Postoperative results and complications of total elbow arthroplasty in patients with rheumatoid arthritis: three types of nonconstrained arthroplasty

Postoperative results and complications of total elbow arthroplasty (TEA) conducted for rheumatoid arthritis (RA) patients at our institute were studied. Primary TEAs were performed in 72 patients. The mean follow-up period was 3.5 years. Three types of prostheses were implanted: JACE prosthesis in 34 elbows, STABLE prosthesis in 13 elbows, and KUDO prosthesis (type 5) in 32 elbows. The outcome was evaluated by the change in the range of motion and the Japanese Orthopaedic Association functional evaluation score for the elbow joint (JOA score). The arc of motion and the JOA score at discharge and at final examination significantly improved in patients with the three types of prosthesis. The loosening rates for the JACE, STABLE and KUDO prostheses were 15, 23, and 0%, respectively, although the follow-up periods were different. The loosening rate decreased to 2.5% when the humeral component was fixed with cement. Intraoperative fractures occurred in eight (10.1%) elbows and ulnar nerve palsy in six. Deep infection developed in three (4.8%) elbows and was treated by removing the prosthesis. Although there were considerable complications, the marked improvements in pain and function favor TEA in patients with rheumatoid elbow.     

Clinical and radiological results of GSB III total elbow arthroplasty in patients with rheumatoid arthritis

Total elbow arthroplasty (TEA) with the GSB III prosthesis was performed in 32 patients (36 elbows) with rheumatoid arthritis between 2001 and 2009. At final follow-up, 31 patients (35 TEAs) were available for clinical and radiological evaluation. The mean follow-up period was 6.3 (2.0–10.3) years, with a minimum follow-up of 2 years. The mean Mayo elbow performance score was significantly improved from 48 points preoperatively to 83 points at final follow-up. The radiographic loosening rate was 14.3% for humeral components and 5.7% for ulnar components. There were 4 cases of intraoperative fracture and 1 case of humeral shaft fracture at 4 months after surgery. The rates for loosening and fracture were relatively low when compared with those in other studies of linked TEA. There were 2 cases of ulnar nerve palsy, but there was no deep infection or triceps disruption. The clinical results of TEA using the GSB III prosthesis in patients with rheumatoid arthritis were found to be satisfactory.     

Outcome of shortened extra-small ulnar component in linked total elbow arthroplasty for patients with rheumatoid arthritis*

Objective. We compared the clinical and radiological results of the 3-inch shortened ulnar stem of the extra-small component of Coonrad–Morrey prosthesis with those of the other ulnar components for patients with rheumatoid arthritis (RA).

Methods. A total of 33 Coonrad–Morrey total elbow arthroplasty (TEA) procedures were performed. Of these, 27 elbows of 25 patients with RA underwent primary TEA. The results of the clinical and radiological findings were compared between groups of patients receiving the shortened ulnar stem of extra-small components (shortened group) and of those receiving the components of the other sizes (control group).

Results. The mean follow-up was 6.2 ± 2.8 years in the shortened group and 7.2 ± 2.5 years in the control group. The Mayo elbow performance score and range of motion results were substantially improved after the operation for both groups. We encountered several peri- and postoperative complications, but no significant differences in clinical results were found between the groups. The control group had three cases of osteolysis around the implant, while the shortened group did not.

Conclusions. TEA with a shortened ulnar implant of the extra-small size of the Coonrad–Morrey prosthesis gave satisfactory mid-term results among patients with RA.     

Outcomes in total elbow arthroplasty in patients with haemophilia at the University of California,San Francisco: a retrospective review

