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Elbow revision arthroplasty in the situation of bone loss using an unlinked long-stem prosthesis
Elbow Revision Arthroplasty in the Situation of Bone Loss Using an Unlinked Long-Stem Prosthesis Stefan Ehrendorfer, MD, Carluke, Lanarkshire, UK The results of 16 first-revision operations using an unlinked cemented long-stem elbow arthroplasty in the situation of major bone loss are presented. Fifteen patients with a mean age of 62 years and longstanding polyarthritis were monitored for a mean period of 31 months (range, 6 – 62 months). Seven revision arthroplasties showed a good result and 7 a fair result with improvement of function and pain. Two patients with postoperative instability requiring further surgery had a poor result, with one infected prosthesis and one elbow with persistent instability and ulnar nerve hypersensitivity. Using a visual analog scale, patients documented good pain relief, good subjective independence, and a high level of satisfaction. In the follow-up SF-36 health survey, patients scored low physical function but good mental function. These results show that in the absence of infection and instability, revision elbow arthroplasty, even in the situation of major bone loss, can be a successful treatment option using this unlinked cemented long-stem system. (J Hand Surg 1999;24A:1337–1343. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Elbow, revision, arthroplasty, polyarthritis.
According to Souter,1 the elbow joint is affected in 50% of cases of longstanding rheumatoid disease. Primary elbow arthroplasty is a well-established treatment option in rheumatoid arthritis, with documented improvement of function and pain.1–5 The number of arthroplasties performed has increased; consequently, the number of patients requiring revision has increased. Infection, fracture, prosthetic failure, instability, and prosthetic loosening are the main indications for revision.6 Encouraging results of revision elbow arthroplasty using various systems have been described.7,8 If bone stock is well preserved at the time of revision, From Wrightington Orthopaedic Hospital, Wigan, Lancashire, UK. Received for publication May 18, 1998; accepted in revised form June 9, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Stefan Ehrendorfer, MD, Orthopaedic Department, Law Hospital, Carluke, Lanarkshire, ML8 5ER UK. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A06-0018$3.00/0
primary elbow arthroplasty implants can be used. In case of major periarticular bone loss, implants achieving bony anchorage distant to the joint line have to be used for revision arthroplasty. In this scenario, both linked and unlinked systems have been used. Good results have been reported by King et al9 using a linked system, which reduced the risk of postoperative instability without evidence of prosthetic loosening with a sloppy hinge. Based on the good clinical experience with the primary surface replacement elbow arthroplasty, which was designed by Souter in cooperation with Strathclyde University (Glasgow, UK), a different concept was followed at the Upper Limb Unit at Wrightington Orthopaedic Hospital. The results in a group of patients requiring first-revision elbow arthroplasty who have major periarticular bone loss and who were treated using the unlinked cemented long-stem version of this implant are presented.
Patients and Methods From April 1991 to December 1995, 47 revision elbow arthroplasties were performed at this instituThe Journal of Hand Surgery 1337
1338 Stefan Ehrendorfer / Elbow Revision Arthroplasty
tion, where the Souter-Strathclyde prosthesis has evolved as the preferred implant both for primary and revision arthroplasty. Thirty-one of 47 elbow revisions were performed using a primary elbow prosthesis, mainly the Souter-Strathclyde; a few Wadsworth Mark 2 prostheses (Biomet, Bridgend, UK) were used early in the study period. In 16 revision surgeries involving 15 patients, major periarticular bone loss warranted bony anchorage distant to the joint line. These patients form the study group; all were managed with the cemented long-stem version of the Souter-Strathclyde prosthesis in the absence of infection. All 15 patients were available for review and gave informed consent to participate in this retrospective study. Assessment by an independent orthopedic surgeon included the collection of demographic data, the length of the follow-up period, the presence and duration of rheumatoid arthritis, the side of operation, and the time between the primary and revision surgeries. The preoperative bone loss was recorded according to Morrey et al.10 The reasons for revision (aseptic loosening, traumatic loosening, instability), complications (humeral or ulnar intraoperative perforation, fracture, and postoperative instability), the humeral and ulnar stem lengths, and the type of implant were determined from patient records and x-rays. We further assessed the range of movement in the sagittal plane, including flexion contracture, the maximum flexion, and the arc of motion using a goniometer, and recorded lifting power (in 90° elbow flexion) and clinical ulnar nerve function with sensory and motor function (impairment: paresthesia, numbness, hypersensitivity, motor function reduced to grade 4). Using visual analog scales, we measured subjective pain (1, severe; 10, no pain), subjective independence (1, completely dependent; 10, absolutely independent), and subjective satisfaction (1, very dissatisfied; 10, extremely satisfied). The assessment of x-ray findings and the grading of results was performed according to Morrey and Bryan.7 All patients were given information and instructions for the SF-36 health survey11 at the final review and were asked to complete it.
Demographic Data The average patient age at the time of revision surgery was 62 years (range, 37–74 years). Fourteen of the 15 patients were female. Thirteen patients had rheumatoid polyarthritis with an average duration of disease of 25 years (range, 7–39 years). Two patients
had psoriatic arthritis. All 15 patients had polyarthritic disease with significant co-morbidity. At the time of review all 15 patients had undergone previous surgery of various other joints: 4 hemi or total shoulder replacements, 1 contralateral revision, 3 contralateral primary elbow arthroplasties, 14 wrist joint arthrodeses or replacements, 10 total hip replacements, 15 total knee replacements, and 4 ankle arthrodeses or replacements. All 15 patients had undergone their first revision elbow arthroplasty. Three patients had undergone synovectomy before the primary elbow arthroplasty. The left to right distribution of the revision arthroplasties was even (patient 5 in Table 1 had bilateral revisions).
