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16
J Shoulder Elbow Surg Volume 16, Number 2
fractures, previous surgery, poorer health status and women had lower SST scores. Eighty-four percent of patients complained of pain. Stiffness (65%) was the most common finding on examination, especially for arthroplasty used in the treatment of fractures. Component malposition (65%) and malalignment (67%) were commonly noted. Tuberosity healing problems were present in 65% of patients treated for fracture nonunion. Glenoid loosening was common in total shoulders (63%) and glenoid erosion common in hemiarthroplasties (55%). Of the 237 patients undergoing revision surgery, intraoperative cultures were positive in 9%. Many shoulders manifested more than one of these characteristics. Conclusions: This study reveals many factors that can be associated with a shoulder arthroplasty having a poor and unsatisfying outcome. Dedication to strategies for avoiding these factors should improve the results of this procedure.
15 RESULTS OF NON-CEMENTED SEMI-CONSTRAINED TOTAL ELBOW ARTHROPLASTY FOR INFLAMMATORY ARTHRITIS: A MINIMUM TEN YEAR FOLLOW-UP Mark P. Figgie, MD, Joseph Lipman, MS, Barbara A. Kahn, RN, ONC, Hospital for Special Surgery, New York, NY Between 1988 and 1995, ten patients with inflammatory arthritis underwent fourteen total elbow arthroplasties with custom fit, non-cemented semi-constrained components. The diagnosis was rheumatoid arthritis for four elbows and juvenile rheumatoid arthritis for ten. There were seven females and three males with an average age of 28 years at the time of surgery (range 17 to 45). Each implant had a semi-constrained articulation and was designed for metaphyseal fit in both the ulna and humerus. The average follow-up was 13 years with a range from ten to seventeen years. The average HSS elbow score improved from 35 points (range 25 to 53) to 91 (85 to 95) at current follow-up. The average flexion arc was 57 degrees preoperatively (range 0 to 120) and improved to 115 degrees (range 90 to 140). The average rotation arc improved from 80 degrees (range 0 to 170) to 135 degrees (range 80 to 170). There were no peri-operative complications and only one patient has required reoperation for polyethylene wear. That patient underwent successful revision of her polyethylene bushing eight years after her index operation. Radiographic analysis of the elbows shows osteolysis from polyethylene wear, but the implant fixation at the porous surfaces remains stable in all fourteen elbows. While the cost of custom fit implants may be prohibitive, non-cemented fixation may be a consideration for the younger patients with inflammatory arthritis undergoing total elbow arthroplasty.
16 RESULTS OF SEMI-CONSTRAINED PRIMARY AND REVISION TOTAL ELBOW ARTHROPLASTY Lewis L. Shi, BA, Deryk G. Jones, MD, Mark Koris, MD, Thomas S. Thornhill, MD, Brigham and Women’s Hospital, Boston, MA Total elbow arthroplasty (TEA) has been reported to be successful using either a non-constrained or a semi-constrained implant. When semi-constrained implants are used in selected cases, the results may be different than when they are used routinely. Specifically, cases with intact ligaments will not “test” the constraining mechanism of the prosthesis. Conversely, “selected” use of a semi-constrained implant might provide inferior results when compared with series where their use is routine. We studied the results of a single semi-constrained implant, Coonrad-Morrey (Zimmer) when used selectively in patients with elbow arthritis. The results of 64 semi-constrained total elbow replacements that were performed between 1990 and 2001 in 61 patients were evaluated. The average follow-up was 6 years (range, 2 months to 13.5 years). A 100-point elbow functional scoring system, patient-derived outcome measures and radiographic analysis were used to assess the clinical results. The diagnoses leading to the 46 primary TEAs were
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post-traumatic/osteoarthritis (25), rheumatoid arthritis (19), factor VIII deficiency (1), and post-sepsis (1); the diagnoses leading to the 18 revision TEAs were prosthetic loosening (14), post-traumatic (2), prosthetic wear (1), and post-sepsis (1). At latest follow-up the average elbow score improved from 23 (range 0-55) pre-operatively to 79 (range 22-100). No pain was present in 37%, slight pain with activities in 37%, and moderate pain requiring daily medication in 14% of the patients. The flexion arc was greater than 90 degrees in 80% of patients postoperatively versus 40% preoperatively. Pronation and supination improved an average of 20 degrees in each direction. Eighty-eight percent of patients were satisfied with the outcome and would undergo the procedure again. Standard anteroposterior and lateral radiographs revealed 1 mm radiolucencies along the ulnar and humeral components in 30% of patients. An additional 11% of patients demonstrated 2 mm radiolucencies along the proximal humeral component. Finally, 10% of patients had significant 2 mm voids at the humeral component tip. Complications included: transient ulnar nerve palsy (14%), persistent ulnar nerve palsy (11%), infection (3%), triceps avulsion/ dysfunction (3%), intraoperative fracture (3%), persistent flexion contracture (3%), and aseptic loosening requiring revision (14%). A semi-constrained hinge elbow arthroplasty provides excellent pain relief and good functional return in patients with severe destructive arthropathy and in revision TEAs. The increased incidence of radiolucent lines and loosening requiring revision compared with unconstrained resurfacing arthroplasties at similar follow-up suggest that this implant should be reserved for patients with severe bone loss and ligamentous laxity that are not candidates for an unconstrained resurfacing arthroplasty. The higher incidence of failure in this cohort is likely due to patient selection as this implant is reserved for more complex arthroplasties.
