Total elbow replacement with the GSB III prosthesis

Fourteen consecutive elbows have been treated for rheumatoid arthritis (9 elbows) and for post-traumatic osteoarthrosis (5 elbows) by total elbow replacement with the GSB III implant. The elbows were reviewed retrospectively after a mean follow-up of 6 years (2 to 9 years). Ten of 14 elbows had a functioning GSB III implant at follow-up; 7 of them were rated satisfactory and 3 unsatisfactory with the Mayo elbow performance score. In 5 of these 10 cases, the patients had significant pain relief with no or only mild pain at follow-up, whereas 5 had moderate to severe pain. With a functioning implant the range of motion averaged 140 degrees of flexion, 19 degrees of lack of extension, 65 degrees of pronation, and 84 degrees of supination. Six (43%) elbows had major complications requiring 1 to 8 additional operations. Aseptic loosening requiring revision occurred in 4 (29%) elbows. Two of them were treated by a resection arthroplasty, and 2 were revised with another hinged semiconstrained device. Three further elbows had radiolucent lines involving more than 50% of the cement-bone interface of either the humeral or the ulnar component. However, in 8 elbows the cementing technique was considered marginal or inadequate. Poor cementing (marginal or inadequate) was associated with loosening (P = .008). The GSB III total elbow prosthesis can restore function and reduce pain. The rate of aseptic loosening in this series was higher than previously reported. Based on this observation, we conclude that the GSB III implant seems to be sensitive to the insertion technique and does not tolerate suboptimal cementing.     

Arthroplasty of the elbow. Experience with the Mark III GSB prosthesis

Forty-five total elbow replacements using the Mark III GSB prosthesis are reviewed. Average follow-up was 2.7 years. The overall results were good in 87% of cases, fair in 9%, and poor in 4%. Excluding the two poor results, which required prosthesis removal, 96% of cases had no significant pain. The flexion/extension are improved 24 degrees and the supination/pronation arc improved 22 degrees. No prosthesis was loose and only one had a significant radiolucent line. The overall complication rate was 25%. Disassembling of the two components, due to inadequate ligament tension, was the most frequent complication and this occurred in four elbows.     

Long-term survival of GSB III elbow prostheses and risk factors for revisions

Introduction

Although replacement of the elbow joint is a complex procedure there is not much clinical evidence that contributes to surgical decision-making, mainly due to small clinical samples and short follow-up. Therefore, we performed a long-term analysis up to 30 years after implantation of a GSB III total elbow prosthesis to quantify long-term outcome and to identify possible risk factors for implant revision.

Materials and methods

All patients who received a primary GSB III total elbow prosthesis between 1978 and 1998 were included. Information about patient characteristics, the latest known implant status and possible risk factors were collected, Kaplan–Meier survival curves plotted, and 10- and 20-year survival calculated. The cohort was stratified for known risk factors such as diagnosis, age, or gender and included in a Cox regression analysis.

Results

A total of 253 patients [mean age at operation 56.9 years (range from 17.5 to 84 years)] with 293 GSB III prostheses were included. The median follow-up was 9.1 years (0 months to 29.3 years). Whereas 81 prostheses did not need revision during the observation period, 76 had been implanted in patients who died before any revision was required, and 75 had not been revised by the last known follow-up. 61 prostheses were revised. This corresponds to a 10-year survival rate of 0.8 (95 % CI 0.74–0.85) and a 20-year rate of 0.67 (95 % CI 0.57–0.76). Prostheses in patients with post-traumatic conditions survived significantly shorter than those in patients with rheumatoid arthritis; previous operations lead to a 2.8 times greater risk of revision (p = 0.004). Neither age at implantation nor gender had a significant influence on prosthesis survival.

Conclusions

The results indicate a good long-term prognosis for this design. The prognosis has to be adjusted for the underlying disease. Previous operations such as joint reconstruction significantly increase the risk of revision.     