Revision Procedure The surgical technique was standardized with the use of laminar air-flow operating rooms, body exhaust suits, a proximal arm tourniquet, and lateral decubitus patient positioning. A direct posterior triceps reflecting approach12 was used. The ulnar nerve was identified and decompressed but not transposed anteriorly, according to the standard surgical technique at this institution. The anteromedial collateral ligament was preserved if possible. The preoperative bone loss in the distal aspect of the humerus was assessed according to the method of Morrey et al10 and is shown in Table 1. This classification comprises grade 1 (no patients) when the subchondral bone architecture is intact, grade 2 (11 elbows) when the medial and lateral supracondylar columns are preserved, grade 3 (3 elbows) when either the medial or the lateral supracondylar column is absent, and grade 4 (2 elbows) when the entire distal aspect of the humerus to or proximal to the level of the olecranon fossa is absent. The olecranon process was sufficiently preserved to allow attachment of the triceps tendon in all patients. The removal of loose components (12 cases) posed no major problem. Two elbows were revised for instability and 2 for traumatic loosening (Table 1). Both components were removed in all revisions. For cement removal an air-powered drill and various burrs and goose neck gouges were used. At trial reduction, correct spacing of the joint is important as it controls tension in the posterior structures because of the fixed length of the anterior capsule. The positioning of the components is crucial as it influences the tension of the soft tissues, including the collateral ligaments, if preserved. The aim of the procedure is to restore the anatomic position of the joint axis. The
62 56 54 53 45 7 45 41 38 26 18 14 13 12 11 6 31.3
70 37 56 65 43 46 65 70 74 66 67 71 62 67 64 67 62
F F M F F F F F F F F F F F F F
30 15 15 24 33 35 0 7 39 23 30 25 19 34 13 0 24.5
R L R R L R L R L R R L L R L L 8 L:8 R
Side 19 3 4 4 5 8 4 3 7 6 4 0.5 2 8 0.2 3 5
4 2 2 2 2 2 2 3 2 3 2 3 2 2 2 4
AL AL AL AL AL AL AL Instability AL AL AL TL Instability AL TL AL
Reason for Revision
UF HIP HIP HIP UIP UIP 1 PI HIP
HIP UIP HIP 1 PI
HIP 1 UIP
HIP
15,D 8,A 15,C 8,A 15,C 15,A 4, P 8,A 8,A 15,C 15,A 15,A 15,A 15,A 8,A 15,A
9, A 7, A 9, A 7, A 7, A 5, A 7, A 5, B 5, A 7, A 7, A 2.5, P 7, A 5, A 5, A 5, A
Humeral Ulnar Stem Stem Length Length Complications (cm)* (cm)* 55–135 5 80 45–150 5 105 10–120 5120 55–125 5 70 60–150 5 90 30–120 5 90 95–120 5 35 20–90 5 70 65–150 5 85 60–135 5 75 35–125 5 90 25–130 5 105 60–135 5 75 40–135 5 95 25–90 5 65 25–135 5 110 85
Range of Movement in the Sagittal Plane (°)† 1.5 2 3.5 0.5 2 2 0.5 0 1 1.5 1.5 2 1 1.5 0.5 1.5 1.4 SI:H, F4 SI:P, F4
SI:P
SI:N
SI: P SI:P, F4
9 5 6 7 5 5 6 4 7 10 9 10 10 4 4.5 9 6.9
8 7 7 4 7 7 3 5 8 7.5 7 3 6 7 5 9 6.2
8 7 10 10 8 8 2 1 6 10 8 10 7 8 1 7.5 6.9
84 70 76 72 70 70 56 46 72 90 94 100 90 64 47 94 75
Both
Ulna Fig. 1
Lifting Power in 90° Elbow Ulnar Flexion Nerve Function X-ray (kg) Function Pain‡ Independence§ Satisfaction11 Score¶ Findings#
AL, aseptic loosening; TL, traumatic loosening; HIP, humeral intraoperative perforation; UIP, ulnar intraoperative perforation; PI, postoperative instability; UF, ulnar fracture; SI: P, sensory impairment with paresthesia; SI:N, sensory impairment with numbness; SI:H, sensory impairment with hypersensitivity; F4, motor function reduced to grade 4. * A–D, see text; P, primary implant. † The first number is the fixed flexion contracture, the second is the maximum flexion, and the third is the absolute arc of motion. ‡ Subjective pain graded according to the visual analog scale: 1, severe; 10, no pain. § Subjective independence: 1, completely dependent; 10, absolutely independent. \ Subjective satisfaction: 1, very dissatisfied; 10, extremely satisfied. ¶ Elbow revision arthroplasty score. # Only loose components are specified.
1 2 3 4 5 5 6 7 8 9 10 11 12 13 14 15 Mean
Length of Duration of FollowRheumatoid Arthritis Patient up Period Age (mo) (y) Gender (y) No.
Time Between Primary and Revision Surgery Preoperative (y) Bone Loss
Table 1. Patient Demographics and Results
1340 Stefan Ehrendorfer / Elbow Revision Arthroplasty
restoration of length at revision increased soft tissue tension in a few patients, but closure was achieved in all cases by standard methods with attention to the distal attachment of the triceps to the olecranon. After surgery the elbow was placed in a plaster splint in 30° flexion for 36 hours. Mobilization was started on the sixth postoperative day, commencing with isometric exercises; it was delayed to 6 weeks in the patients with the ulnar snap fit implant. Postoperative wound healing was achieved in all cases.
