Total elbow arthroplasty in rheumatoid arthritis: A population-based study from the Finnish Arthroplasty Register

Background and purpose Although total elbow arthroplasty (TEA) is a recognized procedure for the treatment of the painful arthritic elbow, the choice of implant is still obscure. We evaluated the survival of different TEA designs and factors associated with survival using data from a nationwide arthroplasty register.Methods 1,457 primary TEAs for rheumatoid elbow destruction were performed during 1982 to 2006 in one hospital specialized in the treatment of rheumatoid arthritis (n = 776) and in 19 other hospitals (n = 681). The mean age of the patients was 59 years and 87% of the TEAs were performed in women. We selected different contemporary TEA designs, each used in more than 40 operations including the Souter-Strathclyde (n = 912), i.B.P./Kudo (n = 218), Coonrad-Morrey (n = 164), and NESimplavit/Norway (n = 63) to assess their individual survival rates. Kaplan-Meier analysis and the Cox regression model were used for survival analysis.Results The most frequent reason for revision was aseptic loosening (47%). We found no differences in survival rates between different TEA designs. We did, however, find a 1.5-fold (95% CI: 1.1–2.1) elevated risk of revision in unspecialized hospitals as compared to the one hospital specialized in treatment of rheumatoid arthritis. In the Souter-Strathclyde subgroup, there was a reduced risk of revision (RR 0.6, p = 0.001) in TEAs implanted over 1994–2006 as compared to those implanted earlier (1982–1993). The 10-year survivorship for the whole TEA cohort was 83% (95% CI: 81–86), which agrees with earlier reports.Interpretation The influence of implant choice on the survival of TEA is minor compared to hip and knee arthroplasties. Inferior survival rates of the TEAs performed in the unspecialized hospitals demonstrates the importance of proper indications, surgical technique, and postoperative follow-up, and endorses the need for centralization of these operations at specialized units.     

Total elbow arthroplasty in rheumatoid arthritis

Background and purpose Although total elbow arthroplasty (TEA) is a recognized procedure for the treatment of the painful arthritic elbow, the choice of implant is still obscure. We evaluated the survival of different TEA designs and factors associated with survival using data from a nationwide arthroplasty register.

Methods 1,457 primary TEAs for rheumatoid elbow destruction were performed during 1982 to 2006 in one hospital specialized in the treatment of rheumatoid arthritis (n = 776) and in 19 other hospitals (n = 681). The mean age of the patients was 59 years and 87% of the TEAs were performed in women. We selected different contemporary TEA designs, each used in more than 40 operations including the Souter-Strathclyde (n = 912), i.B.P./Kudo (n = 218), Coonrad-Morrey (n = 164), and NESimplavit/Norway (n = 63) to assess their individual survival rates. Kaplan-Meier analysis and the Cox regression model were used for survival analysis.

Results The most frequent reason for revision was aseptic loosening (47%). We found no differences in survival rates between different TEA designs. We did, however, find a 1.5-fold (95% CI: 1.1–2.1) elevated risk of revision in unspecialized hospitals as compared to the one hospital specialized in treatment of rheumatoid arthritis. In the Souter-Strathclyde subgroup, there was a reduced risk of revision (RR 0.6, p = 0.001) in TEAs implanted over 1994–2006 as compared to those implanted earlier (1982–1993). The 10-year survivorship for the whole TEA cohort was 83% (95% CI: 81–86), which agrees with earlier reports.

Interpretation The influence of implant choice on the survival of TEA is minor compared to hip and knee arthroplasties. Inferior survival rates of the TEAs performed in the unspecialized hospitals demonstrates the importance of proper indications, surgical technique, and postoperative follow-up, and endorses the need for centralization of these operations at specialized units.     

