The guildford elbow

THE GUILDFORD

EL

0. BRADY and W. QUINLAN from

St Mary’s Orthopaedic Hospital Cappagh, Dublin, Eire

The Guildford elbow is a new unconstrained elbow arthroplasty. From 1985 to 1991, this arthroplasty was used in 24 patients with rheumatoid arthritis. The patients were reviewed after an average of 28 months (4-59 months). Good to excellent results were obtained in 95% regarding pain relief and functional improvement. Complications were few, with only one case of clinical loosening and three of radiological loosening. Ulnar nerve hypo-aesthesia was common but did not jeopar the final result in any patient.

Journal of Hand Surgery (British and European Volume, 1993) 18B: 389-393 The elbow joint is commonly involved in rheumatoid arthritis. Synovectomy and radial head excision are helpful in treating early joint disease and provide satisfactory results in 50% of patients for up to 5 years. With advanced arthritis, however, joint movement is restricted and severe pain is present because of joint incongruity. As arthrodesis of the elbow is contraindicated in multi joint disease, and poor results have been reported with excisional arthroplasty (Dickson et al, 1976), elbow replacement is indicated in this small group of patients. This paper reports on our early results of an unconstrained total elbow prosthesis.

and the second is perpendicular to this in the coronoid process. A template is placed along the posterior cortex of the humerus allowing precise humeral cuts to be made, which ensure correct varus/valgus alignment. Medullary canals are gently reamed to prevent perforation of the usually weak, thin cortices. The humeral component is cemented in place before the ulnar component. After a trial of flexion and extension two drains are inserted and the wound is closed in layers. Transposition of the ulnar nerve is usually not required. The elbow is then immobilized at 90” of flexion in a plaster of paris backslab for 2 weeks, after which time the sutures are removed and a 2-week course of physiotherapy begins. This consists of active and continuous passive motion exercises.

THE PROSTHESIS The Guildford elbow was designed by Stiles in the Royal Surrey County Hospital, Guildford (Karanjia and Stiles, 1990). The components are totally unlinked and replace the humero-ulnar compartment of the elbow joint. Both the ulnar and humeral components are stemmed. The humeral component consists of a cobalt-chromemolybdenum alloy, and the ulnar component of ultrahigh molecular weight polyethylene. Together they provide a low friction arthroplasty. Both components are cemented in position with low viscosity methyl methacrylate (Fig 1). SURGICAL

Between 1985 and 1991 25 Guildford elbow arthroplasties were inserted in 24 patients at St Mary’s Orthopaedic Hospital, Cappagh, Dublin. All operations were performed by one surgeon (WQ). Three patients died from other causes during the follow-up period and were excluded from the study. All 22 remaining arthroplasties

TECHNIQUE

All operations are performed under tourniquet with the patient lying supine and the arm placed across the chest. The posterior skin incision begins in the mid-line proximally and gently curves to the radial side of the forearm. This incision allows minimum soft tissue dissection. The ulnar nerve is then identified, isolated and preserved. The triceps aproneurosis is not disrupted. The soft tissues on the medial and lateral sides of the olecranon are dissected subperiosteally down to the level of the joint. In all cases the radial head is excised. A bone lever is inserted from the lateral side of the joint, deep to the triceps tendon across to the medial supracondylar ridge. The forearm is now supinated which gives good exposure of the elbow joint. Two subchondral cuts can now be made in the ulna with the reciprocating saw. The first is parallel with the posterior border of the ulna

Fig 1 389

The prosthesis.

THE JOURNAL OF HAND SURGERY VOL. 18B No. 3 JUNE 1993

390

were reviewed clinically and radiologically by the other author. There were 14 women and seven men. The dominant side was involved in 11 patients, with an equal number involving the non-dominant elbow. The age of the patients ranged from 38 to 76 years (Mean 60.6 years). All patients reviewed were serologically proven to have rheumatoid arthritis. Patients had suffered from the disease for between 5 and 20 years (mean 14.4 years), with a duration of symptoms in the effected elbow from 6 months to 10 years (mean 4 years) prior to operation. The follow-up period ranged from 4 to 59 months with an average of 28 months. 12 patients had previously had other joints replaced. Three patients had three other joints replaced, one patient had four other joints replaced and one patient had five other joints replaced. Four patients had previous operations on the affected elbow, three had excision of the radial head and one had open reduction and internal fixation for a fractured olecranon. The majority of patients had other joints in the same limb affected by their disease, the shoulder in 13 patients, the wrist in 15 patients, the hand in 14 patients, The indications for surgery were severe pain and/or dysfunction. 18 patients complained of both, two patients complained of severe pain alone, and two patients complained of dysfunction alone. All patients who were reviewed were assessed regarding pain, arm function, X-rays and patient satisfaction with the result. A goniometer was used to measure elbow flexion and extension, as well as forearm pronation and supination. Serial radiographs were performed at each out-patient visit. These were compared for radiological evidence of loosening.

