Total Elbow Arthroplasty Research Articles

Elbow joint loads during simulated activities of daily living: implications for formulating recommendations after total elbow arthroplasty

Overloading of the elbow joint prosthesis following total elbow arthroplasty can lead to implant failure. Joint moments during daily activities are not well-contextualized for a prosthesis' failure limits and the effect of the current postoperative instruction on elbow joint loading is unclear. This study investigates the difference in elbow joint moments between simulated daily tasks and between flexion-extension, pronation-supination, varus-valgus movement directions. Additionally, the effect of the current postoperative instruction on elbow joint load is examined. Nine healthy participants (age 45.8 ± 17 years, 3 males) performed eight tasks; driving a car, opening a door, rising from chair, lifting, sliding, combing hair, drinking, emptying cup, without and with the instruction "not lifting more than 1 kg". Upper limb kinematics and hand contact forces were measured. Elbow joint angles and net moments were analyzed using inverse dynamic analysis, where the net moments are estimated from movement data and external forces. Peak elbow joint moments differed significantly between tasks (p < 0.01) and movement directions (p < 0.01). The most and least demanding tasks were, rising from a chair (13.4 Nm extension, 5.0 Nm supination, 15.2 Nm valgus) and sliding (4.3 Nm flexion, 1.7 Nm supination, 2.6 Nm varus). Net moments were significantly reduced after instruction only in the chair task (p < 0.01). This study analyzed elbow joint moments in different directions during daily tasks. The outcomes question whether postoperative instruction can lead to decreasing elbow loads. Future research might focus on reducing elbow loads in the flexion-extension and varus-valgus directions.

Outcomes of Revision Unlinked Total Elbow Arthroplasty for Rheumatoid Elbow.

Background: Although unlinked total elbow arthroplasty (TEA) is a treatment option for end-stage rheumatoid arthritis (RA) of the elbow, its long-term outcomes were inferior. Moreover, revision TEA could be technically challenging. The unlinked TEA procedure comprises the ease of implant removal at revision and advantage of bone preservation. This study evaluated the clinical outcomes in patients who underwent revision TEA using primary unlinked TEA for rheumatoid elbows. It also aimed to determine whether selecting the unlinked prosthesis for the primary TEA would make revision more accessible and successful. Methods: We retrospectively reviewed data of 13 consecutive patients (14 elbows) who underwent revision TEAs for implant failure due to different aetiologies, excluding septic loosening. Three different unlinked TEA implants were used: the Kudo type-5 with all-polyethylene (AP) ulnar component, Kudo type-5 with metal-backed (MB) ulnar component and K-Now TEA. We evaluated the patients' pre- and postoperative outcomes, including the range of motion, pain score and Mayo Elbow Performance Index (MEPI). Results: Among the 14 elbows, 11 were revised using the Kudo type-5 ulnar component (nine and two with AP and MB ulnar component, respectively), and three using the K-Now. We found that each model of TEA had different tendencies to indication for revision surgery. Three more resulted in further failure. The clinical outcomes were assessed in the 11 surviving elbows. Eight of the 11 elbows showed no pain at the final follow-up. However, the remaining three showed only mild pain. The MEPI revealed that seven cases were excellent, two were good and two were fair. Conclusions: The mode of implant failure was largely dependent on the implant design. Furthermore, partial revision with the same implant design was sufficient in managing implant failure in the early phase. However, conversion from unlinked to linked design could be recommended in patients with progressive failure or instability. Level of Evidence: Level IV (Therapeutic).

Revision Arthroplasty in the Challenging Elbow.

Compared with hip and knee arthroplasty, total elbow arthroplasty (TEA)hasa higher complication rate and lower survivorship. Modern TEA implants most commonly require revision due to implant loosening, infection, and periprosthetic fracture. Concerns with revision TEA include handling of the soft tissues and possible necessity of flap coverage, triceps management, preservation of bone stock, and management of concurrent infection or fracture. In this review, we will discuss preoperative evaluation of the failed elbow arthroplasty, surgical approaches, techniques for revision, outcomes, and complications following revision total elbow arthroplasty.