Results of total elbow arthroplasty as a salvage procedure for failed elbow reconstructive operations

Total elbow arthroplasty (TEA) was used as a salvage procedure following failed open reduction and internation fixation, failed triaxial arthroplasties, and septic and aseptic loosening of implant arthroplasty. A minimally constrained bicondylar implant with a block to disarticulation was substituted for the reconstruction of 20 revision TEAs. Custom-designed implant TEA was substituted in cases with substantial bony or soft tissue loss. Revision of the polyethylene-bearing component, coupled with the addition of a yolk-type locking mechanism, was implanted when only the bearing system of a well-fixed implant had failed. TEA can be performed successfully with satisfactory durability as a revision procedure. Revision of failed open reduction internal fixation or a failed bearing system was highly successful. Revision of previously infected elbows in a single-stage procedure was unsuccessful in two of three cases and has been abandoned in favor of a staged procedure. A revision of loose TEA was successful in only three of five cases. Further investigations are necessary to improve the function durability of TEA.     

Treatment trends in distal humerus fractures between ABOS part II candidates

PurposeThe purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF).MethodsThe American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications.ResultsThere were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%).ConclusionOur data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF.Level of EvidenceIII.     

Elbow arthroplasty using a convertible implant

Total elbow arthroplasty remains the most definitive functional procedure for patients with end-stage painful arthritis of the elbow. Complication rates have historically been quite high, and early revision was not uncommon. A greater understanding of elbow anatomy and kinematics has led to advances in prosthetic design and surgical technique. The success of modern elbow arthroplasty for low-demand patients with rheumatoid arthritis has approached that of hip and knee arthroplasty. Mechanical failures have been noted to increase as a complication of both longevity and the use of elbow arthroplasty in a younger, higher-demand patient population. As the indications for total elbow arthroplasty widen to include more complex situations, it becomes more important to precisely recreate the flexion-extension axis of the elbow to optimally balance muscle forces and ligaments in an effort to improve implant durability. Advances in implant modularity and instrumentation can make determination and recreation of the flexion-extension axis more reliable and reproducible. An anatomic convertible implant allows the surgeon great versatility in choosing to perform hemiarthroplasty or unlinked or linked total elbow arthroplasty with assurance that later revision can be performed without the compulsory removal of well-fixed components. Conversion from an unlinked to a linked constraint, and visa versa, can be performed at any time. If late conversion is required, it can be performed in a minimally invasive fashion.     

Bicruciate-retaining total knee arthroplasty: What’s new?

Primary total knee arthroplasty(TKA) is a widespread procedure to address end stage osteoarthritis with good results, clinical outcomes, and long-term survivorship. Although it is frequently performed in elderly, an increased demand in young and active people is expected in the next years. However, a considerable dissatisfaction rate has been reported by highly demanding patients due to the intrinsic limitations provided by the TKA. Bicruciate-retaining(BCR) TKA was developed to mimic knee biomechanics, through anterior cruciate ligament preservation. First-generation BCR TKA has not gained popularity due to its being a challenging technique and having poor survival outcomes. Thanks to implant design improvement and surgeon-friendly instrumentation, secondgeneration BCR TKA has seen renewed interest. This review will focus on surgical indications, kinematical basis, clinical results and latest developments of secondgeneration BCR TKA.     

Direct surgery on the aorto-iliac area. Prostheses--endarterectomy?

Of the 365 surgical techniques performed on the aorto-iliac area in 354 patients, 448 extremities were revascularized by means of the insertion of a prosthesis as a by-pass, and 165 by thromboendarterectomy (TEA), either global or ilio-femoral. The patency rate at five years was 83% for prostheses, and 72% for TEAs, studied as a whole, or 75% for global TEAs, and 60% for ilio-femoral, once they had been individually analysed. The analysis of these results proves that the patency of the ravascularized aorto-iliac area depends more on the associated pathology in the femoro-popliteal distal area, than on the surgical technique that has been applied. There are no significant differences in relation to the early patency or mortality between the three groups, although as regards age, younger patients with fewer risk factors were selected for global TEA operations.     

