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Total elbow arthroplasty for treatment of elbow arthritis
REVIEW ARTICLE Total elbow
arthroplasty
Donald
Denver,
C. Ferlic, MD,
for treatment
Th
HEMIARTHROPLASTY
In 1971 Peterson and Janes38 reported on 2 Vitalliurn-mold arthroplasties of the olecranon notch. One had excellent results, the other fair results. In 1974 Street and Stevens@ reported on their use of a metallic distal humeral resurfacing device in 10 patients. Three of the patients had rheumatoid arthritis, and results in 2 of the 3 were unsatisfactory. One patient had complete elbow ankylosis and a transient ulnar neuropathy develop; the other patient’s case was complicated by elbow dislocation. HINGES
The results with the disappointing. Cooney a combination of 1 1 1 and Coonrad elbows,
arthritis
Co/o
ere are 3 basic types of elbow prostheses: constrained, semiconstrained, and nonconstrained. The constrained hinge is constructed with either metal-tometal or metal-to-high-density polyethylene, with the aid of a bushing or a separate polyethylene piece. The semiconstrained elbow (the so-called “sloppy hinge”) is designed to link the components together with an axle and-bushing arrangement but is less constrained in the varus/valgus plane than the constrained design. This type of prosthesis was designed to help correct some of the loosening problems associated with the constrained hinges. The unconstrained design consists of separate units of metal-to-high-density polyethylene components. This design relies on the soft tissue envelope, muscle tendon, and muscle ligament to maintain the articulation rather than an axle-bushing linkage. Some unconstrained prostheses are designed for use in tandem with a radial head replacement.
RIGID
of elbow
rigid hinges have likewise been and Bryan5 tabulated results on Schiers, Dee, McKee-Dee, GSB, with 24% associated with poor
From Denver Orthopedic Specialists, PC Reprint requests: Donald Cl Ferlic, MD, 1601 E 19th Ave, Suite 5000, Denver, CO 802 18. J Shoulder Elbow Surg 1999;8:367-78. Copyright 0 1999 by Journal of Shoulder and E/bow Surgery Board of Trustees. 1058-2746/99/$8.00 + 0 32/l/94890
Table
Types of elbow
Constrained
Coonrad Schiers Dee GSB McKee Mazas Stanmore
prostheses Semiconstrained
1
Nonconstrained
AHSC (Volz) Pritchard-Walker Pritchard Mark II Triaxial Coonrad II Schlein Silva St George-Bucholz Swanson Coonrad-Morrey GSB Ill Dee IV Norway Mayo
Kudo London Pritchard ERS Capitellocondylar (Ewald) Wadsworth Covendish Gunston Stevens-Street Souter-Strathclyde Guildford Liverpool Norway
results (Table). Cofield et al4 tabulated the complications in 346 hinged total elbow replacements of both constrained and semiconstrained types and found loosening in 13% of cases. Other complications in their series included fracture in 9%, wound problems in 9%, infection in 5%, ankylosis in 4%, neuropathy in 6%, and triceps rupture in 2%. Twelve cases required revision. personal
experience
with
the
rigid
hinge
The first 4 total elbow replacements that I participated in were performed with rigid hinge in patients with rheumatic elbow (3 GSB, 1 Coonrad I). The first of these procedures was in 1971. My team10 chose the GSB initially because we believed that its small size would preserve bone stock so that if the device necessitated removal, a stable fascial arthroplasty would still be possible. Two of the 4 elbows loosened with a marked amount of bone resorption (Figure 1). In light of these results, we started using nonconstrained resurfacing devices, including the Ewald, London, and Wadsworth. There is no place for the rigid hinge today. NONCONSTRAINED
DESIGNS
Nonconstrained elbow protheses were introduced to alleviate the loosening problem, but these have also been plagued with a high complication rate. Kudo et
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Figure 1 A, Radiograph of GSB hinge 1 year after operation shows solid fixation. B, Same hinge 18 years later with marked loosening and bone resorption.