17 COMPARISON OF ELBOW CONTRACTURE RELEASE IN PATIENTS WITH AND WITHOUT HETEROTOPIC OSSIFICATION Jesse B. Jupiter, MD (a–AO Foundation), Job N. Doornberg, MS, Durk S. Linzel, BS, Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA Introduction: Heterotopic ossification has been regarded with trepidation and considered a poor prognostic factor for operative restoration of elbow motion. We compared the results of elbow contracture release in patients with and without heterotopic ossification blocking elbow motion to test the hypothesis that heterotopic bone is associated with diminished elbow motion after release. Methods: Nineteen patients with heterotopic bone restricting elbow motion (but not complete bony ankylosis) were compared with twenty-two patients with capsular contracture alone. The sex, age, initial injuries, percentage of dominant limbs, number of prior procedures, mechanisms of injury, open injuries, polytrauma patients were comparable between groups. The average pre-operative arc of flexion and extension in the patients with heterotopic bone was 52 degrees (range, 5 to 90 degrees) and 52 degrees (range, 10 to 90 degrees) in patients with capsular contracture alone. Results: After the index procedure, the flexion-extension arc in patients with heterotopic ossification averaged 105 (range, 45 to 105 degrees) and the arc in the capsular release group averaged 86 degrees (range, 0 to 135 degrees). The average improvement in F-E arc was 53 degrees (range, ⫺20 to 107 degrees) for the HO patients and 34 degrees in the capsular release group (range, ⫺20 to 75 degrees). The difference in improvement after the first release was significant (p ⫽ 0.034). Six of 22 patients (26%) in the capsular release group and two of eighteen patients (12%) in the HO group had a second procedure for capsular release. At an average of 24 months follow-up (range, 6 to 63 months), the final arc of flexion and extension averaged 105 degrees in the patients with heterotopic bone (range 40 to 145 degrees) and 96 degrees (range, 45 to 135 degrees) in patients without HO.
fractures, previous surgery, poorer health status and women had lower SST scores. Eighty-four percent of patients complained of pain. Stiffness (65%) was the most common finding on examination, especially for arthroplasty used in the treatment of fractures. Component malposition (65%) and malalignment (67%) were commonly noted. Tuberosity healing problems were present in 65% of patients treated for fracture nonunion. Glenoid loosening was common in total shoulders (63%) and glenoid erosion common in hemiarthroplasties (55%). Of the 237 patients undergoing revision surgery, intraoperative cultures were positive in 9%. Many shoulders manifested more than one of these characteristics. Conclusions: This study reveals many factors that can be associated with a shoulder arthroplasty having a poor and unsatisfying outcome. Dedication to strategies for avoiding these factors should improve the results of this procedure.
15 RESULTS OF NON-CEMENTED SEMI-CONSTRAINED TOTAL ELBOW ARTHROPLASTY FOR INFLAMMATORY ARTHRITIS: A MINIMUM TEN YEAR FOLLOW-UP Mark P. Figgie, MD, Joseph Lipman, MS, Barbara A. Kahn, RN, ONC, Hospital for Special Surgery, New York, NY Between 1988 and 1995, ten patients with inflammatory arthritis underwent fourteen total elbow arthroplasties with custom fit, non-cemented semi-constrained components. The diagnosis was rheumatoid arthritis for four elbows and juvenile rheumatoid arthritis for ten. There were seven females and three males with an average age of 28 years at the time of surgery (range 17 to 45). Each implant had a semi-constrained articulation and was designed for metaphyseal fit in both the ulna and humerus. The average follow-up was 13 years with a range from ten to seventeen years. The average HSS elbow score improved from 35 points (range 25 to 53) to 91 (85 to 95) at current follow-up. The average flexion arc was 57 degrees preoperatively (range 0 to 120) and improved to 115 degrees (range 90 to 140). The average rotation arc improved from 80 degrees (range 0 to 170) to 135 degrees (range 80 to 170). There were no peri-operative complications and only one patient has required reoperation for polyethylene wear. That patient underwent successful revision of her polyethylene bushing eight years after her index operation. Radiographic analysis of the elbows shows osteolysis from polyethylene wear, but the implant fixation at the porous surfaces remains stable in all fourteen elbows. While the cost of custom fit implants may be prohibitive, non-cemented fixation may be a consideration for the younger patients with inflammatory arthritis undergoing total elbow arthroplasty.