Survivorship and clinical outcomes of total elbow arthroplasty using the Zimmer Nexel Elbow system

BackgroundTotal elbow arthroplasty (TEA) is a treatment option for patients with rheumatoid arthritis, post-traumatic arthritis, or distal humerus fracture. The objective of this study was to evaluate the clinical, functional, and radiographic outcomes of the semiconstrained Nexel Total Elbow (Nexel) at a single center.MethodsThis is a retrospective case series of consecutive Nexel TEA procedures at a single center between 2014 and 2019. Of the 21 TEAs, 18 were alive and asked to return to the clinic to complete a physical exam, radiographs, the Mayo Elbow Performance Score, Quick Disabilities of the Arm, Shoulder, and Hand, and EuroQol 5D. Patients who could not return in person were offered a remote participation option. Outcomes included the following: implant survival, surgical complications, reoperation for any reason, radiographic assessment to identify loosening and bushing wear, and mean scores on patient-reported outcomes.ResultsThere were 11 TEA procedures who responded (61%), with eight returning to the clinic and three remote participants. The mean follow-up was 53.3 months (28-89 months). None of the TEAs were revised or reoperated on for any reason; the survival rate was 100%. One TEA (13%) had radiographic evidence of loosening, limited to the humeral component. There was no evidence of bushing wear. One TEA experienced ulnar nerve neuropraxia postoperatively, without permanent dysfunction (13%). The majority of patients reported satisfactory outcomes as measured by the Mayo Elbow Performance Score (73%), with a mean score of 90 (standard deviation [sd] = 13). On average, patients reported minimal disability on the Quick Disabilities of the Arm, Shoulder, and Hand (mean = 29, sd = 23) and relatively high health-related quality of life (EuroQol 5D, mean = 0.83, sd = 0.08).ConclusionsClinical and radiographic results of the Nexel TEA, a semiconstrained implant, were favorable. In contrast to the high complication rate and concerning radiographic findings reported previously, the current study reports 100% implant survival, with revision or indication for revision as the endpoint, and low rates of complications with an average of 53 months of follow-up. Bushing wear was not identified as a problem in this series; however, loosening of the humeral component may emerge as an indication for revision. More studies on the Nexel TEA are needed to better understand clinical and radiographic outcomes.     

Sustained functionality and survivorship of the Coonrad-Morrey linked elbow prosthesis is replicated by an Asian institution with evolving indications over 18 years

BackgroundThe purpose of this study is to assess the changing indications, survivorship, and functional outcomes of patients who underwent a semi-constrained total elbow arthroplasty (TEA) of a homogenous design at an Asian institution.MethodsRetrospective analysis of 47 patients (47 elbows) who underwent TEA from January 1998 to December 2016 was performed. Demographic data, baseline comorbidities as defined by the Charlson Comorbidity Index, indication for surgery, preoperative and postoperative range of motion, radiographic analysis, complications, and need for revisions were collected. Kaplan-Meier survivorship analysis was performed.ResultsOf the 47 patients, none were lost to follow-up. The mean duration of follow-up was 127 months. There was a total of 13 male patients and 34 female patients with a mean age at the time of implantation of 65.4 years (range 24-92). The final arc of motion had a mean flexion of 115.8° and a mean extension of 14.8°. The functional range of motion of the elbow improved from 58.8° ± 38.2° preoperatively to 106.6° ± 20.3° postoperative (P < .001). From 1998 to 2004, 39.1% of TEAs were associated with trauma and another 39.1% with rheumatoid arthritis. From 2010 to 2016, 66.7% of TEAs were performed for trauma and only 20% were performed for rheumatoid arthritis. All our patients had either the extra small or the small-sized Coonrad-Morrey TEA prosthesis implanted with 21.1% of patients with the ulna stem ending before the proximal ulna dorsal angulation. There was a total of 11 complications with revision surgery required for 2 periprosthetic fractures, 1 humeral loosening, and 1 linkage disassembly. The overall survivorship for TEA at our institution was 91.5%.ConclusionOur results reflect that good outcomes and robust survivorship to that experienced in the United States are demonstrated despite the changing indications of TEA. Current trends of usage demand continued development of linked elbow prosthesis with smaller sizing options.     