Prosthesis Major bone deficiencies precluded the use of a primary elbow prosthesis at revision in all patients. In this situation the long-stem version of the Souter-Strath-
clyde prosthesis was always used. In 2 patients one primary component, which is interchangeable, was used. The long-stem system provides a variety (Fig. 1) of humeral components with preservation of both (model A) the lateral and (model B) the medial (model C) supracondylar bone stock. Model D resects 4 cm of the distal humerus. Stem length is available at 8 or 15 cm. The options for the ulnar component include the all-polyethylene implant, which has a length of 2.5 cm (patient 11) and the metal backing model A (olecranon retained, used in 14 elbows) and model B (minimum resection, used in patient 7). Stem length is available at 5, 7, and 9 cm. A snap-fit polyethylene inlay is optional and was used in the patients revised for instability (nos. 7 and 12).
Figure 1. Anteroposterior (A) and lateral (B) x-rays of patient 3.
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1341
Results For the 15 patients (16 elbows) included in this study, the time interval between primary elbow replacement and revision varied between 2 months (traumatic loosening) and 228 months (average, 60 months). The time between revision and the latest clinical and radiographic follow-up examinations averaged 31 months (range, 6 – 62 months). Intraoperative complications included humeral shaft perforation alone in 6 patients, ulnar shaft perforation alone in 3, and perforation of both in 1. In patient 9 an ulnar fracture at the tip of the component became a nonunion without clinical symptoms (Table 1). The most devastating postoperative complication was instability, leading to the 2 poor results. Patient 7 underwent several soft tissue procedures, ending with a deep infection with humeral fracture and loose components at the time of review (41 months after revision arthroplasty) and resection arthroplasty at a later stage. Patient 14 had revision elbow arthroplasty 2 months after the primary surgery because of traumatic loosening; she underwent a soft tissue procedure because of instability 1 month thereafter, but remained unstable. The additional treatment was conservative. Range of movement in the sagittal plane averaged 85° (range, 35° to 110°). The mean flexion contracture was 44° (range, 10° to 95°). Rotation ranged from 80° to 180° (average, 141°). Lifting power was measured at 90° elbow flexion with the forearm horizontal. Measurements varied between 0 and 3.5 kg (average, 1.3 kg). The ulnar nerve function was clinically intact in 10 extremities. Five patients experienced paresthesia (patient 14 also had marked hypersensitivity) and 1 patient (no. 10) had recurrent numbness in the ulnar nerve distribution. In 3 of these extremities, motor function in the ulnar nerve distribution was reduced to grade 4, according to the Medical Research Council (see Table 1). The pre-revision ulnar nerve function was not recorded, but only patient 14 stated a revision-related subjective deterioration of sensory and motor function. Pain in the revised elbow arthroplasty was measured with a visual analog scale (1, extremely severe; 10, no pain). Six patients reported values of 9 or 10 without the use of medication. The average score was 6.9; the worst score was 4, reported by the patient with the deep infection and a patient with a flair-up of rheumatoid disease. Subjective independence was assessed on a visual analog scale (1, completely dependent; 10, abso-
lutely independent). The average value was 6.2 (range, 3–9). The main complaint of patients was impaired ability to carry. Subjective satisfaction with the revision operation and implant was measured with a visual analog scale (1, very dissatisfied; 10, extremely satisfied) and averaged 6.8. The 2 patients with a poor result scored 1. One elbow implant was deeply infected and loose (patient 7, Table 1); the other arthroplasty had dislocated repeatedly and the patient (no. 14, Table 1) was suffering from ulnar nerve hypersensitivity. One patient (no. 6) reported a score of 2 because of only 35° range of movement. All the other patients graded themselves between 6 and 10. The SF-36 health survey11 was administered to all 15 patients at the final review. It could be assessed completely for 14 patients and partially for the remaining patient. Physical health was poor, with an average physical functioning score of 23% and a role–physical score of 15%. General health aspects revealed an average bodily pain score of 50%, a general health score of 43%, a vitality score of 41%, and a social functioning score of 63%. Mental health was less impaired, with an average role– emotional score of 59% and a mental health score of 68%. Morrey and Bryan7 described a classification system used to grade the results of elbow revision arthroplasty. There are 3 categories with a maximum combined score of 100 points: for pain, between 0 points (severe pain) and 60 points (no pain) are given. For range of movement, 0 points (,30°) to 30 points (.90°) are added. Stability gives an additional 0 points if unstable and 10 points if stable. The revision arthroplasties in this study achieved an average of 75 points (range, 46 –100 points). This was divided into 7 good (.75 points), 7 fair (50 –74 points), and 2 poor (,50 points) results (Table 1). The assessment of x-rays with regard to loosening after revision surgery is difficult because of bony defects or fractures after failure of the primary implant. Morrey and Bryan7 suggested that a 1-mm cement bone interface involving more than 50% of the implant surface should be considered as inadequate fixation. According to these criteria, the patient (no. 7) with the deep periprosthetic infection (poor result [46 points]) radiographically showed loosening of both components. Another patient (no. 2) with a fair result (70 points) radiographically showed insufficient fixation of the ulnar implant. All other implants were radiographically shown to be stable.