16 RESULTS OF SEMI-CONSTRAINED PRIMARY AND REVISION TOTAL ELBOW ARTHROPLASTY Lewis L. Shi, BA, Deryk G. Jones, MD, Mark Koris, MD, Thomas S. Thornhill, MD, Brigham and Women’s Hospital, Boston, MA Total elbow arthroplasty (TEA) has been reported to be successful using either a non-constrained or a semi-constrained implant. When semi-constrained implants are used in selected cases, the results may be different than when they are used routinely. Specifically, cases with intact ligaments will not “test” the constraining mechanism of the prosthesis. Conversely, “selected” use of a semi-constrained implant might provide inferior results when compared with series where their use is routine. We studied the results of a single semi-constrained implant, Coonrad-Morrey (Zimmer) when used selectively in patients with elbow arthritis. The results of 64 semi-constrained total elbow replacements that were performed between 1990 and 2001 in 61 patients were evaluated. The average follow-up was 6 years (range, 2 months to 13.5 years). A 100-point elbow functional scoring system, patient-derived outcome measures and radiographic analysis were used to assess the clinical results. The diagnoses leading to the 46 primary TEAs were
ASES Abstracts
e27
post-traumatic/osteoarthritis (25), rheumatoid arthritis (19), factor VIII deficiency (1), and post-sepsis (1); the diagnoses leading to the 18 revision TEAs were prosthetic loosening (14), post-traumatic (2), prosthetic wear (1), and post-sepsis (1). At latest follow-up the average elbow score improved from 23 (range 0-55) pre-operatively to 79 (range 22-100). No pain was present in 37%, slight pain with activities in 37%, and moderate pain requiring daily medication in 14% of the patients. The flexion arc was greater than 90 degrees in 80% of patients postoperatively versus 40% preoperatively. Pronation and supination improved an average of 20 degrees in each direction. Eighty-eight percent of patients were satisfied with the outcome and would undergo the procedure again. Standard anteroposterior and lateral radiographs revealed 1 mm radiolucencies along the ulnar and humeral components in 30% of patients. An additional 11% of patients demonstrated 2 mm radiolucencies along the proximal humeral component. Finally, 10% of patients had significant 2 mm voids at the humeral component tip. Complications included: transient ulnar nerve palsy (14%), persistent ulnar nerve palsy (11%), infection (3%), triceps avulsion/ dysfunction (3%), intraoperative fracture (3%), persistent flexion contracture (3%), and aseptic loosening requiring revision (14%). A semi-constrained hinge elbow arthroplasty provides excellent pain relief and good functional return in patients with severe destructive arthropathy and in revision TEAs. The increased incidence of radiolucent lines and loosening requiring revision compared with unconstrained resurfacing arthroplasties at similar follow-up suggest that this implant should be reserved for patients with severe bone loss and ligamentous laxity that are not candidates for an unconstrained resurfacing arthroplasty. The higher incidence of failure in this cohort is likely due to patient selection as this implant is reserved for more complex arthroplasties.
17 COMPARISON OF ELBOW CONTRACTURE RELEASE IN PATIENTS WITH AND WITHOUT HETEROTOPIC OSSIFICATION Jesse B. Jupiter, MD (a–AO Foundation), Job N. Doornberg, MS, Durk S. Linzel, BS, Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA Introduction: Heterotopic ossification has been regarded with trepidation and considered a poor prognostic factor for operative restoration of elbow motion. We compared the results of elbow contracture release in patients with and without heterotopic ossification blocking elbow motion to test the hypothesis that heterotopic bone is associated with diminished elbow motion after release. Methods: Nineteen patients with heterotopic bone restricting elbow motion (but not complete bony ankylosis) were compared with twenty-two patients with capsular contracture alone. The sex, age, initial injuries, percentage of dominant limbs, number of prior procedures, mechanisms of injury, open injuries, polytrauma patients were comparable between groups. The average pre-operative arc of flexion and extension in the patients with heterotopic bone was 52 degrees (range, 5 to 90 degrees) and 52 degrees (range, 10 to 90 degrees) in patients with capsular contracture alone. Results: After the index procedure, the flexion-extension arc in patients with heterotopic ossification averaged 105 (range, 45 to 105 degrees) and the arc in the capsular release group averaged 86 degrees (range, 0 to 135 degrees). The average improvement in F-E arc was 53 degrees (range, ⫺20 to 107 degrees) for the HO patients and 34 degrees in the capsular release group (range, ⫺20 to 75 degrees). The difference in improvement after the first release was significant (p ⫽ 0.034). Six of 22 patients (26%) in the capsular release group and two of eighteen patients (12%) in the HO group had a second procedure for capsular release. At an average of 24 months follow-up (range, 6 to 63 months), the final arc of flexion and extension averaged 105 degrees in the patients with heterotopic bone (range 40 to 145 degrees) and 96 degrees (range, 45 to 135 degrees) in patients without HO.