Placement of the stemless humeral component in the Total Evolutive Shoulder System (TESS)

Humeral implant design in shoulder arthroplasty has evolved over the years. The third generation shoulder prostheses have an anatomic humeral stem that replicates the 3-dimensional parameters of the proximal humerus. The overall complication rate has decreased as a result of these changes in implant design. In contrast, the rate of periprosthetic humeral fractures has increased. To avoid stem-related complications while retaining the advantages of the third generation of shoulder implants, the stemless total evolutive shoulder system has been developed. The indications, the surgical technique, and the complications of this humeral implant in shoulder arthroplasty will be described.     

Total elbow arthroplasty: current indications, factors affecting outcomes, and follow-up results

Indications for total elbow arthroplasty (TEA) are expanding in light of newly published follow-up studies. The unique characteristics of the pathologic condition, appropriate patient selection, suitable choice of prosthesis, and proper surgical technique are critical factors that have a large impact on the ultimate results of TEA for any indication. This article addresses these factors as they relate to various indications and presents a review of the recently published results of the 10-year follow-up studies for TEA.     

Comparison of functional outcomes of total elbow arthroplasty vs plate fixation for distal humerus fractures in osteoporotic elbows

Treating intra-articular fractures about the osteoporotic distal humerus poses a significant challenge. The purpose of this retrospective study was to evaluate functional outcomes for distal humeral fractures treated with total elbow arthroplasty (TEA) or open reduction and internal fixation (ORIF) in a nonarthritic elderly population with osteoporosis. We reviewed the records of all women older than age 60 who had undergone surgical treatment for intraarticular distal humerus fractures (Orthopaedic Trauma Association types 13B and 13C) by 1 of 2 surgeons. Demographic and operative data were obtained, charts were reviewed, and patients were asked to have their outcomes evaluated with the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance Index (MEPI). Twenty-two patients (23 elbows) were identified, and 2 of these (3 elbows) were excluded. Of the remaining 20 patients, 9 had undergone cemented, semiconstrained TEA as initial treatment, and 11 had undergone ORIF. These 2 groups were compared. Mean follow-up was 14.8 months (range, 6-38 months). There were no significant differences between the TEA and ORIF groups with respect to demographic factors. Final elbow range of motion was 92° flexion-extension arc (arthroplasty group) and 98° (fixation group). Two patients in the arthroplasty group and 2 in the fixation group died. For the remaining patients, mean DASH scores were 30.2 (arthroplasty) and 32.1 (fixation), and mean MEPI scores were 79 (arthroplasty) and 85 (fixation). These differences were not statistically significant. Four TEAs developed radiographic loosening by a mean of 15 months, and 1 of these underwent revision with good outcome. Ten of the 11 fractures in the fixation group healed radiographically; the 1 nonunion with collapse continued to be asymptomatic. Two patients in the fixation group underwent contracture release after union for limited elbow range of motion. Many factors come into play in the treatment of intra-articular distal humerus fractures in patients with osteoporosis. Implant selection must be based on bone quality, expected outcome, and surgeon experience. For these injuries, good outcomes may be obtained with either TEA or ORIF.     

Total wrist arthroplasty: A review

Total wrist arthroplasty was first performed over a hundred years ago. However, it did not prove a viable option until the late 1960s with the advent of the Swanson implant. Since then there have been many advances. The changes in design, and their rationale, are discussed in this article. The latest implants, the advances made and the indications for surgery are addressed.     

Surgical approaches in total hip arthroplasty: a review of the mini-incision and MIS literature

Modern advances in total hip arthroplasty have included improved biomaterials, alternative bearings, so-called fourth-generation cement techniques, and enhanced in-growth prostheses. Recently, much attention has been focused on improving the surgical technique for total hip arthroplasty. This endeavor has included the development of mini-incision arthroplasty and has now progressed to minimally invasive procedures. Minimally invasive techniques are modified versions of the classic approaches to the hip, with the goal of decreasing soft tissue dissection and trauma. While these new surgical exposures may result in improved short-term outcomes, their long-term results have yet to be proven. In addition, they are technically demanding, may require specialized training, and can be associated with a difficult learning curve. Only the future will determine if mini-incision and minimally invasive arthroplasty are as successful as the well-proven standard surgical approaches used for the last three to four decades.     