Summary. Severe haemophilic arthropathy of the elbow is a significant cause of morbidity among adults with haemophilia. However, previous reports of total elbow arthroplasty (TEA) in the haemophilic population have been based on small numbers of patients with relatively short‐term follow‐up. The records of seven total elbow arthroplasties in six adult men with haemophilia at the University of California, San Francisco who underwent TEA over a period of 25 years were retrospectively reviewed. Type of haemophilia, age at time of TEA, HIV infection status, pre‐ and postoperative range‐of‐motion (ROM) scores, complications (including infections), need for subsequent surgical revision and functional outcomes were recorded. Four patients had severe factor VIII deficiency and two patients had severe factor IX deficiency. None of the patients had an inhibitor. The mean age at the time of surgery was 34 years (range, 22–46 years) and the mean follow‐up period was 118 months (range, 37–176 months). One of the six patients had TEA in both elbows. Five of the six patients were infected with HIV. There were no immediate perioperative complications. At a mean of 19.2 months postoperatively, ROM had improved in five of seven TEAs: mean flexion had increased from 110.7° (SD = 15.0) to 120.1° (SD = 14.5), whereas mean preoperative extension increased from ?44.3° (SD = 21.5) to ?36.9° (SD = 27.0). One patient required a revision at 30 months because of ulnar component loosening. This same patient sustained a staph epidermidis infection and ultimate removal of the prosthesis 15 years postoperatively. At a mean of 118 months postoperatively, five of six patients continued to report reduced pain and preserved functionality, with ability to perform normal daily activities. TEA resulted in favourable results in six of seven procedures. Our findings support the viability of TEA for individuals with severe haemophilic arthropathy of the elbow, especially to reduce pain and preserve or restore functionality. Level of evidence .  Level IV.     

A new total elbow arthroplasty for rheumatoid arthritis

We have followed up the results of total elbow arthroplasties on 36 elbows in 28 patients using a prosthesis newly designed in our department. The characteristics of this elbow joint (NR type) were: none constrained type, minimum bone resection and adapting each elbow joint size. The results were compared before and after operations on the basis of the Elbow Evaluation Sheet prepared by the Japanese Orthopaedic Association. The usefulness of the new prosthesis is evaluated and the problems involved are discussed. Seven years and 8 months on average (from 3 years 6 months to 13 year 9 months) after the operation, relief of pain and an increase in the flexion angle were particularly remarkable. As compared with the preoperative conditions, the activities of daily living of patients were improved, especially washing their faces, buttoning-up their shirts and eating food with greater ease. The most frequent complication was restriction to extension, which developed in 12 elbows (33%). Postoperative infection was seen in two joints of two patients (5.5%), fall out the ulnar component due to fracture of olecranon in one (2.8%) and dislocation of the elbow joint in another (2.8%). The survival rate of this elbow joint was 90% at an average 7 years and 8 months follow-up. This new elbow joint has good durability and is very useful in improving the function of the elbow joint destroyed by rheumatoid arthritis.     

A new total elbow arthroplasty for rheumatoid arthritis

Abstract

We have followed up the results of total elbow arthroplasties on 36 elbows in 28 patients using a prosthesis newly designed in our department. The characteristics of this elbow joint (NR type) were: none constrained type, minimum bone resection and adapting each elbow joint size. The results were compared before and after operations on the basis of the Elbow Evaluation Sheet prepared by the Japanese Orthopaedic Association. The usefulness of the new prosthesis is evaluated and the problems involved are discussed. Seven years and 8 months on average (from 3 years 6 months to 13 year 9 months) after the operation, relief of pain and an increase in the flexion angle were particularly remarkable. As compared with the preoperative conditions, the activities of daily living of patients were improved, especially washing their faces, buttoning-up their shirts and eating food with greater ease. The most frequent complication was restriction to extension, which developed in 12 elbows (33%). Postoperative infection was seen in two joints of two patients (5.5%), fall out the ulnar component due to fracture of olecranon in one (2.8%) and dislocation of the elbow joint in another (2.8%). The survival rate of this elbow joint was 90% at an average 7 years and 8 months follow-up. This new elbow joint has good durability and is very useful in improving the function of the elbow joint destroyed by rheumatoid arthritis.     

Results of the Kudo elbow prosthesis in patients with rheumatoid arthritis: a preliminary report

Sixteen elbows in 15 rheumatoid arthritis patients had a total elbow replacement with insertion of a non-constrained surface-replacement prosthesis. One patient died of an unrelated cause, but all the others were available for follow-up (mean follow-up period: 35.4 months). The results were graded according to a modified version of the Morrey elbow score. A good result was seen in 13 elbows and a fair result in two. One infection occurred, which was cured with intravenous antibiotics and maintenance of the prosthesis in place; however, recurrent dislocation persisted. Another patient had postoperative instability with recurrent subluxations. Eleven patients were very satisfied and one was satisfied. The total active range of motion increased significantly from 70.3^o (SD 29.6) to 97.0^o (SD 15.4), mainly by increased flexion. The modified Morrey score increased significantly from 32.7 (SD 13.1) to 89.3 (SD 10.3). Pain decreased from severe (n=12) and moderate (n=3) preoperatively to mild (n=5) and absent (n=10) postoperatively.     