Do Intramedullary Screws Provide Adequate Fixation for Humeral and Ulnar Components in Total Elbow Arthroplasty? A Cadaveric Analysis

The objective of this study was to determine the structural properties of the cadaver bone-screw interface for cementless intramedullary screw fixation in the context of total elbow arthroplasty. The intramedullary canals of seven humerus and seven ulna specimens from fresh-frozen cadavers were drilled using custom drill bits until the inner cortex was reached and then hand tapped for the corresponding thread size. Titanium screws were advanced into the tapped holes until securely seated. The bones were potted and then mounted on a uniaxial material testing machine. A tensile load was applied, and end-of-test elongation, failure load, energy absorbed, and stiffness were determined. End-of-test load and elongation were defined as the elongation and load experienced by the structure at 3,000 N or failure. Each specimen was inspected for evidence of pullout, loosening, or visible fractures. The end-of-test load and elongation for the humerus specimens were 2721 ± 738 N and 3.0 ± 0.9 mm, respectively. The ulna specimens reached 92% of the humerus specimens' end-of-test load at 2,514± 678 N and 120% of their end-of-test elongation (3.6 ± 0.6 mm). The stiffness of the humerus specimens was 1,077 ± 336 N/mm, which was 1.3 times greater than the stiffness of the ulna specimens (790 ± 211 N/mm). Lastly, the energy absorbed by the humerus samples was 3.6 ± 1.6 J, which was 92% of the energy absorbed by the ulna samples at 3.9 ± 1.1 J. One humerus and three ulnas failed before the end-of-test load of 3,000 N. Two failures were caused by screw pullout and two by bone fracture. Our findings demonstrate that intramedullary screw fixation is successful in withstanding forces that are greater than required for osseointegration. Uncemented fixation may be beneficial in elbow arthroplasty.

Low risk of postoperative ulnar nerve affection in surgically treated distal humeral fractures when the nerve is released in situ.

Adult distal humeral fractures (DHF) comprise 2%-5% of all fractures and 30% of all elbow fractures. Treatment of DHF may be technically demanding due to fracture complexity and proximity of neurovascular structures. Open reduction and internal fixation (ORIF) are often the treatment of choice, but arthroplasty is considered in case of severe comminution or in elderly patients with poor bone quality. Ulnar nerve affection following surgical treatment of distal humerus fractures is a well-recognized complication. To report the risk of ulnar nerve affection after surgery for acute DHFs. We retrospectively identified 239 consecutive adult patients with acute DHFs who underwent surgery with ORIF, elbow hemiarthroplasty (EHA) or total elbow arthroplasty (TEA) between January 2011 and December 2019. In all cases, the ulnar nerve was released in situ without anterior transposition. We used our institutional database to review patients' medical records for demographics, fracture morphology, type of surgery and ulnar nerve affection immediately; records were reviewed after surgery and at 2 wk and 12 wk of routine clinical outpatient follow-up. Twenty-nine percent patients were excluded due to pre- or postoperative conditions. Final follow-up examination was a telephone interview in which ulnar nerve affection was reported according to the McGowen Classification Score. A total of 210 patients were eligible for interview, but 13 patients declined participation and 17 patients failed to respond. Thus, 180 patients were included. Mean age at surgery was 64 years (range 18-88 years); 121 (67.3%) patients were women; 59 (32.7%) were men. According to the AO/OTA classification system, we recorded 47 patients with type A3, 55 patients with type B and 78 patients with type C fractures. According to the McGowen Classification Score, mild ulnar nerve affection was reported in nine patients; severe affection, in two. A total of 69 patients were treated with ORIF of whom three had mild temporary ulnar nerve affection and one had severe ulnar nerve affection. In all, 111 patients were treated with arthroplasty (67 EHA, 44 TEA) of whom seven had mild ulnar nerve affection and one had severe persistent ulnar nerve affection. No further treatment was provided. The risk of ulnar nerve affection after surgical treatment for acute DHF is low when the ulnar nerve is released in situ without nerve transposition, independently of the treatment provided.

Computed Tomography-Based Templating of Proximal Ulna Intramedullary Screw Fixation.