The GSB III elbow prosthesis in rheumatoid arthritis: a 2- to 9-year follow-up

BACKGROUND: The optimal design of an elbow prosthesis for badly damaged elbows is unkown. We evaluated 23 GSB III semi-constrained (sloppy-hinged) total elbow arthroplasties in 16 consecutive patients with rheumatoid arthritis. PATIENTS AND METHODS: After a mean follow-up period of 5 (2-9) years, we assessed quality of the cementing technique, signs of aseptic loosening, patient satisfaction, range of movement, and determined the Hospital for Special Surgery (HSS) elbow score. 3 patients had died before follow-up; thus, 20 replacements in 16 patients were available for clinical and radiographic study. All patients had endstage rheumatoid arthritis (RA) of the elbow joint. RESULTS: In 2 patients, humeral components were revised due to malorientation. 1 arthroplasty was revised due to aseptic loosening of the humeral component. There were 4 cases of intraoperative fracture which healed uneventfully. The total rate of complications was thus one-third. In 17 of 40 components, the cementing technique was rated as marginal or inadequate. We found no association between cementing technique and loosening. The arc of extension/flexion increased by 19 degrees (0-80), and the range of pronation/supination increased by 31 degrees (0-130). There were no cases of infection or ulnar nerve dysfunction. At the latest follow-up, the HSS elbow score was 84 (40-100) points. 11 of 20 elbows were rated as excellent, 4 elbows were rated as good, 2 elbows were rated as fair, and 3 elbows were rated as poor. 14 of 16 patients were satisfied with the result and the 2 patients who were not satisfied had persistent pain. INTERPRETATION: Despite the inherent problems of cementing in small-calibre medullary cavities, the clinical outcome of the GSB III arthroplasty was encouraging for patients with-end stage RA. The rate of overall complications compared favorably with other studies of semiconstrained elbow arthroplasty for end-stage RA. Most complications of the series were minor and did not necessitate revision.     

Long-term results of the GSB III elbow arthroplasty

Between 1978 and 1986, 59 patients received a GSB III elbow prosthesis, six of them in both elbows. Rheumatoid arthritis (RA) was the underlying cause in 51 of the patients and post-traumatic osteoarthritis (PTOA) in eight. Of these, 24 patients (28 prostheses) have since died; two, both operated on bilaterally, had had their implants for more than ten years and had already been assessed for inclusion in the long-term follow-up. Two patients, each with one elbow prosthesis, have been lost to follow-up and three males who are still living (two with PTOA, one with juvenile RA) had their prosthesis removed before ten years had elapsed. The remaining 32 patients (28 RA, 4 PTOA) with 36 GSB III elbows were examined clinically and radiologically after a mean period of 13.5 years. Pain was considerably reduced in 91.6%. Mobility was increased by 37 degrees in those with RA and by 67 degrees in those with PTOA. There were three cases of aseptic loosening and three of deep infection. The main complication was disassembly of the prosthetic component in nine elbows (13.8%). This last group included two patients with postoperative fractures unrelated to the operative technique and one with neuropathic arthritis. Ulnar neuritis occurred in two patients. Since 87.7% of all the GSB III prostheses implanted in this period remained in situ, our results are comparable with those for hip and knee arthroplasty.     

Semiconstrained primary and revision total elbow arthroplasty with use of the Coonrad-Morrey prosthesis