1342 Stefan Ehrendorfer / Elbow Revision Arthroplasty
Discussion Revision elbow arthroplasty is a well-described treatment option for failed elbow arthroplasty.7–9,13 With preserved bone stock, revision can be completed using primary elbow arthroplasty implants. This was possible in 31 of 47 elbow revision arthroplasties performed in this institution between April 1991 and December 1995. In the remaining 16 revision procedures, bone loss necessitated the use of a long-stem prostheses to achieve bony anchorage of the implant distant to the joint. Both linked and unlinked systems have been used at various institutions. The initial use of highly constrained hinge prostheses showed an early loosening rate of approximately 25%,14,15 which was reduced with the evolution of design to surface replacements and loose hinges.4,5,16,17 Good results have been reported by King et al,9 who used a linked system with a sloppy hinge, which reduced the risk of postoperative instability without evidence of prosthetic loosening. In 1997, these investigators reported the 6-year results using the semiconstrained Mayo-modified Coonrad implant in 41 patients with major bone loss, including 20 patients with posttraumatic osteoarthrosis. They reported a similar proportion of intraoperative complications and the need for 8 additional operative interventions, including 1 resection arthroplasty at 4 years because of recurrent aseptic loosening. They also reported 2 exchanges of worn polyethylene axis in the osteoarthrosis group and 1 revision of an ulnar component because of a periprosthetic fracture in a rheumatoid patient. There was complete pain relief in 22 patients and mild discomfort in 16. The disability remained in 3 patients: 1 with pain due to loosening, 1 because of a pre-existing nerve injury, and 1 because of a revision-related nerve injury. Dent et al8 reported 26 primary elbow revision arthroplasties using 14 primary (9 Wadsworth Mark 2 and 5 Souter-Strathclyde) prostheses and 12 longstem Souter-Strathclyde prostheses. At a mean follow-up period of 35 months, these investigators recorded 10 good, 14 fair, and 2 poor results according to Morrey and Bryan’s7 revision classification. These results compare slightly favorably with the results of this study, but include a majority of patients with insignificant bone loss at the time of revision. Alternative procedures, such as the use of elbow allografts for reconstruction of massive bone loss,18 have a high complication rate. Of 23 patients, allograft removal was required in 6 and second-stage
arthroplasty was required in 3. Because of instability, resection arthroplasty is likely to give less-satisfying results than revision arthroplasty in the situation of major periarticular bone loss. Because of the good results obtained with the primary surface replacement Souter-Strathclyde elbow arthroplasty, a different concept was followed at the Upper Limb Unit at Wrightington Orthopaedic Hospital and the long-stem version of this prosthesis was used in circumstances of bone loss. The performance of this implant and patient satisfaction were assessed in 16 elbows that had a mean follow-up period of 31 months. Using the revision elbow arthroplasty classification system described by Morrey and Bryan,7 7 good results, 7 fair results, and 2 failures were encountered. In both of the failures postoperative instability necessitated further surgical procedures. This led to one deeply infected implant undergoing resection arthroplasty more than 41 months after revision arthroplasty and one poor result due to elbow instability with ulnar nerve hypersensitivity needing splinting after 11 months. This suggests that the use of a linked arthroplasty system might be preferable in cases of significant, irreparable ligament instability. Impairment of ulnar nerve function was encountered in 6 of the 16 limbs undergoing surgery and was a point of major concern. Three of these 6 patients experienced paresthesia; more importantly, however, the other 3 also suffered from reduced ulnar motor function, combined in 1 patient with ulnar nerve hypersensitivity, causing severe functional limitation. In these patients the ulnar nerve was identified and decompressed; however, it was left in situ according to the surgical strategy at this institution. King et al9 reported less ulnar nerve complications with routine anterior nerve transposition, which is the standard procedure at the Mayo Clinic and might be a preferable technique in revision elbow surgery. The average revision elbow score in our patient group was 75 points (out of 100), thus just achieving the level considered good. In particular, the good functional result, the good pain relief, and the high level of patient satisfaction in the 14 successful revision elbow replacements was encouraging. This has to be considered in light of a low-demand patient group with longstanding severe polyarthritis. In the SF-36 health survey these patients scored low in physical function and poor in role–physical; however, they scored good in role– emotional, especially in mental health, at the time of the latest review.
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1343
The reported early results are encouraging and support the use of an unlinked cemented long-stem prosthesis in elbow revision arthroplasty in cases with major bone loss provided joint stability can be achieved. The 2 poor results in this study were due to postoperative instability. Poor results appear to be more likely in patients lacking one or both of the supracondylar columns who have incompetent collateral ligaments and in patients with pre-revision instability. The use of a linked prosthesis in such patients might be preferable. The author is grateful to the team of the Upper Limb Unit at Wrigthington Hospital for their support.
References 1. Souter WA. Surgery for rheumatoid arthritis: 1. Upper limb surgery of the elbow. Curr Orthop 1989;3:9 –13. 2. Ewald FC, Scheinberg RD, Poss R, Thomas WH, Scott RD, Sledge CB. Capitellocondylar total elbow arthroplasty: two to five-year follow-up in rheumatoid arthritis. J Bone Joint Surg 1980;62A:1259 –1263. 3. Ewald FC, Simmons ED Jr, Sullivan JA, et al. Capitellocondylar total elbow replacement in rheumatoid arthritis: long-term results. J Bone Joint Surg 1993;75A:498 –507. 4. Rosenberg GM, Turner RH. Nonconstrained total elbow arthroplasty. Clin Orthop 1984;187:154 –162. 5. Kudo H, Iwano K. Total elbow arthroplasty with a nonconstrained surface-replacement prosthesis in patients who have rheumatoid arthritis: a long-term follow-up study. J Bone Joint Surg 1990;72A:355–362. 6. Morrey BF. Revision of failed total elbow arthroplasty. In:
7. 8. 9.