Table l-Pain

assessment Pre-op

Visual Analogue Present/absent Rest Movement

Scale (VAS)

Post-op

7.2

0.24

57% 100%

0% 9.5%

intensive physiotherapy after arthroplasty her ability to perform the above activities did not improve. All patients who had arthroplasties performed on the non-dominant side showed improvement in all of the above activities. Two patients who had an arthroplasty on the non-dominant side subsequently used this hand to perform perineal toilet, as the dominant shoulder was severely affected. Improvement in function was documented in 21 out of 22 elbows (95.4%). Movement The average range of flexion and extension was 53”-114” pre-operatively and 38.9”-143.9” post-operatively (Fig 2). 15 patients (71%) achieved a range greater than 100”. Full flexion was restored in 15 patients (71%). The average range of pronation and supination postoperatively was 144”, pronation being 73” and supination 71” (Fig 3). Pre-operative pronation and supination were not accurately assessed. 13 patients (63%) achieved a flexion-extension range of 36”-130”. The functionally significant range of 50” pronation and 50” supination was achieved in 17 elbows (77%) (Morrey et al, 1981). Radiography

RESULTS Pain The subjective assessment of pain was graded on a visual analogue scale and recorded as either present or absent while at rest and/or during movement. The average score was 7.2 on movement pre-operatively and 0 for all but one patient (95.5%) post-operatively. This patient had a loose prosthesis and gave a score of 5 during movement and 0 at rest (Table 1).

Three elbows showed radiological evidence of loosening. In one patient the tip of the humeral component had perforated the anterior cortex of humerus (Fig 4). The patient was asymptomatic despite the humeral compoMOVEMENT GONIOMETER - >lOO’IN 71% Pre - op

Function Functional assessment was based on the ability to perform daily activities, including, feeding, dressing, washing, combing hair, shirt buttons, collar buttons, perineal toilet, carrying weights and the return to former activities. Ten of 11 arthroplasties performed on the dominant side showed improvement in all the above activities. One unimproved patient was noted to have severe arthritis affecting her ipsilateral shoulder and wrist. Despite having two MUA’s of her elbow and

180’

0'

Wrist

Fig 2

Elbow

Pre-operative

and post-operative

Shoulder

flexion and extension

ranges.

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391

ELBOW

MOVEMENT GONIOMETER

Minor complications occurred in a further 42%. These did not compromise the final outcome.

CONTINUED - >lOO’IN 77% 0’

Instability

In one patient the prosthesis subluxed posteriorly in the early post-operative period. This was confirmed radiologically. 2 weeks post-operatively an EUA was performed which showed that the joint was stable. The same patient had radial nerve hypoaesthesia. One other patient has a feeling of instability when a valgus strain is applied to the joint; however it has never dislocated. 90’

Axis of

Full Supination

Fig 3

rotation

Post-operative

forearm

90’

Fractures

Full

In one case a small fracture occurred through the medial condyle of the humerus. This later gave rise to the only clinically loose prosthesis (Fig 5).

Pronation

rotation.

nent being palpable beneath the biceps tendon. A second patient had clinical and radiological evidence of loosening and is awaiting revision (Fig 5). A third patient 5 years after joint replacement has radiological signs of loosening but is asymptomatic (Fig 6). COMPLICATIONS

Major complications -

Frg 4

occurred in 3 patients (14%):

Migration of humeral prosthesis Ulnar nerve entrapment which required transposition A fractured condyle which was later responsible for loosening of the prosthesis.

Humerai

prosthesis

perforating

anterior

cortex

of humerus.