Intramedullary screw fixation of the proximal ulna can be used for fixation of the ulnar component in total elbow arthroplasty. Our purpose was to use computed tomography (CT) to characterize proximal ulna anatomy with respect to intramedullary screw fixation, and then to validate this templating process by inserting intramedullary screws into 3-dimensional (3D)-printed models. Thirty elbow CT scans were reformatted in the axis of the proximal ulna. Screw placement was templated by fixing a length at 78 mm distal to the centerline of ulnohumeral rotation and measuring diameter, and then fixing the screw pitch diameter to 5.5 mm and measuring length. Three-dimensional models were printed for 5 patients, and intramedullary screws were advanced as distal as possible until endosteal fit was achieved. All patients had an anatomic limit for intramedullary screw fixation, due to dorsal angulation, varus angulation, or both. At 78 mm distal to the centerline of rotation, mean screw diameter was 5.4 mm (range, 3.2-8.0). When fixing screw diameter to 5.5 mm, the mean screw length was 79.9 mm (range, 64.2-107.9). All intramedullary screws were placed in the 3D models within 3 mm of the templated length, with correlation coefficient 0.992. This study characterized proximal ulna anatomy in the context of intramedullary screw fixation. Templating allows surgeons to predict intramedullary screw sizing, and a broad range of screw lengths and diameters is required when attempting intramedullary screw fixation for placement of the ulnar component in uncemented total elbow arthroplasty.

A Soft-Tissue Landmark to Assess Humeral Component Rotation in Total Elbow Arthroplasty.

Assessing the rotational alignment of the humeral component during total elbow arthroplasty is dependent upon bony landmarks that can be absent or altered in cases of distal humerus fractures, revision arthroplasty, severe bone loss, or deformity. We hypothesize that the intermuscular septum can be used as a reliable soft-tissue landmark to set the rotation of the humeral component intra-operatively when previously described bony landmarks are not reliable or present. Forty-eight unpaired cadaveric human subjects (mean age and standard deviation 63 ± 12 years; 24 males, 24 females) underwent computed tomography (CT) scans. The geometric centers of the trochlea and capitellum were assessed, and the line through these two points was set as the flexion-extension axis (FEA) of the elbow. The intermuscular septum axis (IMSA) was drawn proximal to the olecranon fossa and at least 4 cm proximal to the most distal point of the articular surface, where the posterior humeral cortex was flat. The angles between the FEA and IMSA were calculated and compared using a two-tailed t-test. Regression analysis was used to assess the inter- and intra-observer reliability of the IMSA. The IMSA was externally rotated 10.3° ± 2.8 compared to the FEA (p < 0.001 and confidence interval (CI) of 2.8 with α set to 0.01). The inter- and intra-observer reliability of the IMSA was high, with an R-value of 0.91 and 0.97, respectively. The intermuscular septum can be used as a soft-tissue landmark to set humeral component rotation and is 10.3° externally rotated with respect to the FEA of the ulnohumeral joint.

Intraoperative modification of total elbow arthroplasty implants.

Modification of total elbow arthroplasty (TEA) implants may be necessary in selected patients with substantial anatomic bone deformity or those undergoing revision surgery. The purpose of this study was to investigate the prevalence and consequences of implant modifications during TEA at our institution. We hypothesized that TEA implant modification would be more common in revisions than in primary replacements, and that it would not be associated with worse clinical outcomes or increased rates of radiographic or surgical complications directly related to the implant modification. Elbows that had undergone TEA by any of 3 surgeons at our institution with use of intraoperative implant modification between January 1992 and October 2019 were retrospectively reviewed for the type of modification and complications. Complications were classified as definitely related, probably related, possibly related, or nonrelated to the implant's modification according to the consensus review by the 3 senior surgeons. A survey was sent out to surgeons outside of our institution to investigate whether intraoperative modification to TEA implants is a common clinical practice. A total of 106 implant components were modified during 94 of 731 TEA procedures (13%) in 84 of 560 patients. Implant modifications were performed in 60 of 285 revision cases (21%) compared with 34 of 446 (8%) primary cases (P<.0001). These included shortening the stem in 40 (44%), bending the stem in 16 (15%), notching the stem in 16 (15%), tapering the stem in 9 (9%), and a combination of 2 or more of these modifications in 19 implants (17%). Among the 55 index surgeries available for complication analysis, 40 complications occurred in 28 index surgeries (11 primary and 17 revisions; 25 patients), making the overall complication rate 51%. Of these 40 complications, 23 were considered independent of any implant modification. Of the remaining 17 complications, 9 were considered nonrelated to the implant modification, 6 were possibly related, and 2 were probably related to the implant modification. Therefore, the complication rate possibly related or probably related to implant modification was 15% (8 of 55). No complication was classified as definitely related to the implant modification. No implant breakage or malfunction occurred after any modification. A total of 442 survey responses were received representing 29 countries, of which 144 surgeons (39%) performed modification to implants during TEA procedures. This study confirmed our hypothesis that modification of TEA implants is not uncommon at our institution, particularly in revision arthroplasty. Surgeons should keep in mind that complications possibly related or probably related to implant modification were at minimum 15% and could have been as high as 30% if the patients lost to follow-up had all had complications. Implant modification may be necessary in some cases but should be exercised with thoughtful consideration and caution.