10.
11.
12. 13.
14. 15. 16.
17.
18.
Morrey BF, ed. The elbow and its disorders. Philadelphia: WB Sanders, 1985:676 – 677. Morrey BF, Bryan RS. Revision total elbow arthroplasty. J Bone Joint Surg 1987;69A:523–532. Dent CM, Hoy G, Stanley JK. Revision of failed total elbow arthroplasty. J Bone Joint Surg 1995;77B:691– 695. King GJW, Adams RA, Morrey BF. Total elbow arthroplasty: revision with use of a non-custom semiconstrained prosthesis. J Bone Joint Surg 1997;79A:394 – 400. Morrey BF, Adams RA, Bryan RS. Total replacement for post-traumatic arthritis of the elbow. J Bone Joint Surg 1991;73B:607– 612. Ware JE: SF-36 Health Survey Manual and Interpretation Guide. Boston: The Health Institute, New England Medical Centre, 3.1–9.34. Campbell WC. Incision for exposure of the elbow joint. Am J Surg 1932;15:65– 67. Figgie HE III, Inglis AE, Ranawat CS, Rosenberg GM. Results of total elbow arthroplasty as a salvage procedure for failed elbow reconstructive operations. Clin Orthop 1987;219:185–193. Dee R. Reconstructive surgery following total elbow endoprosthesis. Clin Orthop 1982;170:196 –203. Morrey BF, Bryan RS. Complications of total elbow arthroplasty. Clin Orthop 1982;170:204 –212. Burnett R, Fyfe IS. Souter-Strathclyde arthroplasty of the rheumatoid elbow: 23 cases followed for 3 years. Acta Orthop Scand 1991;62:52–54. Morrey BF, Adams RA. Semiconstrained arthoplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg 1992;74A:479 – 490. Dean GS, Holliger EH IV, Urbaniak JR. Elbow allograft for reconstruction of the elbow with massive bone loss: long term results. Clin Orthop 1997;341:12–22.
According to Souter,1 the elbow joint is affected in 50% of cases of longstanding rheumatoid disease. Primary elbow arthroplasty is a well-established treatment option in rheumatoid arthritis, with documented improvement of function and pain.1–5 The number of arthroplasties performed has increased; consequently, the number of patients requiring revision has increased. Infection, fracture, prosthetic failure, instability, and prosthetic loosening are the main indications for revision.6 Encouraging results of revision elbow arthroplasty using various systems have been described.7,8 If bone stock is well preserved at the time of revision, From Wrightington Orthopaedic Hospital, Wigan, Lancashire, UK. Received for publication May 18, 1998; accepted in revised form June 9, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Stefan Ehrendorfer, MD, Orthopaedic Department, Law Hospital, Carluke, Lanarkshire, ML8 5ER UK. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A06-0018$3.00/0
primary elbow arthroplasty implants can be used. In case of major periarticular bone loss, implants achieving bony anchorage distant to the joint line have to be used for revision arthroplasty. In this scenario, both linked and unlinked systems have been used. Good results have been reported by King et al9 using a linked system, which reduced the risk of postoperative instability without evidence of prosthetic loosening with a sloppy hinge. Based on the good clinical experience with the primary surface replacement elbow arthroplasty, which was designed by Souter in cooperation with Strathclyde University (Glasgow, UK), a different concept was followed at the Upper Limb Unit at Wrightington Orthopaedic Hospital. The results in a group of patients requiring first-revision elbow arthroplasty who have major periarticular bone loss and who were treated using the unlinked cemented long-stem version of this implant are presented.
Patients and Methods From April 1991 to December 1995, 47 revision elbow arthroplasties were performed at this instituThe Journal of Hand Surgery 1337
1338 Stefan Ehrendorfer / Elbow Revision Arthroplasty
tion, where the Souter-Strathclyde prosthesis has evolved as the preferred implant both for primary and revision arthroplasty. Thirty-one of 47 elbow revisions were performed using a primary elbow prosthesis, mainly the Souter-Strathclyde; a few Wadsworth Mark 2 prostheses (Biomet, Bridgend, UK) were used early in the study period. In 16 revision surgeries involving 15 patients, major periarticular bone loss warranted bony anchorage distant to the joint line. These patients form the study group; all were managed with the cemented long-stem version of the Souter-Strathclyde prosthesis in the absence of infection. All 15 patients were available for review and gave informed consent to participate in this retrospective study. Assessment by an independent orthopedic surgeon included the collection of demographic data, the length of the follow-up period, the presence and duration of rheumatoid arthritis, the side of operation, and the time between the primary and revision surgeries. The preoperative bone loss was recorded according to Morrey et al.10 The reasons for revision (aseptic loosening, traumatic loosening, instability), complications (humeral or ulnar intraoperative perforation, fracture, and postoperative instability), the humeral and ulnar stem lengths, and the type of implant were determined from patient records and x-rays. We further assessed the range of movement in the sagittal plane, including flexion contracture, the maximum flexion, and the arc of motion using a goniometer, and recorded lifting power (in 90° elbow flexion) and clinical ulnar nerve function with sensory and motor function (impairment: paresthesia, numbness, hypersensitivity, motor function reduced to grade 4). Using visual analog scales, we measured subjective pain (1, severe; 10, no pain), subjective independence (1, completely dependent; 10, absolutely independent), and subjective satisfaction (1, very dissatisfied; 10, extremely satisfied). The assessment of x-ray findings and the grading of results was performed according to Morrey and Bryan.7 All patients were given information and instructions for the SF-36 health survey11 at the final review and were asked to complete it.