BACKGROUND: Semiconstrained total elbow prostheses are used routinely by many surgeons to treat a variety of severe elbow disorders. Our objective was to review the results of primary and revision total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. The selected use of this semiconstrained implant in patients with instability and poor bone stock was hypothesized to provide inferior results compared with those in the published reports. METHODS: The results of sixty-seven semiconstrained total elbow arthroplasties that were performed in fifty-six patients between 1990 and 2003 were evaluated. Thirty-seven elbows had a primary arthroplasty and were followed for a mean of eighty-six months, and thirty elbows had a revision arthroplasty and were followed for a mean of sixty-eight months. Mayo elbow performance scores and radiographic analyses were used to assess the clinical results. RESULTS: In the primary arthroplasty group, the average flexion improved from 116 degrees to 135 degrees; average extension, from -40 degrees to -33 degrees; average pronation, from 60 degrees to 81 degrees; and average supination, from 60 degrees to 69 degrees. The improvements in flexion and pronation were significant (p<0.001 for both). Preoperatively, twenty-five (74%) of thirty-four elbows with data available had moderate or severe pain, whereas only four (11%) had pain postoperatively. The average postoperative Mayo score (and standard deviation) was 84+/-16. Eleven of the thirty-seven primary replacements failed, and the five-year survival rate was 72%. In the revision arthroplasty group, average flexion improved from 124 degrees to 131 degrees; average extension, from -32 degrees to -22 degrees; average pronation, from 66 degrees to 75 degrees; and average supination, from 64 degrees to 76 degrees; the improvement in supination was significant (p<0.05). Preoperatively, eighteen (64%) of the twenty-eight elbows with data available had moderate or severe pain, while only five (17%) had pain postoperatively. The average postoperative Mayo score was 85+/-16. Eleven of the thirty revision replacements failed, and the five-year survival rate was 64%. CONCLUSIONS: A Coonrad-Morrey semiconstrained total elbow arthroplasty provides excellent pain relief and good functional return in patients with severe destructive arthropathy. The higher prevalence of failure in this cohort compared with series reported elsewhere is likely due to adverse patient selection as this implant was reserved for more complex arthroplasties with severe bone loss and ligamentous laxity.     

GSB III total elbow replacement in rheumatoid arthritis

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

Five- to thirteen-year follow-up of the GSB III total elbow arthroplasty

Between 1988 and 1995, the senior author performed total elbow arthroplasty in 28 elbows (23 patients) with the GSB III prosthesis. At the most recent follow-up, 7 patients had died (9 elbows) and 1 had the implant removed because of a deep infection. The remaining 18 elbows (15 patients) were available for clinical and radiographic review at a mean period of 7.6 years (range, 5.5-11.9 years). All 15 patients were satisfied with the results of their elbow replacement, with a mean Mayo elbow performance score of 91 (range, 75-100). The mean flexion/extension and supination/pronation arcs improved by 33 degrees and 67 degrees, respectively. Radiographic follow-up demonstrated progressive loosening in only 1 patient and no progressive loosening in those with an adequate cement technique. Mild or moderate lysis of the distal humeral or proximal ulnar components was noted in 10 elbows, and severe lysis of the distal humerus was seen in 1. Of the patients, 6 (21%) had mild complications: triceps avulsions in 3, superficial wound infections in 2, and an undisplaced fracture of the distal humeral medial condyle in 1. In 4 patients (14%) complications developed requiring reoperation, including exchange of the polyethylene bushing because of wear, debridement of synovitis, resection arthroplasty for deep infection, and exploration of an ulnar nerve palsy. In 2 additional patients (7%), persistent ulnar nerve paresthesias developed postoperatively. Of the 28 elbow replacements performed with the GSB III prosthesis, only 1 required revision because of loosening at a mean follow-up of 7.6 years. The results of this series of GSB III elbow replacements in patients with rheumatoid arthritis demonstrate reasonable survivorship of this prosthesis.     

Experience with the cementless hip prosthesis, with special reference to the implantation of prosthesis stems

Authors report on their experiences gained during 7 years with 102 PM (Aesculap) and 76 Etropal cementless hip endoprosthesis and with the implantation without sticking of 264 standard prosthesis stems. They explain their results with bone rebuilding that can be certified also by Roentgenograms. The lack of success in a few per cent of the cases can be explained mainly by technical insufficience.     

Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow.