Comparison of clinical outcomes between the olecranon osteotomy approach and the Bryan-Morrey approach for total elbow arthroplasty.

This study aims to investigate the clinical efficacy of the olecranon osteotomy approach and the Bryan-Morrey approach in total elbow arthroplasty (TEA). In this retrospective study, 49 patients with elbow disease were treated with TEA. A total of 22 patients with TEA by olecranon osteotomy approach were designated as group A, and 27 patients with TEA by Bryan-Morrey approach were designated as group B. There were 22 males and 27 females, aged 32-82years with a mean age of 62years. There were 44 cases of unilateral elbow joint, including 27 cases on the left elbow and 17 cases on the right elbow, and 5 cases of the bilateral elbow joint. There were 6 cases of osteoarthritis (7 elbows), 18 cases of rheumatoid arthritis (22 elbows), 14 cases of traumatic arthritis (14 elbows), 7 cases of distal humeral fractures (7 elbows), and 4 cases of elbow tuberculosis (4 elbows). For each group, we recorded the operative time, intraoperative bleeding, elbow flexion, extension, pronation, supination, postoperative complication rates, and Mayo Elbow Performance Score after surgery. Operative time and intraoperative bleeding were less in group A than in group B (53-120min [70 (62.5, 78) min] vs. 64-105min [77 (73, 87) min], and 10-200ml [50 (20, 90) ml] vs. 5-250ml [100 (50, 150) ml], P<.028). The elbow flexion, pronation activity, and Mayo Elbow Performance Score were higher in group A than in group B, [(121±12)° vs. (112±10)°, 85 (85,85)° vs. 80 (77,85)°, and (94±3) points vs. (91±4) points, P<.036], while elbow extension and supination activity and complication rates were not statistically significant in either group. Compared to Bryan-Morrey approach, the olecranon osteotomy approach to TEA provides adequate visualization, saves operative time and reduces bleeding, provides better flexion activity, effectively improves elbow function, and achieves satisfactory clinical outcomes.

What factors can reduce the need of repeat revision for humeral loosening in revision total elbow arthroplasty?

This study aims to determine re-revision rate in a cohort who underwent revision total elbow arthroplasty (rTEA) for humeral loosening (HL) and identify factors contributing to re-revision. We hypothesize that proportional increases in the stem and flange lengths will stabilize the bone-implant interface significantly more than disproportional increases in stem or flange length alone. Additionally, we hypothesize that the indication for the index arthroplasty will impact the need for repeat revision for HL. The secondary objective was to describe the functional outcomes, complications, and radiographic loosening after rTEA. We retrospectively reviewed 181 rTEAs performed from 2000-2021. Forty rTEAs for HL performed on 40 elbows that either required a subsequent revision for humeral loosening (10 rTEAs) or had a minimum of two years of clinical or radiographic follow-up were included. One hundred thirty-one cases were excluded. Patients were grouped based on stem and flange length to determine the re-revision rate. Patients were divided based on re-revision status into a single revision group and re-revision group. The stem to flange lengths (S/F) ratio was calculated for each surgery. Mean clinical and radiographic follow-up was 71 months (range, 18-221 months; 3-221 months, respectively). Rheumatoid arthritis (RA) was statistically significant in predicting re-revision TEA for HL (p value = 0.024). The overall re-revision rate for HL was 25% at average 4.2 years (range, 1-19) from revision procedure. There was a significant increase in stem and flange lengths from index procedure to revision, on average by 70±47mm (p<0.001) and 28±39mm (p<0.001), respectively. In cases of re-revisions (n=10), four patients went into excisional procedure, and in the remaining six cases the size of re-revision implant increased on average by 37±40mm for stem and 73±70mm for flange (p=0.075 and p=0.046). Furthermore, average flange in these 6 cases was 7 times shorter than average stem (S/F=6.7±2.2). This was significantly different from cases were not re-revised (p=0.03; S/F=4.6±1.8 and 4.2±2, respectively). Mean range of motion was 16° (range: 0°-90°; SD: 20°) to 119° (range: 0°-160°; SD: 39°) at final follow-up. Complications included ulnar neuropathy (38%), radial neuropathy (10%), infection (14%), ulnar loosening (14%), and fracture (14%). None of the elbows were considered radiographically loose at final follow-up. We show that the primary diagnosis of RA and a humeral stem with a relatively short flange relative to the stem length significantly contribute to re-revision of TEA. The use of an implant where flange can be extended beyond one fourth of the stem length may increase implant longevity.