Demographic Data The average patient age at the time of revision surgery was 62 years (range, 37–74 years). Fourteen of the 15 patients were female. Thirteen patients had rheumatoid polyarthritis with an average duration of disease of 25 years (range, 7–39 years). Two patients
had psoriatic arthritis. All 15 patients had polyarthritic disease with significant co-morbidity. At the time of review all 15 patients had undergone previous surgery of various other joints: 4 hemi or total shoulder replacements, 1 contralateral revision, 3 contralateral primary elbow arthroplasties, 14 wrist joint arthrodeses or replacements, 10 total hip replacements, 15 total knee replacements, and 4 ankle arthrodeses or replacements. All 15 patients had undergone their first revision elbow arthroplasty. Three patients had undergone synovectomy before the primary elbow arthroplasty. The left to right distribution of the revision arthroplasties was even (patient 5 in Table 1 had bilateral revisions).
Revision Procedure The surgical technique was standardized with the use of laminar air-flow operating rooms, body exhaust suits, a proximal arm tourniquet, and lateral decubitus patient positioning. A direct posterior triceps reflecting approach12 was used. The ulnar nerve was identified and decompressed but not transposed anteriorly, according to the standard surgical technique at this institution. The anteromedial collateral ligament was preserved if possible. The preoperative bone loss in the distal aspect of the humerus was assessed according to the method of Morrey et al10 and is shown in Table 1. This classification comprises grade 1 (no patients) when the subchondral bone architecture is intact, grade 2 (11 elbows) when the medial and lateral supracondylar columns are preserved, grade 3 (3 elbows) when either the medial or the lateral supracondylar column is absent, and grade 4 (2 elbows) when the entire distal aspect of the humerus to or proximal to the level of the olecranon fossa is absent. The olecranon process was sufficiently preserved to allow attachment of the triceps tendon in all patients. The removal of loose components (12 cases) posed no major problem. Two elbows were revised for instability and 2 for traumatic loosening (Table 1). Both components were removed in all revisions. For cement removal an air-powered drill and various burrs and goose neck gouges were used. At trial reduction, correct spacing of the joint is important as it controls tension in the posterior structures because of the fixed length of the anterior capsule. The positioning of the components is crucial as it influences the tension of the soft tissues, including the collateral ligaments, if preserved. The aim of the procedure is to restore the anatomic position of the joint axis. The
62 56 54 53 45 7 45 41 38 26 18 14 13 12 11 6 31.3
70 37 56 65 43 46 65 70 74 66 67 71 62 67 64 67 62
F F M F F F F F F F F F F F F F
30 15 15 24 33 35 0 7 39 23 30 25 19 34 13 0 24.5
R L R R L R L R L R R L L R L L 8 L:8 R
Side 19 3 4 4 5 8 4 3 7 6 4 0.5 2 8 0.2 3 5
4 2 2 2 2 2 2 3 2 3 2 3 2 2 2 4
AL AL AL AL AL AL AL Instability AL AL AL TL Instability AL TL AL
Reason for Revision
UF HIP HIP HIP UIP UIP 1 PI HIP
HIP UIP HIP 1 PI
HIP 1 UIP
HIP
15,D 8,A 15,C 8,A 15,C 15,A 4, P 8,A 8,A 15,C 15,A 15,A 15,A 15,A 8,A 15,A
9, A 7, A 9, A 7, A 7, A 5, A 7, A 5, B 5, A 7, A 7, A 2.5, P 7, A 5, A 5, A 5, A
Humeral Ulnar Stem Stem Length Length Complications (cm)* (cm)* 55–135 5 80 45–150 5 105 10–120 5120 55–125 5 70 60–150 5 90 30–120 5 90 95–120 5 35 20–90 5 70 65–150 5 85 60–135 5 75 35–125 5 90 25–130 5 105 60–135 5 75 40–135 5 95 25–90 5 65 25–135 5 110 85
Range of Movement in the Sagittal Plane (°)† 1.5 2 3.5 0.5 2 2 0.5 0 1 1.5 1.5 2 1 1.5 0.5 1.5 1.4 SI:H, F4 SI:P, F4
SI:P
SI:N
SI: P SI:P, F4
9 5 6 7 5 5 6 4 7 10 9 10 10 4 4.5 9 6.9
8 7 7 4 7 7 3 5 8 7.5 7 3 6 7 5 9 6.2
8 7 10 10 8 8 2 1 6 10 8 10 7 8 1 7.5 6.9
84 70 76 72 70 70 56 46 72 90 94 100 90 64 47 94 75
Both
Ulna Fig. 1
Lifting Power in 90° Elbow Ulnar Flexion Nerve Function X-ray (kg) Function Pain‡ Independence§ Satisfaction11 Score¶ Findings#
AL, aseptic loosening; TL, traumatic loosening; HIP, humeral intraoperative perforation; UIP, ulnar intraoperative perforation; PI, postoperative instability; UF, ulnar fracture; SI: P, sensory impairment with paresthesia; SI:N, sensory impairment with numbness; SI:H, sensory impairment with hypersensitivity; F4, motor function reduced to grade 4. * A–D, see text; P, primary implant. † The first number is the fixed flexion contracture, the second is the maximum flexion, and the third is the absolute arc of motion. ‡ Subjective pain graded according to the visual analog scale: 1, severe; 10, no pain. § Subjective independence: 1, completely dependent; 10, absolutely independent. \ Subjective satisfaction: 1, very dissatisfied; 10, extremely satisfied. ¶ Elbow revision arthroplasty score. # Only loose components are specified.