Systematic review of primary total elbow prostheses used for the rheumatoid elbow

Total elbow prosthesis (TEP) has been shown to be a viable option for treatment of the rheumatoid elbow. Many types of TEP have been studied, but the heterogeneity of the studies makes most conclusions subject to discussion. The aim of this systematic review is to show the differences between the most commonly used TEP for the destroyed rheumatoid elbow. After a search in Pubmed (NLM, Bethesda, USA) the senior author selected eight frequently used TEP: the Capitellocondylar, Coonrad-Morrey, GSB III, Kudo, Liverpool, Norway, Roper–Tuke and Souter–Strathclyde. For inclusion studies we arbitrarily formulated nine criteria , after which clearly adverse events were defined for comparison purposes. The Capitellocondylar and Souter–Strathclyde prostheses are the most-studied treatments for replacing the rheumatoid elbow. In contrast to the Capitellocondylar, the Souter–Strathclyde prosthesis showed higher loosening rates but implemented modifications of the design have reduced these rates in recent studies. Nevertheless, in relation to most other joint replacements in rheumatoid patients, all TEP still have higher complication rates. For this reason an elbow prosthesis may just be warranted in seriously disabled patients. Abbreviations TEP Total elbow prosthesis     

Long-term results of open elbow synovectomy for rheumatoid arthritis

Long-term results of open synovectomy of the elbow with rheumatoid arthritis (RA) were reviewed in 15 elbows. The subjects were evaluated at two time points with average follow-up periods of 4 and 8.7 years, and the results were compared between the two follow-ups. The Mayo Clinic performance score showed significant improvement in pain, motion, and daily function from the intermediate to the long-term follow-up. Overall results were satisfactory with little time-dependent deterioration in radiological grading, confirming the long-term effectiveness of this procedure.     

Limited extension after linked total elbow arthroplasty in patients with rheumatoid arthritis

Objective: Total elbow arthroplasty (TEA) has become an established procedure to relieve pain and to increase the range of motion of the destructed elbow in patients with rheumatoid arthritis (RA). However, some patients still have limited extension after TEA, and the causes of limited extension after TEA have yet to be elucidated.

Methods: To examine whether widening of the joint space can cause such limited extension, we retrospectively analyzed 55 cases of linked TEA in patients with RA. There were seven male and 40 female with a mean age of 63.8 years (range, 30–80 years) and a mean follow-up of 7.5?±?4.2 years (range, 2.5–15.6 years). The Mayo Elbow Performance Score (MEPS) and radiological measurements were recorded. Widening of the joint space was calculated by subtracting the length measured on postoperative radiograph from preoperative radiograph.

Results: MEPS and range of motion were significantly improved after surgery except for extension. The degree of extension was significantly correlated with radiological widening of the joint space in the limited extension group. Correlation analyses showed that postoperative limited extension was correlated with lower MEPS daily function.

Conclusions: Limited extension after linked TEA is partly derived from perioperative widening of the joint space and potentially limits daily function in patients with RA.     