Outcomes After Acute Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures

Compare outcomes of acute versus delayed total elbow arthroplasty (TEA) following distal humerus fractures (DHF). This retrospective study included 39 patients who underwent primary TEA with semiconstrained implants for DHF, either within 4 weeks of their injury or after failing initial open reduction and internal fixation (ORIF) or nonsurgical management, between June 1, 2003 and February 1, 2018 with minimum 1-year follow-up. Our outcome measures included QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score, complications, reoperations, and range of motion (ROM). Demographics, clinical variables, and outcomes were compared using the Student's t-test, Mann-Whitney U test, and Fisher's exact test as appropriate. Kaplan-Meier curves for mortality, implant survivorship, and reoperation were created. Our patients were categorized into acute TEA (n= 22), ORIF to TEA (n= 10), and nonsurgical to TEA (n= 7) treatment groups. Additional analysis was performed comparing acute to delayed TEA, which combined data from failed ORIF and nonsurgical cohorts. The median follow-up, average age, and median Charlson comorbility index were similar between groups. The most common fracture pattern was AO13C. At median follow-up of 5.8 years, QuickDASH differed between cohorts: mean of 31 (SD 19) in acute TEA and 52 (SD 27) in delayed TEA, which further subdivided to 44.2 (SD 25) in failed ORIF and 76 (SD 23) in failed nonsurgical management. Poorer QuickDASH scores at final follow-up were associated with delayed TEA, initial nonsurgical management, and depression. Surgical complications were associated with delayed TEA. Higher Charlson comorbidity index was associated with death. No variables were associated significantly with ROM, revision, or reoperation. Comminuted DHFs are difficult to treat in the elderly with high rates of complication and poor function after surgery. Our study suggests TEA performed acutely result in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management. Therapeutic, III.

Clinical results of total elbow arthroplasty after treatment failure for Monteggia-like injuries

Monteggia-like fractures (MLF) are complex injuries with high complication rates and frequently unsatisfying clinical results. Total elbow arthroplasty (TEA) represents the only option to salvage the functional requirements in some patients with pronounced posttraumatic arthropathy. This case series provides clinical results of TEA following failed treatment of MLF. All patients who underwent TEA from 2017 to 2022 for failed treatment of MLF were retrospectively included in this study. Complications and revisions before and after TEA and functional results, measured by the Broberg/Morrey score, were evaluated. In this study 9 patients with amean age of 68 (±7; 54-79) years were included. The mean follow-up was 12 (±9; 2-27) months. The main reasons leading to posttraumatic arthropathy were chronic infections (44.4%), bony instability due to coronoid deficiency (33.3%) or acombined coronoid and radial head deficiency (22.2%) and non-union of the proximal ulna with radial head necrosis (11.1%). The mean number of surgical revisions between primary fixation and TEA was 2.7 (±1.8; 0-6). The revision rate following TEA was 44%. The mean Broberg/Morrey score at the time of the latest follow-up was 83 (±10; 71-97) points. Chronic infection and coronoid deficiency are the main reasons for posttraumatic arthropathy after MLF leading to TEA. While the overall clinical results are satisfying, the indications should be reserved for selected cases due to high revision rates.

Comparison of total elbow arthroplasty complications between various surgical indications at 90-day and one-year follow-ups in 1600 elbows.