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aI30 reported 24 cases of rheumatoid arthritis treated with a resurfacing prosthesis. Results were excellent in 14 cases and poor in 3. Two elbows failed to regain functional motion. Proximal migration of the humeral component occurred in 1 of the 2 elbows; the other had persistent sub1 uxation with pain and instability. In 1990 Kudo and lwano29 reported on 37 elbows in 36 patients. Because of a high incidence of proximal migration of the humeral component, they now use a humeral component with an intramedullary stem. Ewald et al14 reported on 60 prosthetic replacements for rheumatoid arthritis. Although the results were excellent or good in 87% of the cases, they encountered a 39% complication rate. Eight cases required revision of the arthroplasty: 4 for dislocation, 2 for sepsis, 1 for loosening, and 1 for fracture. Five patients had recurrent dislocation, and 5 had permanent and 6 had transient ulnar nerve palsy. There were 3 fractures, 2 of the olecranon and 1 of the humeral shaft. Three wounds demonstrated some degree of breakdown and skin loss. In a later report, Ewald and Jacobs13 described a lateral surgical approach that they used in an attempt to reduce the incidence of soft tissue problems in 54 elbows. The results were good or excellent in 90% of the cases. Complications included dislocation in 7% of the cases and permanent sensory ulnar nerve palsy in 4%. There was 1 deep and 1 superficial wound infection. Transient ulnar nerve palsy developed in 14% of the cases. Thus the lateral surgical approach did not change the rate of serious complications. They used a cemented radial head prosthesis in 8 elbows, but in 4 of these there was a radiolucent line at the cement/bone interface of the humeral component and at the radial head. By comparison, only 1 prosthesis without a radial head implant had a radiolucent line. In 1993 Ewald et al15 evaluated long-term results in 202 capitellocondylar elbows in 172 patients with rheumatoid arthritis with an average follow-up of 69 months (range 24 to 178 months). The greatest improvements were in terms of pain, function, and range of motion. Range of motion improved in all planes except extension and was not reversed with time. Roentgenograms showed a radiolucent line adiacent to 8 humeral and 19 ulnar components; most of the lines were incomplete and 11 mm. Revision was necessary in 3 (1.5%) elbows because of aseptic loosening and in another 3 (1.5%) because of dislocation. Complications included deep space infection in 3 (1.5%) elbows, wound problems in 15 (7%), permanent partial sensory ulnar nerve palsy in 5 (2.5%), permanent partial motor ulnar nerve palsy in 1 (O.S%), and dislocation in 7 (3.5%). Rosenberg and Turner44 reported on 28 Ewald cap itellocondylar arthroplasties for rheumatoid arthritis. Satisfactory results were obtain in 86% of the elbows. There was 1 failure from loosening, 2 remote infec-
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tions, and 4 dislocations, 1 of which required additional surgery. Davis et aI*0 reported on 30 Ewald arthroplasties for rheumatoid arthritis that resulted in excellent relief of pain. Wound infections developed in 2 cases that ultimately required removal of the prosthesis. There were 4 cases of subluxation, 1 of which required additional surgery. Ulnar neuropathy developed in 3 cases, 2 of which required neurolysis and rerouting of the nerve. Weiland et aI52 reported on 40 capitellocondylar arthroplasties in 35 patients, 32 of whom had rheumatoid arthritis. Malarticulation or dislocations occurred in 10 (29%). Deep infection necessitating removal of the prosthesis developed in 2 patients, and transient nerve palsy developed in 7. Adoption of the lateral Kocher approach was associated with a reduced incidence of nerve palsy. Trancik et aI50 reported a 57% complication rate in 35 capitellocondylar arthroplasties in 29 patients. There were 3 infections, 3 dislocations, 2 intraoperative fractures, 9 transient nerve palsies, 2 postoperative hematomas, and 1 intraoperative perforation of the ulna. Despite these problems, pain relief was achieved in all but 1 patient. There were no unstable elbows. Ljung et aI32 reviewed 50 capitellocondylar elbow replants performed with the lateral approach in 42 patients with rheumatoid arthritis who were followed up for a median of 3 years. Eight elbows required reoperation. Soft tissue problems developed in 7 elbows, and 1 prosthesis was removed because of deep infection. There was 1 case of traumatic disla cation that was stabilized after ligament reconstruction. Wound healing was delayed in 2 elbows. Transient ulnar nerve palsy developed in 1 1 patients; permanent palsy developed in 3. At follow-up, all elbows were either free of pain or only slightly painful; 49 of the elbows were stable and 43 had a range of motion sufficient for activities of daily living. Radiologic loosening of the humeral component was suspected in 1 asymptomatic elbow. Ljung et ,131 reported no wound problems and no loss of function in 42 capitellocondylar elbow replants that were immobilized for 12 days after operation. In 5 such elbows that were immobilized for only 5 days, however, they reported 2 cases of wound problems. Schemitsch et aI45 compared the results of capitellocondylar arthroplasties in patients previously operated on for rheumatic elbow with the results of the same procedure in patients with the same condition who had not undergone such an operation. They concluded that conversion to a capitellocondylar elbow is not onl more difficult after a previous operation has been per Yormed but that the results in such cases are inferior. Six of 23 patients who had the total elbow done as a secondary procedure had instability develop, whereas none of a similarly matched group with primary elbows did. Sjoden and Blomgren47 reported in 1992 on 13