Total hip arthroplasty in the young arthritic patient

Background : Hip disease is a major cause of immobility and pain in children and young adults with inflammatory arthritides. Total hip arthroplasty (THA) has previously been avoided in young patients because of the concern about durability of the prosthesis and the need for multiple revisions. There are now, however, growing reports of the success of such procedures in improving mobility and relieving pain in the young patient with severe hip disease. In this study we aimed to determine the clinical and radiological results in patients with inflammatory arthritides who had undergone THA before the age of 35 years.
Methods : Twenty-one patients who had undergone a total of 38 hip arthroplasties were identified. Patients' hips were scored both pre-operatively and at follow-up using the scoring system of the Hospital for Special Surgery, which allots a score for pain, walking, motion and muscle power, and function. Complications were noted and follow-up X-rays were compared to postoperative films to assess radiological loosening.
Results : The mean age at operation was 24 years, and the mean follow-up was 8.6 years. The results in terms of pain relief, mobility, movement and functional capacity were good. Revision was required in 13 hips (34%). This was mostly due to the failure of resurfacing prostheses. Radiological loosening was evident in a further six hips, five of which were asymptomatic.
Conclusions : THA can dramatically improve the quality of life of the young patient with arthritis. The main concern is the likely need for multiple revisions, with progressive loss of bone stock.     

Reconstruction of large bone defect using autogenous fibular strut and iliac bone graft for revision total elbow arthroplasty

The stability and longevity of the prosthesis after revision total elbow arthroplasty (TEA) are greatly influenced by the reconstruction of bone defects around the distal humerus and proximal ulna. This study evaluated the clinical and radiological results of reconstruction of a large bone defect using an autogenous fibular strut and iliac bone graft in revision TEA.This retrospective study reviewed 10 patients who underwent revision TEA with autogenous fibular strut and iliac corticocancellous bone graft between March 2007 and May 2016. Range of motion (ROM), Visual Analog Scale (VAS), and Mayo Elbow Performance Score were used to evaluate clinical outcomes at the final follow-up. Plain radiographs were reviewed for bone union and the presence of re-loosening or for the presence of peri-prosthetic fractures.At the final follow-up, the ROMs of the elbow was 102.5° (range, 90–120°) from extension to flexion, 60.0° (range, 40–80°) in pronation, and 58.5° (range, 35–80°) in supination. The mean preoperative VAS and Mayo Elbow Performance Score were 5.1 and 46.5, and theses scores were improved to 2.6 and 79.0, at the final follow-up (P < .05). Union of the grafted bone with the distal humerus was achieved at an average of 4.5 months (range, 3–6 months). Re-osteolysis recurred in 2 cases, and additional surgery for bone grafting was performed in 1 case.Autogenous fibular strut bone grafting is an effective technique when revision TEA has large bone defects around the prosthesis resulting in a relatively stable prosthesis fixation and good union rate with a satisfactory clinical outcome after TEA revision.     

Long-term results of open elbow synovectomy for rheumatoid arthritis

Abstract

Long-term results of open synovectomy of the elbow with rheumatoid arthritis (RA) were reviewed in 15 elbows. The subjects were evaluated at two time points with average follow-up periods of 4 and 8.7 years, and the results were compared between the two follow-ups. The Mayo Clinic performance score showed significant improvement in pain, motion, and daily function from the intermediate to the long-term follow-up. Overall results were satisfactory with little time-dependent deterioration in radiological grading, confirming the long-term effectiveness of this procedure.     

Influence of previous open synovectomy on the outcome of Souter-Strathclyde total elbow prosthesis

OBJECTIVES: Open synovectomy of the elbow joint is often performed in early stages of rheumatoid arthritis. Because of poor long-term results after synovectomy, insertion of a total elbow prosthesis is commonly used as a secondary procedure. The aim of this study is to evaluate the influence of previous synovectomy on the outcome after placement of a total elbow prosthesis. METHODS: We inserted 204 primary Souter-Strathclyde total elbow prostheses for rheumatoid arthritis. Two groups could be distinguished: group A with previous synovectomy 3.9 yr (mean) before the elbow replacement (n = 33) and group B without previous synovectomy (n = 171). The mean follow-up was 5.8 yr for group A and 6.3 yr for group B. All patients were assessed clinically and radiologically before the operation, 1 and 2 years later and then at regular intervals. The effect of previous synovectomy was analysed via a Cox model and a generalized linear mixed model for binomial data with multivariate normal random effects. RESULTS: No statistically significant effect of previous synovectomy on pain, function or complaints of the ulnar nerve could be found post-operatively. The post-operative flexion was significantly higher in group B than in group A. The complication-rates were similar for both groups. The overall survival rate for respectively group A and B with revision as endpoint was 66.9% (s.e. 13.4) versus 79.6 (s.e. 4.3) after 10 yr. CONCLUSIONS: Previous synovectomy does not diminish the outcome after total elbow prosthesis in this series and could therefore be considered in early, painful stages of rheumatoid destruction of the elbow joint.     