Total elbow arthroplasty (TEA) was traditionally a mainstay of treatment for patients with severe inflammatory arthritis. Recently, the indications for TEA have expanded and it has grown into a versatile procedure that can be used to treat several pathologies of the elbow. The objective of this study was to compare complication rates between TEA performed for rheumatoid arthritis (RA), fracture (FX), or osteoarthritis (DJD). A retrospective analysis of the MUExtr dataset of the PearlDiver National Database was performed. ICD10 codes were utilized to identify TEA patients from 2010-2020 and separate them into RA, FX, and DJD cohorts. Demographics, comorbidities, and hospital data were identified and compared using ANOVA. Systemic complications at 90 days, as well as surgical complications at 90 days and 1 year were compared using multivariable logistic regression. Surgical complications included wound dehiscence, hematoma, deep infection, periprosthetic fracture, stiffness, instability, triceps injury, nerve injury, and need for revision. 1600 patients (38.9% DJD, 48.8% FX, 12.3% RA) were identified. The majority of patients in all three cohorts were female with the RA group having a significantly higher percentage of female patients compared to DJD and FX (87.3% versus 81.4% and 76.9%, p = 0.003). There were no significant differences noted in systemic complications and surgical complications between all three groups at 90 days postoperative. After controlling for patient factors, FX patients were more likely to develop elbow stiffness (OR 1.53, p=0.006) and less likely to have a triceps injury (OR 0.26, p<0.001) at 1 year than RA or DJD patients. The indications for TEA have expanded over the last ten years with nearly half of all cases being performed for fracture. At one year, those TEAs performed for fracture have a significantly lower rate of triceps injury and higher rate of elbow stiffness postoperatively than when performed for other indications. This is important to consider when preoperatively planning, as well as when discussing expected outcomes with patients prior to surgery, especially with the expanded incidence of TEA for fracture being performed over the last decade.

Lifting limitations following elbow arthroplasty: A survey of British Elbow and Shoulder Society members

The primary aim of this survey was to capture current practice with regard to lifting limitations following elbow arthroplasty. An online survey was emailed to all members of the British Elbow and Shoulder Society. All consultant respondents who reported performing elbow arthroplasty were asked about their advice for post-operative lifting limitations. In total, 115 surveys were completed: 55 consultants reported performing linked total elbow arthroplasty, 18 reported performing unlinked total elbow arthroplasty and 44 reported performing distal humeral hemiarthroplasty. The majority of elbow consultants advise a lifelong lifting limitation following linked and unlinked total elbow arthroplasty (78% and 61% respectively). There was variation in the weight specified for lifelong lifting limitations, the median weight restriction in linked total elbow arthroplasty was 5 lb, and in unlinked total elbow arthroplasty was 10 lb (range 1−20 lb). In total, 13% of consultants performing linked total elbow arthroplasty and 33% of consultants performing unlinked total elbow arthroplasty do not advise any lifelong lifting limitations post-operatively. In a perceived attempt to prolong implant longevity, most surgeons recommend lifelong lifting limitations following total elbow arthroplasty. There is variation in the weight restriction advised by consultant elbow surgeons. Currently the optimal weight restriction to maximise implant longevity is not known and further work needs to be done to understand the true relationship between activity, loading and implant failure.

Clinical and Radiographic Outcomes of Total Elbow Arthroplasty Using a Semi-constrained Prosthesis with a Triceps-preserving Approach over a Minimum Follow-up Period of 4 Years.

Complications related to triceps after total elbow arthroplasty (TEA) have become a major surgical concern. The triceps-preserving approach has the advantage of not disturbing the insertion of triceps but is disadvantaged by the reduced exposure of the elbow joint. The aim of this study was to investigate the clinical and radiological outcomes of TEA with a triceps-preserving approach and to compare the outcomes of TEA to treat arthropathy with that of TEA to treat acute distal humerus fracture. From January 2010 to December 2018, 23 patients undergoing primary TEAs were retrospectively reviewed with a mean follow-up time of 92.6 months (range, 52-136months). Each TEA was performed using the triceps-preserving approach with a semi-constrained Coonrad-Morrey prosthesis. Patient demographics, range of motion (ROM), pain visual analogue scale (VAS), and triceps strength (Medical Research Council [MRC] scale) were compared before and after surgery. The Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiographic outcome, and complications were evaluated at follow-up. In total, seven males and 16 females were included in this study, with a mean age of 66.1 years (range:46-85 years). By the last follow-up, pain had been significantly relieved in all patients. The average MEPS in the arthropathy group and fracture group were 90.8 ± 10.3 points (range: 68-98 points) and 91.7 ± 0.4 (range: 76-100 points), respectively. The average DASH of the arthropathy group and fracture group was 37.3 ± 18.8 points (range: 18-52 points) and 38.4 ± 20.1 (range: 16-60 points). At the last follow-up after surgery, the mean flexion arcs in the arthropathy group and fracture group were 100.4° ± 24.1° and 97.8° ± 28.1°, respectively. The mean pro-supination arcs in the arthropathy group and fracture group were 142.4° ± 15.2° and 139.2° ± 17.5°, respectively. There were no significant differences in clinical outcomes between the two groups (P≥ 0.05). Triceps strength was normal (MRC grade V) in 15 elbows and good in eight elbows. None of the cases experienced weakness of the triceps strength, infection, periprosthetic fractures, or prosthesis breakage. The clinical and radiographical outcomes of TEA with the triceps-preserving approach were satisfactory in patients with distal humerus fracture, osteoarthritis and rheumatoid arthritis.