1 2 3 4 5 5 6 7 8 9 10 11 12 13 14 15 Mean
Length of Duration of FollowRheumatoid Arthritis Patient up Period Age (mo) (y) Gender (y) No.
Time Between Primary and Revision Surgery Preoperative (y) Bone Loss
Table 1. Patient Demographics and Results
1340 Stefan Ehrendorfer / Elbow Revision Arthroplasty
restoration of length at revision increased soft tissue tension in a few patients, but closure was achieved in all cases by standard methods with attention to the distal attachment of the triceps to the olecranon. After surgery the elbow was placed in a plaster splint in 30° flexion for 36 hours. Mobilization was started on the sixth postoperative day, commencing with isometric exercises; it was delayed to 6 weeks in the patients with the ulnar snap fit implant. Postoperative wound healing was achieved in all cases.
Prosthesis Major bone deficiencies precluded the use of a primary elbow prosthesis at revision in all patients. In this situation the long-stem version of the Souter-Strath-
clyde prosthesis was always used. In 2 patients one primary component, which is interchangeable, was used. The long-stem system provides a variety (Fig. 1) of humeral components with preservation of both (model A) the lateral and (model B) the medial (model C) supracondylar bone stock. Model D resects 4 cm of the distal humerus. Stem length is available at 8 or 15 cm. The options for the ulnar component include the all-polyethylene implant, which has a length of 2.5 cm (patient 11) and the metal backing model A (olecranon retained, used in 14 elbows) and model B (minimum resection, used in patient 7). Stem length is available at 5, 7, and 9 cm. A snap-fit polyethylene inlay is optional and was used in the patients revised for instability (nos. 7 and 12).
Figure 1. Anteroposterior (A) and lateral (B) x-rays of patient 3.
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1341
Results For the 15 patients (16 elbows) included in this study, the time interval between primary elbow replacement and revision varied between 2 months (traumatic loosening) and 228 months (average, 60 months). The time between revision and the latest clinical and radiographic follow-up examinations averaged 31 months (range, 6 – 62 months). Intraoperative complications included humeral shaft perforation alone in 6 patients, ulnar shaft perforation alone in 3, and perforation of both in 1. In patient 9 an ulnar fracture at the tip of the component became a nonunion without clinical symptoms (Table 1). The most devastating postoperative complication was instability, leading to the 2 poor results. Patient 7 underwent several soft tissue procedures, ending with a deep infection with humeral fracture and loose components at the time of review (41 months after revision arthroplasty) and resection arthroplasty at a later stage. Patient 14 had revision elbow arthroplasty 2 months after the primary surgery because of traumatic loosening; she underwent a soft tissue procedure because of instability 1 month thereafter, but remained unstable. The additional treatment was conservative. Range of movement in the sagittal plane averaged 85° (range, 35° to 110°). The mean flexion contracture was 44° (range, 10° to 95°). Rotation ranged from 80° to 180° (average, 141°). Lifting power was measured at 90° elbow flexion with the forearm horizontal. Measurements varied between 0 and 3.5 kg (average, 1.3 kg). The ulnar nerve function was clinically intact in 10 extremities. Five patients experienced paresthesia (patient 14 also had marked hypersensitivity) and 1 patient (no. 10) had recurrent numbness in the ulnar nerve distribution. In 3 of these extremities, motor function in the ulnar nerve distribution was reduced to grade 4, according to the Medical Research Council (see Table 1). The pre-revision ulnar nerve function was not recorded, but only patient 14 stated a revision-related subjective deterioration of sensory and motor function. Pain in the revised elbow arthroplasty was measured with a visual analog scale (1, extremely severe; 10, no pain). Six patients reported values of 9 or 10 without the use of medication. The average score was 6.9; the worst score was 4, reported by the patient with the deep infection and a patient with a flair-up of rheumatoid disease. Subjective independence was assessed on a visual analog scale (1, completely dependent; 10, abso-
lutely independent). The average value was 6.2 (range, 3–9). The main complaint of patients was impaired ability to carry. Subjective satisfaction with the revision operation and implant was measured with a visual analog scale (1, very dissatisfied; 10, extremely satisfied) and averaged 6.8. The 2 patients with a poor result scored 1. One elbow implant was deeply infected and loose (patient 7, Table 1); the other arthroplasty had dislocated repeatedly and the patient (no. 14, Table 1) was suffering from ulnar nerve hypersensitivity. One patient (no. 6) reported a score of 2 because of only 35° range of movement. All the other patients graded themselves between 6 and 10. The SF-36 health survey11 was administered to all 15 patients at the final review. It could be assessed completely for 14 patients and partially for the remaining patient. Physical health was poor, with an average physical functioning score of 23% and a role–physical score of 15%. General health aspects revealed an average bodily pain score of 50%, a general health score of 43%, a vitality score of 41%, and a social functioning score of 63%. Mental health was less impaired, with an average role– emotional score of 59% and a mental health score of 68%. Morrey and Bryan7 described a classification system used to grade the results of elbow revision arthroplasty. There are 3 categories with a maximum combined score of 100 points: for pain, between 0 points (severe pain) and 60 points (no pain) are given. For range of movement, 0 points (,30°) to 30 points (.90°) are added. Stability gives an additional 0 points if unstable and 10 points if stable. The revision arthroplasties in this study achieved an average of 75 points (range, 46 –100 points). This was divided into 7 good (.75 points), 7 fair (50 –74 points), and 2 poor (,50 points) results (Table 1). The assessment of x-rays with regard to loosening after revision surgery is difficult because of bony defects or fractures after failure of the primary implant. Morrey and Bryan7 suggested that a 1-mm cement bone interface involving more than 50% of the implant surface should be considered as inadequate fixation. According to these criteria, the patient (no. 7) with the deep periprosthetic infection (poor result [46 points]) radiographically showed loosening of both components. Another patient (no. 2) with a fair result (70 points) radiographically showed insufficient fixation of the ulnar implant. All other implants were radiographically shown to be stable.