Long-term clinical and radiographic results of cementless total hip arthroplasty for patients with rheumatoid arthritis: minimal 10-year follow-up

Abstract

Objectives. The aim of this study was to clarify the long-term clinical and radiographic results of cementless total hip arthroplasty (THA) for patients with rheumatoid arthritis (RA).

Methods. Twenty-eight total hip arthroplasties in 24 patients with a diagnosis of RA were performed from October 1992 to October 1996. All components were titanium alloy with a circumferential porous coating. Six patients (six hips) died before the 10-year follow-up, and one patient (one hip) was lost to follow-up, leaving 21 joints of 17 patients for review at a minimum 10-year follow-up after surgery. There were 3 men and 14 women with an average age of 55.0 years. The average duration of RA at the time of the operation was 12.6 years, and the average follow-up period was 12.2 years. We evaluated the Japanese Orthopaedic Association (JOA) hip scores, radiographic changes and survivor rates of components.

Results. Compared with the preoperative JOA hip scores, there was significant improvement in the postoperative scores. Spot welds consistent with bone ingrowth were identified in 95.0% of the femoral components. No femoral components showed radiographic loosening or required revision for aseptic loosening, but two acetabular revisions were performed because of aseptic loosening. The 14-year survivor rates of the stem and cup with the end point of loosening were 100% and 88.2%, respectively.

Conclusions. Cementless THA with this component design in patients with RA appears to be a promising treatment.     

Indications, complications, and results of shoulder arthroplasty

OBJECTIVE: To provide estimates of patient outcomes following shoulder arthroplasty using Neer-II type humeral prosthesis and to examine variation in outcomes due to patient and prosthesis characteristics. METHODS: North American and Western European published articles were identified through a computerized literature search and bibliography review. Studies were included if they enrolled 15 or more patients, discriminated between hemi-arthroplasty (HEMI) and total shoulder arthroplasty (TSA) and measured pain relief, gain in range of motion (ROM), radiographic follow-up (> 2 years), short- and long-term complications, and revision surgery. RESULTS: A total of 40 studies satisfied the inclusion criteria. The total number of patients enrolled was 3584. The mean follow-up was 59 months. The mean patient age was 62 years, 65% of patients were women and 73% underwent TSA. All reports showed relevant pain relief, increase in ROM, and high satisfaction rates for HEMI and TSA in both osteoarthritis (OA) and rheumatoid arthritis (RA). The overall rate of revision was 8%. Significant differences between HEMI and TSA for both diagnoses were found for all outcome parameters. CONCLUSION: Shoulder arthroplasty is a safe and effective procedure for OA and RA patients. The diagnosis, shoulder pathology, and prosthesis specifics were significant predictors of outcomes. We therefore emphasize that conclusions on the outcome of shoulder arthroplasty can only be made if differentiated between these patient and prosthesis specifics. Limitations in the reporting style of these articles severely constrain the ability to explore variation in outcomes due to study, patient, or prosthesis characteristics and restrict their generalisability.     

Total joint arthroplasty and the immune response

Total joint replacement arthroplasty has proved highly successful in themanagement of osteoarthritis and rheumatoid arthritis. The cause of aseptic loosening of prosthetic joint replacement components is unclear. Early experience with total joint arthroplasty was plagued by a number of problems that no longer exist as major impediments to long-term success. Improvements in the operating room environment and the use of prophylactic antibiotics have substantially reduced the high incidence of infection to less than 1%. Implant materials have long been considered biologically inert, but recent studies indicate that inflammatory reactions directed against the implanted materials may contribute to aseptic loosening. Currently, particulate debris from cement or polyethylene causing loosening of the prosthesis is the major problem in total joint arthroplasty. Significant data suggest a progression from a simple inflammatory reaction to complex immune responses against the biomaterials. The cellular responses to particles of polymethyl methacrylate, ultra-high-molecular-weight polyethylene, and alloys of cobalt-chromium and titanium have been assayed in vitro in patients with osteoarthritis, rheumatoid arthritis, and avascular necrosis who had total joint replacement. Elevated immunologic cell proliferation responses to both acrylic and cobalt chromium were observed in patients with aseptically loosened prostheses. These findings suggest that the development of a cellular response to particulate debris may be significant in the pathogenesis of aseptic loosening.     

