elbow replacement surgery is a difficult complication to manage, especially when it comes together with implant loosening. If stem revision and internal fixation of the periprosthetic fracture are performed simultaneously, this would be a very challenging procedure. Most of total elbow replacement implants are cemented type. Cement usage at periprosthetic fracture site may interfere healing of fractured site. Authors underwent internal fixation with use of locking plate and cerclage wire for periprosthetic fracture, allogenous fibular strut bone inserted into the humerus intramedullary canal allowing the fractured site to be more stable without cement usage. At 10-month follow-up, the complete union and good clinical outcome was achieved. We present a novel technique for treating periprosthetic fracture with implant loosening after total elbow replacement surgery, using intramedullary allogenous fibula strut bone graft.

Shoulder and Elbow Surgery in Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory arthropathy that manifests itself prior to the age of sixteen years with symptoms lasting six weeks or longer. As JIA frequently effects the upper extremities, activities of daily living become compromised during the stages of development when young adults are striving for independence. Symptomatology includes ankylosing, pain and early growth plate closure. Patients with joint involvement prior to growth plate closure have the most destruction in terms of joint abnormality and surgical complexity.Medical management of JIA has allowed for better non-surgical management, yet, there is a continued need to understand the appropriate surgical intervention and order for the greatest functional gains. Comparative studies have shown that varied results as to whether the shoulder replacement should supersede the elbow replacement or should that be reversed or both joint replacements done simultaneously. Our experience found a more significant functional improvement after total elbow replacement due to the unpredictable nature from the shoulder replacement outcomes and an inability for patients to do simple tasks such as bringing a cup to their mouths or handling a toothbrush. The exception to this occurs if the ipsilateral shoulder joint is severely limited to the point that the stressors placed on the elbow due to compensation will lead to early loosening or failure of the elbow joint replacement.Various methods for performing joint replacement of the shoulder and elbow in the JIA population will be discussed. Soft tissue integrity including the functional status of the rotator cuff will be a consideration for which surgical procedure should be considered. Surgical approaches for the elbow present fewer options for improving pain and function in this patient population. Pre, peri and postoperative management is reviewed as careful attention to irregular bony dimensions and dysmorphic anatomy precludes the use of standard implants.Total shoulder and total elbow arthroplasty should be considered in the JIA population where pain and significant functional compromise are present. The order of procedures is dependent on multiple factors and expected outcomes. Educating patients on postoperative expectations over the lifespan is an important part of surgical management for patients with JIA.

Revision Total Elbow Replacement Arthroplasty with an Allograft-Prosthesis Composite: Case Series and Technical Points

Purpose: The purpose of this study was to report the results of revision total elbow replacement arthroplasty (TERA) with an allograft-prosthesis composite (APC). Methods: We retrospectively reviewed 6 patients with an average age of 75 years who had undergone revision TERA with an APC for periprosthetic fracture or loosening of the component. The mean follow-up period was 13 months. We assessed serial radiographs for bone union and evaluated the outcomes in terms of pain visual analogue scale (VAS), the Mayo Elbow Performance Score (MEPS), range of motion, and complications. Results: The APC was used for the humerus in 5 patients and for the ulna in 1 patient. The clinical bone union was achieved at average 9 months after surgery. The mean pain VAS score improved from 6.8 to 1.7, the mean elbow joint range of motion increased from 95° to 129° and the MEPS score improved from 40 to 79 at the last follow-up. There were no major complications such as infection, nonunion, malunion, limitation of motion or refracture. One patient experienced transient radial nerve palsy and another patient a prominent edge of the humeral allobone that needed a trimming surgery later.Conclusion: Revision TERA with an APC provides good functional outcomes and can be recommended as one of the options for failed total elbow arthroplasty.

Primary Total Elbow Replacement for Treatment of Complex Distal Humerus Fracture: Outcomes of Short-term Follow-up.

BackgroundHigh complication rate after open reduction and internal fixation can lead to use of primary total elbow replacement (TER) in treatment of complex distal humerus fractures in elderly patients. The purpose of this study was to investigate the short-term outcomes and complications after primary TER in patients with complex distal humerus fracture. MethodsNine patients with acute complex distal humerus fracture were treated by primary TER using the semiconstrained Coonrad-Morrey prosthesis. The mean age of patients was 72.7 years (range, 63–85 years). Clinical and radiographic outcomes were evaluated over a mean follow-up of 29.0 months (range, 12–65 months) using visual analog scale (VAS) score for pain; Mayo elbow performance score (MEPS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; and serial plain radiographs. Complications were also evaluated. ResultsAt the final follow-up, mean VAS, MEPS, and Quick-DASH scores were 1.2, 80.5, and 20, respectively. The mean range of motion was 127.7º of flexion, 13.8º of extension, 73.3º of pronation, and 74.4º of supination. There was no evidence of bushing wear or high-grade implant loosening on serial plain radiographs. Three complications (33.3%) comprising two periprosthetic fractures and one ulnar neuropathy were observed.ConclusionsPrimary TER for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes. However, surgeons should consider the high complication rate after primary TER.

Management of unusual metallosis and failed elbow replacement in rheumatoid female: a case report

&lt;p class="abstract"&gt;42 years old female who was operated for rheumatoid arthritis elbow right side with revision of total replacement. Her elbow was primarily replaced 10 years before this surgery. She had severe metallosis and breakage of ulnar stem, loosening of cement (ulnar). Humerus stem was well fixed. Massive metal debris in soft tissue was removed. humerus side cement and stem were removed by splitting the bone. Revision stem was fixed with cement and circumferential wiring. On 6 yrs following surgery, patient is doing well in terms of pain relief and range of motion around elbow. She is doing almost all activities of daily life. Early detection and removal primary implant are the need of hour to save the ill effects of metallosis and bone resorption.&lt;/p&gt;

Venous thromboembolism following 672,495 primary total shoulder and elbow replacements: Meta-analyses of incidence, temporal trends and potential risk factors

BackgroundThere is wide variability in reported venous thromboembolism (VTE) incidence following total shoulder replacement (TSR) or total elbow replacement (TER). It is uncertain which risk factors influence the risk of VTE following TSR or TER. We conducted a PRISMA compliant meta-analysis to evaluate the incidence, temporal trends and potential risk factors for VTE following primary TSR and TER. MethodsMEDLINE, Embase, Web of Science, and Cochrane Library were searched to September 2019 for longitudinal studies reporting VTE outcomes after TSR or TER. Incidence and relative risks (RR) (95% confidence intervals) were estimated. ResultsWe identified 43 articles with data on 672,495 TSRs and TERs (668,699 TSRs and 3796 TERs). The overall pooled 3-month VTE incidence following TSR was 0.85% (0.39–1.46). For TER, the 3-month incidence of VTE was 0.23% (0.08–0.44). Older age, body mass index (BMI) ≥25 kg/m2, and alcohol abuse were each associated with increased VTE risk following TSR. Comorbidities associated with increased VTE risk following TSR were chronic pulmonary disease, previous VTE, heart failure, anaemia, coagulopathy, arrhythmia, epilepsy, urinary tract infection, sleep apnoea, and fluid & electrolyte imbalance. Anatomic and outpatient TSR were each associated with decreased VTE risk. ConclusionsThe average 3-month incidence of VTE following TSR or TER is <1%. High risk groups such as older patients, those with a previous VTE history and those undergoing reverse or inpatient TSR may need close monitoring. Modifiable factors such as high BMI, alcohol abuse, and comorbidities could be identified and addressed prior to surgery. Systematic review registrationPROSPERO 2019: CRD42019134096.