Fifty-four patients in whom a total of fifty-eight semiconstrained modified Coonrad elbow implants had been inserted for rheumatoid arthritis were followed for a mean of 3.8 years (range, two to eight years). At the latest follow-up, there was little or no pain in fifty-three elbows (91 per cent). The arc of motion was from an average point in flexion of 20 degrees to an average point in flexion of 129 degrees, representing an average increase of 12 degrees of extension and 11 degrees of flexion. The average arc of pronation was 78 degrees, an increase of 14 degrees, and the average arc of supination was 77 degrees, an increase of 18 degrees. An additional ten patients who had had insertion of ten modified Coonrad implants during the same period were followed for less than two years but were included in the assessment of complications. Fifteen (22 per cent) of the sixty-eight elbows had a complication: four, infection; eight, acute or delayed condylar or ulnar fracture; and one each, ulnar neuritis, avulsion of the triceps, and fracture of the implant. Radiographic evaluation was performed for fifty-four of the fifty-eight elbows; the other four were excluded from this evaluation because of infection. A satisfactory radiographic appearance of the cement--its extent and the absence of skip areas--was noted for all of the ulnar components and for fifty-one (94 per cent) of the humeral components. No patient had radiographic evidence of a loose implant. A reoperation was performed in six elbows (10 per cent of the fifty-eight; 9 per cent of the sixty-eight): four were done for infection; one, for insufficiency of the triceps; and one, for a fractured ulnar component. Of the fifty-eight elbows, forty (69 per cent) had an excellent result; thirteen (22 per cent), a good result; four (7 per cent), a fair result; and one, a poor result.     

Semiconstrained total elbow arthroplasty for severe post traumatic ankylosis of the elbow: a case-report

Post traumatic stiffness in young subjects has been long considered a bad indication for total elbow arthroplasty. We present the case of a 48 year old woman with an elbow fracture, operated in childhood who developed progressive painful stiffness. After treatment with a cemented semi constrained Coonrad-Morrey total arthroplasty, we have obtained a good result at over 4 years follow-up. The gain of ROM is 40 degrees, the analogue scale for pain is 2.5/10 and the Mayo Clinic Performance Index for the Elbow is 80/100. The subjective impression is excellent and there were no complications.     

Semiconstrained total elbow arthroplasty in the context of treated previous infection.

Previous infection has been considered a strict contraindication to implantation or reimplantation of an elbow prosthesis. The purpose of this study was to investigate whether these patients can in fact be successfully treated with a prosthetic arthroplasty given previous treatment of the infection. Ten consecutive prosthetic arthroplasties performed in patients with documented infections in the elbow were retrospectively reviewed. Seven of the patients had infectious complications of total elbow arthroplasties that led to resection. Two patients had previous infections from septic joints and 1 from open reduction internal fixation. The median interval of time from infection treatment to final implant was 45 months (3.8 years). All arthroplasties were performed by the same surgeon with a modified Coonrad-Morrey, semiconstrained prosthesis. Patients were monitored for clinical signs of infection including radiographic and serologic studies and clinical evaluation based on the Mayo Elbow Performance Score. Mean surveillance was 4 years (range 2.8 to 5.4 years). Eight of the 10 cases have not shown signs of infection at the latest assessment. Two have had recurrent infections. The time interval from the original infection to latest implantation did not correlate with infection recurrence. Among those 8 without recurrent infection, 7 had excellent and 1 had satisfactory results according to the Mayo Elbow Performance Score. The recurrent infections were rated as failures. The average score was 32 before and 81 after surgery. The average pain score was 15 before surgery, and the average postoperative pain score was 40. Salvage of previously infected elbows with prosthetic arthroplasty can provide excellent results in a significant proportion of patients. Although the procedure offers superior functional outcomes compared with the alternative treatment options, it is technically demanding.     

An anatomic investigation of the elbow joint, with special reference to aging of the articular cartilage

The architecture of the articular surface of the elbow joint and the location of cartilage degeneration with aging was analyzed. The study included 131 elbow joints of 66 cadavers preserved by embalming. The age of subjects at death ranged from 49 to 96 years (mean 79 years). The elbow joint was observed macroscopically and analyzed. The degenerative changes in the radiohumeral joint were always more advanced than those in the humeroulnar joint. The erosion or chondral defect in the capitulum is located in the area 45° anterior to the long axis of the humerus. The anterior part of the erosion in the crest separating the trochlea from the capitulum was roughly 48.5° to the long axis of the humerus. It was similar in position to the erosion found in the capitulum. Based on the degree and area of cartilage degeneration, the changes in the radial head could be divided into four types. The mode of radial head cartilage degeneration correlated well with cartilage degeneration in the radiohumeral articulation and also with osteoarthritis of the elbow joint. Simplistically, one could classify elbow joint osteoarthritis by knowing the extent of radial head degeneration.     