Total ankle arthroplasty for deformity of the foot in patients with rheumatoid arthritis using the TNK ankle system: clinical results of 21 cases

Abstract

We report the results of total ankle arthroplasty (TAA) of 21 ankle joints performed on 19 patients with rheumatoid arthritis (RA) using the Japanese TNK ankle system. The clinical evaluation for an average follow-up period of 33.8 months was based on the ankle analysis system. The total score, pain score, range of motion, and walking ability significantly improved postoperatively compared with the preoperative period. These parameters also showed significantly different values between the preoperative and the follow-up periods. However, the range of motion significantly improved postoperatively. In the evaluation of TAA using the TNK ankle system, a radiolucent line of about 1?mm was detected, but there was no dislocation or sinking of the tibial and talar prostheses. There were no severe complications except for two cases with a delayed wound healing and one with a deep infection. These results suggest that if the talocrural joint only was destroyed and the neighboring joints (subtalar or talonavicular) had fibrous fusion, or the patient had relatively fewer activities in daily life or was an elderly person, TAA using the TNK ankle system was effective for the treatment of painful and disabling ankle joints in patients with RA in the middle of the follow-up period.     

Total ankle arthroplasty for deformity of the foot in patients with rheumatoid arthritis using the TNK ankle system: clinical results of 21 cases

We report the results of total ankle arthroplasty (TAA) of 21 ankle joints performed on 19 patients with rheumatoid arthritis (RA) using the Japanese TNK ankle system. The clinical evaluation for an average follow-up period of 33.8 months was based on the ankle analysis system. The total score, pain score, range of motion, and walking ability significantly improved postoperatively compared with the preoperative period. These parameters also showed significantly different values between the preoperative and the follow-up periods. However, the range of motion significantly improved postoperatively. In the evaluation of TAA using the TNK ankle system, a radiolucent line of about 1mm was detected, but there was no dislocation or sinking of the tibial and talar prostheses. There were no severe complications except for two cases with a delayed wound healing and one with a deep infection. These results suggest that if the talocrural joint only was destroyed and the neighboring joints (subtalar or talonavicular) had fibrous fusion, or the patient had relatively fewer activities in daily life or was an elderly person, TAA using the TNK ankle system was effective for the treatment of painful and disabling ankle joints in patients with RA in the middle of the follow-up period.     

Survival analysis and longterm results of elbow synovectomy in rheumatoid arthritis

OBJECTIVE: To evaluate longterm results and survival rate of open synovectomy of the elbow joint in patients with rheumatoid arthritis (RA). METHODS: Between 1986 and 2000, synovectomy of the elbow was performed on 103 joints in 92 patients with RA. Eighty-five joints were included in this study. Mean age at time of surgery was 52 years (range 13 to 62 yrs). On 13 elbows with Larsen stage I and II disease, early synovectomy preserving the radial head was performed; in 72 cases with Larsen stage III and IV, late synovectomy with radial head resection was necessary. RESULTS: In early synovectomy, one joint received prosthetic joint replacement and 2 joints underwent resynovectomy a mean of 9 years after primary surgery. The survival rate (no further operations) was 91% after 5 years and 78% after 10 years. In late synovectomy, 16 elbow joints were operated again a mean of 4.6 years after primary surgery (10 prosthetic joint replacements, 2 resection interposition arthroplasties, 4 resynovectomies). Survival rate was 82% after 5 years and 66% after 10 years. Sixty-one elbows were examined clinically at a mean followup period of 8.7 years (range 2.8-17.3 yrs). There was a significant improvement of the Morrey score at followup, especially due to effective relief of pain. Improvement of joint motion was seen in late synovectomy for pronation and supination. The mean preoperative Larsen stage was 3.11, which decreased significantly to 3.66 at followup. CONCLUSION: Our findings suggest that synovectomy is a safe and effective procedure in differential treatment of RA of the elbow.