Comparison of baseline demographics and risk factors for aseptic loosening following primary total elbow arthroplasty.

Aseptic loosening is a feared complication following total elbow arthroplasty (TEA); however, literature regarding factors that may contribute to this complication is limited. The aims of this investigation were to: (1) compare baseline demographics of patients who developed aseptic loosening following primary TEA; and (2) identify patient-specific risk factors for the development of loosening. Retrospective analysis using a nationwide claims database was performed to identify patients who underwent primary TEA and developed aseptic loosening within 2 years (study n = 307, control n = 10,741). Multivariate regression analysis generated odds ratio (OR), 95% confidence interval (95% CI), and p-value of risk factors. p < 0.05 was considered statistically significant. Patients who developed aseptic loosening had significant differences in numerous demographics, including age (p = 0.0001), sex (p = 0.0251), and various comorbid conditions such as obesity (15.96% vs. 8.36%, p < 0.0001). Furthermore, the risk factors most associated with aseptic loosening were obesity (OR 1.65, 95% CI 1.18-2.28, p = 0.002), male sex (OR 1.51, 95% CI 1.13-2.00, p = 0.004), and concomitant opioid use disorder (OR 1.58, 95% CI 1.14-2.15, p = 0.004). This study is the first to identify demographics and patient-related risk factors associated with aseptic loosening following primary TEA. This evidence could be applied to the clinical setting in order to educate at-risk patients of this potential complication as well as inform their post-operative clinical management. Level III: Prognostic.

Study of a constrained finite element elbow prosthesis: the influence of the implant placement

BackgroundThe functional results of total elbow arthroplasty (TEA) are controversial and the medium- to long-term revision rates are relatively high. The aim of the present study was to analyze the stresses of TEA in its classic configuration, identify the areas of greatest stress in the prosthesis–bone–cement interface, and evaluate the most wearing working conditions.Materials and methodsBy means of a reverse engineering process and using a 3D laser scanner, CAD (computer-aided drafting) models of a constrained elbow prosthesis were acquired. These CAD models were developed and their elastic properties, resistance, and stresses were studied through finite element analysis (finite element method—FEM). The obtained 3D elbow-prosthesis model was then evaluated in cyclic flexion–extension movements (> 10 million cycles). We highlighted the configuration of the angle at which the highest stresses and the areas most at risk of implant mobilization develop. Finally, we performed a quantitative study of the stress state after varying the positioning of the stem of the ulnar component in the sagittal plane by ± 3°.ResultsThe greatest von Mises stress state in the bone component for the 90° working configuration was 3.1635 MPa, which occurred in the most proximal portion of the humeral blade and in the proximal middle third of the shaft. At the ulnar level, peaks of 4.1763 MPa were recorded at the proximal coronoid/metaepiphysis level. The minimum elastic resistance and therefore the greatest stress states were recorded in the bone region at the apex of the ulnar stem (0.001967 MPa). The results of the analysis for the working configurations at 0° and 145° showed significant reductions in the stress states for both prosthetic components; similarly, varying the positioning of the ulnar component at 90° (− 3° in the sagittal plane, 0° in the frontal plane) resulted in better working conditions with a greater resulting developed force and a lower stress peak in the ulnar cement.ConclusionThe areas of greatest stress occur in specific regions of the ulnar and humeral components at the bone–cement–prosthesis interface. The heaviest configuration in terms of stresses was when the elbow was flexed at 90°. Variations in the positioning in the sagittal plane can mechanically affect the movement, possibly resulting in longer survival of the implant.Level of evidence: 5

A case of metallosis mimicking cutaneous malignant melanoma following total elbow arthroplasty