Advances in ureterorenoscopy

There has been a shift toward minimally invasive surgery in all surgical subspecialties in recent decades. Ureterorenoscopy represents an area in which there have been numerous advances that have resulted in excellent patient outcomes with low morbidity. Technologic advances such as miniaturization of ureteroscopes and improved video imaging have expanded the indications for ureteroscopy. The entire upper urinary tract can now be accessed for diagnosis and treatment of many common urologic conditions. Technologic research and development will continue to drive future improvements in the technique and applications for ureteroscopy.     

La protesi d’anca: anything new?

Total hip arthroplasty has been described as “the operation of the 20th century”, thanks to the great outcomes, patient satisfaction and improvement in their quality of life. In the last years, changes have been introduced in terms of surgical indications, approaches, tissue preservation, development of different implants, preoperative management and postoperative protocols. The paper analyses different surgical approaches, in particular the anterior vs the postero-lateral approaches; it focuses on surgical indications, either in younger or in older patients, as well as on implants designs. Uncemented stems are frequently used in total hip arthroplasty; among these, short stems have gained space in the market in selected patients. They allow for preservation of the femoral neck, producing a more physiological load pattern in the proximal femur and reducing stress shielding. In short-term follow-up, most of the short stems provided survival rates similar to standard stems; however, long-term studies are not yet available. The aim of this review is to summarise the advances in hip arthroplasty, the current literature on surgical approaches, stems design, biomechanical aspects and clinical outcomes associated mostly with the length of the femoral component in primary hip replacement.

     

Linked total elbow arthroplasty

This article provides an overview of the current state of linked total elbow arthroplasty. Discussed are the general indications for using a linked implant and currently available implants. Disease-specific indications, contraindications, surgical technique, and rehabilitation are discussed. The overall results and disease-specific results, as well as complications after a linked elbow arthroplasty, are reviewed.     

Revision total hip arthroplasty: the femoral side using cemented implants

Advances in surgical technique and implant technology have improved the ten-year survival after primary total hip arthroplasty (THA). Despite this, the number of revision procedures has been increasing in recent years, a trend which is predicted to continue into the future. Revision THA is a technically demanding procedure often complicated by a loss of host bone stock which may be compounded by the need to remove primary implants. Both cemented and uncemented implant designs are commonly used in the United Kingdom for primary and revision THA and much controversy still exists as to the ideal method of stem fixation. In this article we discuss revision of the femur using cemented components during revision THA. We focus on three clinical scenarios including femoral cement-in-cement revision where the primary femoral cement-bone interface remains well fixed, femoral cement-in-cement revision for peri-prosthetic femoral fractures, and femoral impaction grafting. We discuss the clinical indications, surgical techniques and clinical outcomes for each of these procedures.     

Revisionsendoprothetik des Ellenbogens

Total elbow arthroplasty (TEA) is gaining in popularity. An elbow prosthesis is nowadays no longer regarded as a salvage procedure for low demand patients but is increasingly used in younger, active patients with higher demands. In elderly patients TEA is more and more accepted as a primary treatment method for osteoporotic complex distal humerus fractures. Nevertheless, TEA is technically demanding and associated with a higher complication and revision rate compared to e.g. hip prostheses. Increasing implantation rates in a juvenescent population will lead to a considerable increase in revision rates. Most common causes are aseptic and septic loosening as well as implant failure and instability. Cemented semi-constrained prostheses are mostly used for revision elbow arthroplasty. This article deals with the causes of revision elbow arthroplasty and describes the operative technique of revision of total elbow arthroplasty.