1342 Stefan Ehrendorfer / Elbow Revision Arthroplasty
Discussion Revision elbow arthroplasty is a well-described treatment option for failed elbow arthroplasty.7–9,13 With preserved bone stock, revision can be completed using primary elbow arthroplasty implants. This was possible in 31 of 47 elbow revision arthroplasties performed in this institution between April 1991 and December 1995. In the remaining 16 revision procedures, bone loss necessitated the use of a long-stem prostheses to achieve bony anchorage of the implant distant to the joint. Both linked and unlinked systems have been used at various institutions. The initial use of highly constrained hinge prostheses showed an early loosening rate of approximately 25%,14,15 which was reduced with the evolution of design to surface replacements and loose hinges.4,5,16,17 Good results have been reported by King et al,9 who used a linked system with a sloppy hinge, which reduced the risk of postoperative instability without evidence of prosthetic loosening. In 1997, these investigators reported the 6-year results using the semiconstrained Mayo-modified Coonrad implant in 41 patients with major bone loss, including 20 patients with posttraumatic osteoarthrosis. They reported a similar proportion of intraoperative complications and the need for 8 additional operative interventions, including 1 resection arthroplasty at 4 years because of recurrent aseptic loosening. They also reported 2 exchanges of worn polyethylene axis in the osteoarthrosis group and 1 revision of an ulnar component because of a periprosthetic fracture in a rheumatoid patient. There was complete pain relief in 22 patients and mild discomfort in 16. The disability remained in 3 patients: 1 with pain due to loosening, 1 because of a pre-existing nerve injury, and 1 because of a revision-related nerve injury. Dent et al8 reported 26 primary elbow revision arthroplasties using 14 primary (9 Wadsworth Mark 2 and 5 Souter-Strathclyde) prostheses and 12 longstem Souter-Strathclyde prostheses. At a mean follow-up period of 35 months, these investigators recorded 10 good, 14 fair, and 2 poor results according to Morrey and Bryan’s7 revision classification. These results compare slightly favorably with the results of this study, but include a majority of patients with insignificant bone loss at the time of revision. Alternative procedures, such as the use of elbow allografts for reconstruction of massive bone loss,18 have a high complication rate. Of 23 patients, allograft removal was required in 6 and second-stage
arthroplasty was required in 3. Because of instability, resection arthroplasty is likely to give less-satisfying results than revision arthroplasty in the situation of major periarticular bone loss. Because of the good results obtained with the primary surface replacement Souter-Strathclyde elbow arthroplasty, a different concept was followed at the Upper Limb Unit at Wrightington Orthopaedic Hospital and the long-stem version of this prosthesis was used in circumstances of bone loss. The performance of this implant and patient satisfaction were assessed in 16 elbows that had a mean follow-up period of 31 months. Using the revision elbow arthroplasty classification system described by Morrey and Bryan,7 7 good results, 7 fair results, and 2 failures were encountered. In both of the failures postoperative instability necessitated further surgical procedures. This led to one deeply infected implant undergoing resection arthroplasty more than 41 months after revision arthroplasty and one poor result due to elbow instability with ulnar nerve hypersensitivity needing splinting after 11 months. This suggests that the use of a linked arthroplasty system might be preferable in cases of significant, irreparable ligament instability. Impairment of ulnar nerve function was encountered in 6 of the 16 limbs undergoing surgery and was a point of major concern. Three of these 6 patients experienced paresthesia; more importantly, however, the other 3 also suffered from reduced ulnar motor function, combined in 1 patient with ulnar nerve hypersensitivity, causing severe functional limitation. In these patients the ulnar nerve was identified and decompressed; however, it was left in situ according to the surgical strategy at this institution. King et al9 reported less ulnar nerve complications with routine anterior nerve transposition, which is the standard procedure at the Mayo Clinic and might be a preferable technique in revision elbow surgery. The average revision elbow score in our patient group was 75 points (out of 100), thus just achieving the level considered good. In particular, the good functional result, the good pain relief, and the high level of patient satisfaction in the 14 successful revision elbow replacements was encouraging. This has to be considered in light of a low-demand patient group with longstanding severe polyarthritis. In the SF-36 health survey these patients scored low in physical function and poor in role–physical; however, they scored good in role– emotional, especially in mental health, at the time of the latest review.
The Journal of Hand Surgery / Vol. 24A No. 6 November 1999 1343
The reported early results are encouraging and support the use of an unlinked cemented long-stem prosthesis in elbow revision arthroplasty in cases with major bone loss provided joint stability can be achieved. The 2 poor results in this study were due to postoperative instability. Poor results appear to be more likely in patients lacking one or both of the supracondylar columns who have incompetent collateral ligaments and in patients with pre-revision instability. The use of a linked prosthesis in such patients might be preferable. The author is grateful to the team of the Upper Limb Unit at Wrigthington Hospital for their support.
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