Infection

There were no cases of infection. Delayed healing

One patient developed blisters around the incision, but healing was only delayed by a few days and wound breakdown did not occur. Ulnar nerve symptoms

Hypoaesthesia of the ring and little fingers occurred in ten patients (45%). However, no patient had major permanent ulnar nerve damage. Six patients (37%) have

392

Fig 5

THE JOURNAL OF HAND SURGERY VOL. 18B No. 3 JUNE 1993

Radiological signs of marked loosening including osteolysis and cement fracture.

patient had clinical and radiological evidence of loosening. Only one other patient stated that they would not undergo the same procedure again. This was because of severe pain in the immediate post-operative period which was secondary to swelling of the joint. This same patient developed blisters around the wound edges and a temporary ulnar nerve paresis, both of which did not affect the final outcome. DISCUSSION

Fig 6

Radiological signs of loosening around humeral component.

intermitted hypoaesthesia. One patient developed ulnar nerve symptoms 4 days post-operatively. Exploration was carried out and the ulnar nerve was found to be trapped between the ulnar and humeral components. The ulnar nerve was transposed anteriorly and the symptoms resolved immediately. Patient satisfaction

At the latest review 20 patients (95%) stated that they were satisfied with their arthroplasty. One dissatisfied

The elbow joint is not a simple hinge joint. During flexion and extension, there is rotation of the forearm bones, and there is also a change in the carrying angle of the elbow (Ingles and Pellicci, 1980). This facilitates carrying of objects when the elbow is extended and guides the hand towards the mouth as the elbow is flexed. As a result of these complex movements the earlier constrained uniaxial hinge arthroplasties had a very high incidence of failure due to loosening (Ingles and Pellicci, 1980; Souter, 1973). Such complications led to the development of semi-constrained and unconstrained prostheses. These allowed the surrounding soft tissues to absorb most of the shear forces transmitted across the joint resulting in less force being generated in the interfaces between the prosthetis, cement and bone. The Guildford unconstrained elbow is such a prosthesis. It provides excellent pain relief. All patients in our series were pain-free immediately post-operatively, and 95% were pain-free at the last review. 95% of patients have improved their ability to perform daily activities. Full flexion and forearm rotation were achieved in 7 1% of patients. Full extension was never achieved, but 62% of patients had flexion deformities of less than 36”. Elbow arthroplasty has a high incidence of compli-

THE GUILDFORD

ELBOW

cations. Roper et al (1986) reported a major complication rate of 27%. We have a major complication rate of 14%; with a minor complication rate of 42% which did not affect the final outcome. Ulnar nerve symptoms occurred in 45% of patients immediately postoperatively. A number of well-documented factors may be responsible for this, including underlying subclinical peripheral neuropathy, excessive mobilization and traction of the nerve, and interference with the blood supply of the epineurium. However, the most likely cause is stretching of the nerve across the elbow joint as the humerus is lengthened by insertion of the prosthesis. Since reporting this series it has become our policy to transpose the ulnar nerve anteriorly. There were no cases of major nerve damage. Instability, although a common problem with unconstrained prostheses, occurred temporarily in only one patient. Because the major complication of elbow arthroplasty is loosening, we have paid particular attention to cementing technique. Karanjia and Stiles (1990) report a radiological loosening rate of 23% and a revision rate of 12% for primary replacement. In our serious radiological loosening occurred in 13.6% and symptomatic loosening has occurred in one patient (4.5%). We feel that

393

the combination of stemmed ulnar and humeral components as well as meticulous attention to cementing technique has kept our loosening rate to a minimum. Although our results are short term we feel that they are encouraging enough to recommend elbow replacement with this prosthesis. References DICKSON, R. A., STEIN, H., and BENTLEY, 6. (1976). Excision arthroplasty of the elbow in rheumatoid disease. Journal of Bone and Joint Suraerv. I I, 588: 2: 227-229. INGLES, A. E. and PELLICI, P. M. (1980). Total elbow replacement. Journal of Bone and Joint Surgery, 62A: 8: 1252-1258. KARANJIA, N. D., and STILES, P. .I. (1990). The Guildford elbow. International Orthopaedics, 14: 3 15-3 19. MORREY, B. F., ASKEW, L. J., AN, K. N., and CHAO, E. Y. (1981). A biomechanical study of normal functional elbow motion. Journal of Bone and Joint Surgery, 63A: 6: 872-877. ROPER, B. A., TUKE, M., O’RIORDAN, S. M. and BULSTRODE, C. J. (1986). A new unconstrained elbow: A prospective review of 60 replacements. Journal of Bone and Joint Surgery. 688: 4: 566-569. SOUTER, W. A. (1973). Arthroplasty of the elbow with particular reference to metallic hinge arthroplasty in rheumatoid patients. Ortbopaedic Clinics of North America. 4: 2: 395-413.

Accepted: 6 May 1992 MI Owen Brady FRCSI, The Pulvertaft Road, Derby DE1 2QY, UK

Hand

Q

of the Hand

1993 The British

Society

for Surgery

Centre,

Derbyshire

Royal

Infirmary,

London