Total elbow arthroplasty with the Kudo prosthesis

Between 1990 and 1997 we undertook 57 Kudo type-4 total elbow replacements in 45 patients with rheumatoid arthritis. A total of 34 patients (44 elbows) were evaluated at an average of 7 (4.4–11.2) years using the Mayo Clinic Performance Index. At review 29 elbows were excellent or good and four were fair or poor. The main complications were intraoperative fractures and ulnar neuropathy. No luxations were seen. Loosening of the ulnar component and breakage of the humeral component were most frequent indications for revision. Preoperative radiographic joint destruction was not correlated with revision rate.

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Résumé Entre 1990 et 1997 nous avons réalisés 57 prothèses totales du coude Kudo type-4 chez 45 malades atteints de polyarthrite rhumatoïde. Un total de 34 malades (44 coudes) a été évalué à une moyenne de 7 ans (4.4–11.2) en utilisant l'index de performance de la Mayo Clinique. À la révision 29 coudes étaient excellents ou bons et quatre étaient médiocres ou mauvais . Les principales complications étaient les fractures opératoires et les neuropathies ulnaires. Il n'y a eu aucune luxation. Le descellement du composant ulnaire et la rupture du composant huméral étaient les indications les plus fréquentes de révision. La destruction radiographique pré-opératoire de l'articulation n'avait pas de correspondance avec le taux de révision.

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铰链-非铰链联合型人工全肘关节置换术短期随访结果分析

目的通过对11例行铰链-非铰链联合型人工全肘关节置换术患者随访结果的分析，观察其临床疗效。方法对香港玛丽医院骨科2002年3月至2004年6月间，行Acclaim人工全肘关节置换术的11例患者进行定期随访，评定肘关节手术前后疼痛情况、活动度、稳定性及X线表现，使用SPSS统计软件（version 11．0）应用配对t检验，对7例术前没有合并骨折患者的术前，术后关节活动度进行统计分析。结果所有患者肘关节最后随访时均无疼痛；术后亦未出现肘关节不稳的现象；肘关节活动度除伸直较术前降低了以外，屈曲、前臂旋后及屈伸弧度、前臂旋转弧度皆有明显改善（P〈0．05），但前臂旋前角度术前术后对比无显著性差异（P=0．088）；X线片仅1例于尺骨部分出现部分的透亮线；1例术后出现尺神经麻痹症状，但在出院前已恢复；2例术后因外伤出现肱骨内上髁骨折。结论 Acclaim人工全肘关节置换术的短期临床结果满意，长期疗效有待于进一步随访观察。     

Clinicopathological status and treatment of acromioclavicular dislocation with special reference to Tossy's grade III

Seventy patients classified as Tossy's Grade III acromioclavicular dislocation were studied clinically and radiographically, and treated conservatively. Twenty acromioclavicular joints from 11 cadavers were dissected for a detailed anatomical evaluation of acromioclavicular joints. Anatomical findings showed that the conoid ligament played an important role for the fixation of the clavicular end to the acromion. Patients with dislocation classified as Tossy's Grade III were divided into two subtypes, A and B, according to the distance between the clavicle and acromion on the radiograph. Arthorography was performed on 22 patients. The arthograms were classified into three types, I, II and III, depending on the leak spread and flow of the contrast medium around the acromioclavicular joints. Types I and II arthorograms were seen in all cases classified as Type A on X-rays, most of the Type III arthorograms were seen in cases classified as Type B. Favorable results were obtained in eighty-six per cent of Type A cases. Fair to poor results, however, were achieved in 60% of type B cases. From the result of this study, the author concludes that Tossy's Grade III, complete dislocation, should be classified into two subtypes and surgical treatment should be considered for Type B or complete dislocation.