AbstractMetallosis manifests as an abnormal dark macroscopic staining of periprosthetic tissues by metallic particles from the prosthesis. This complication is uncommon in non‐weight‐bearing joints such as the elbow. We describe a rare case of metallosis mimicking cutaneous malignant melanoma following total elbow arthroplasty (TEA). A 77‐year‐old Japanese woman presented to our clinic with a black nodule within a blue‐greyish pigmentation on the left elbow. She had undergone a left TEA 8 years before presentation. X‐ray showed an amorphous increased density shadow accompanied by high‐density substances in the periprosthetic tissues, consistent with the features of metallosis. Surgical debridement and prosthetic removal were performed. Histopathological examination of the pigmented skin around the nodule revealed a dense infiltration of histiocytes with brownish to blackish granular particles in the dermis. The black‐stained periprosthetic tissues exhibited many multinucleated giant cells and histiocytes with similar particles. Additionally, analysis of the paraffin sections containing particles and the scanning electron microscope‐energy dispersive X‐ray spectroscopy (SEM‐EDX) revealed that the metal was composed of titanium and aluminium, which were components of the prosthesis. At the patient's first visit to our clinic, cutaneous malignant melanoma was considered as a possible differential diagnosis based on the clinical appearance. To the best of our knowledge, previous cases of metallosis with this clinical presentation have not been reported.

ELBOW OSTEOARTHRITIS: PATHOGENESIS, CLINICAL PRESENTATION, WORK-UP

ABSTRACT Degenerative joint disease of the elbow, although much rarer than in lower limbs, affecting about 2% of population, may be the result of primary and secondary etiologies and may significantly affect the quality of life, leading to pain, loss of motion and functional disability. A detailed medical history combined with physical examination and imaging modalities can help to locate the source of symptoms and choose the appropriate treatment. Nonoperative management is the initial therapy for elbow arthritis and is limited to relief of pain by rest, activity modification, analgesics and nonsteroid anti-inflammatory medications. When conservative management fails, surgical treatment should be used according to the patient’s expectations, age, severity and etiology of elbow arthritis. Patients with posttraumatic and primary elbow osteoarthritis in mild and moderate stage of disease may be treated by arthroscopic osteocapsular arthroplasty which consist of soft tissue and bony debridement, osteophytes and loose bodies removal, synovectomy, capsular release and bony contouring of humerus and ulnae. Total elbow arthroplasty is dedicated to low-demand, elderly patients with rheumatoid, inflammatory, posttraumatic or primary elbow osteoarthritis in severe stage. For younger, high-demand patients with severe osteoarthritis of the elbow which affects the majority of the ulnohumeral articular surface a good option for surgical treatment is interposition arthroplasty with/using auto or allografts.

Olecranon Tendo-Osseous Allograft Reconstruction for Complex Extensor Mechanism and Bone Loss at the Elbow

The purpose of this study was to present the results of olecranon tendo-osseous allograft (OTOA) reconstruction for patients with an irreparable extensor mechanism from prior trauma or failed total elbow arthroplasty (TEA). A retrospective review was performed of all patients with extensor mechanism loss after trauma or failed TEA who were treated with an OTOA to supplement fracture fixation or elbow arthroplasty, as indicated. Primary outcome measures were successful healing of the allograft, restoration of the extensor mechanism function, and Mayo Elbow Performance Scores (MEPS) at the most recent follow-up. Secondary outcomes included patients' active range of motion and unplanned operative interventions. Nine patients had extensor mechanism and proximal ulna loss as a result of prior TEA, acute trauma, or failed surgeries for prior trauma. All but one had undergone multiple prior surgeries. The mean follow-up was 27 months (6-60 months). At the final follow-up, patients reported MEPS of 92 (80-100). All patients regained active triceps extension (strength 3-5/5). Mean final range of motion was 16° (0° to 45°) extension, 124° (70° to 150°) flexion, 56° (45° to 80°) pronation, and 60° (40° to 80°) supination. Eight (89%) of the nine patients had a radiographically healed graft at the latest follow-up, of which four healed without notable complications or further surgical intervention. Complications included radial/ulnar nerve palsy, allograft olecranon stress fracture, deep infection, wound complications, instability, and complications related to the TEA prosthesis. In the setting of elbow reconstruction in which there is inadequate triceps tendon and/or olecranon bone stock to perform internal fixation and/or revision arthroplasty, OTOA may supplement elbow reconstruction, albeit with high rates of complications. A triceps-olecranon allograft, combined with either internal fixation or TEA, is a potentially useful salvage procedure for managing bone loss and an irreparable extensor mechanism deficit at the elbow. Therapeutic V.