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SouterStrathclyde elbows for rheumatoid arthritis. There were no cases of infection. Three humeral components became loose but remained asymptomatic. Sioden et aI48 later reported that 6 of 19 Souter-StrathClyde implants became loose after 5 years; complications included 1 intraoperative fracture of the medial epicondyle, 3 cases of neuropathy, and 1 dislocation. Burnett and Fyfe3 reported on 23 elbows in 17 patients with rheumatoid arthritis who were followed up for 3 years. A deep wound infection developed in 1 patient, and temporary ulnar nerve paresis developed in 4. Arcs of motion were moderately improved. Three elbows required revision, 2 for recurrent dislocation and the third after loosening caused by a humeral fracture. Lyall et al33 reported on 19 elbow arthroplasties for rheumatoid arthritis in 17 patients. Relief of pain was obtained in all cases but with a 32% complication rate. Complications included 2 temporary nerve palsies, 1 permanent palsy, 3 dislocations, and 2 cases of loosening. The mean follow-up was 41 months. Poll and Rozing39 reported on 34 elbow arthroplasties in 33 patients with a minimal follow-up of 2 years, Four of the arthroplasties were revised, 3 because of irreversible dislocation and 1 because of loosening. One prothesis was removed because of infection. In the remaining cases, pain either decreased markedly or resolved completely; function was greatly improved. Recent results of other total arthroplasties have also been reported.lll2J7 Personal
experience
with
nonconstrained
prostheses
I was part of a team 10 that implanted 21 unconstrained capitellocondylar elbows for rheumatoid arthritis. With an average follow-up of 48 months, the average elbow scored an 89.5 points on a loo-point scale; the pain and function ratings were excellent. We saw moderate gains in motion; however, the gains were less in patients with juvenile rheumatoid arthritis. There was 1 failure because of infection; this implant was removed 6 months after operation. The patient in question died 6 years after the index operation. In a later report17 on the same patients, we noted that 1 other patient had died whose elbow had been unstable at the last follow-up. The elbow of a third patient was revised at 9 years, 7 months after the index procedure because of instability (Figure 2). Follow-ups of the remaining 1 1 patients ranged from 9 years, 9 months to 14 years, 10 months (average 12.5 years). Of these patients, 1 sustained a fracture of the proximal ulna as a result of a fall. The ulnar component loosened and was removed; the fracture was plated and bone was grafted. The result for the patient was a hemiarthroplastic elbow that was free of pain and that had motion restored to the degree before fracture. The other 10 elbows have had satisfactory results with no evidence of loosening, rare or minimal pain, and no instability.
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Figure revised
Ferlic
2 Dislocation of nonconstrained with semiconstrained device.
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elbow.
Complications in my series of capitellocondylar total elbow arthroplasties
Elbow
was
(Ewald)
Eight (40%) of 20 Ewald total elbow arthroplasties had some type of complication.10 A total of 12 complications occurred in these 8 patients. There were 3 cases of postoperative ulnar neuropathy. All resolved completely, but 1 required anterior transposition of the ulnar nerve. A posterior interosseous neuropathy requiring surgical decompression developed in 1 patient 4 months after operation. Skin sloughs developed in 2 patients. Lateral subluxation of the implant developed in 1 of these patients during the early postoperative period, possibly contributing to the complication. An abdominal pedicle flap was required to obtain skin coverage after 2 unsuccessful rotational skin flaps were performed. The postoperative course of the other patient with a skin slough was complicated by acute renal failure, gramnegative septicemia, and acute cholecystitis requiring a prolonged stay in the intensive care unit. The routine postoperative therapy program was delayed, and on removal of the splint an area of pressure necrosis was noted over the olecranon. Skin coverage was obtained with a rotational skin flap.
A dislocation with hemarthrosis was noted in 1 case during the immediate postoperative period. This condition was treated successfully with open reduction and hematoma drainage; there were no further problems in the next 12 years. There were 2 cases of implant sub luxation. One of these cases resolved after 4 weeks of cast immobilization. In the other case, the patient was able to control the subluxation by avoiding external rotation of the shoulder and desired no further surgery. Two triceps ruptures occurred, 1 in the previously mentioned patient with the skin slough. Initial triceps repair was unsuccessful, requiring a second repair with palmaris longus reinforcement. In the second case, a 70-year-old patient debilitated by rheumatoid arthritis, the triceps ruptured 8 years after total elbow arthroplasty while the patient was using her elbow to get out of a wheelchair. She desired no further surgical treatment. A deep infection in 1 patient (the same patient who had acute renal failure and a skin slough) resulted in the only clinical failure. Six months after primary wound healing had been obtained, she had sepsis of the greater trochanteric bursa and ankle develop. Deep sepsis of her total elbow arthroplasty ensued, presumably of hematogenous origin. This case required permanent removal of the prosthesis for salvage. The patient died of sepsis several years after the prosthesis had been removed. To treat the numerous complications discussed, 11 additional operations were required on 5 of the patients. The nonconstrained elbows were introduced to alle viate the loosening problem. Treatment with these elbows is indicated most often in cases of rheumatoid arthritis and other types of arthritis in which there is ligamentous stability and adequate bone stock. THE SEMICONSTRAINED, “SLOPPY HINGE” DESIGN At about the same time as the nonconstrained prostheses were being developed, “sloppy hinges” were adopted in place of the rigid-hinged elbow in an attempt to control loosening. Coonrad6 performed a multicenter study on 150 semiconstrained elbows in patients with rheumatoid arthritis. He reported that the results were good in 95% of the cases. There were only 6 failures, 4 because of loosening and 2 because of infection. However, in 12% of the cases the humeral stems became loose. He concluded that semiconstrained elbow arthroplasties were well suited for cases with rheumatoid arthritis but not for cases with posttraumatic problems. However, of the first 14 semiconstrained elbow arthroplasfies that he personally performed, Coonrad7 reported 2 cases in which deep infections developed. Both were posttraumatic cases. Morrey collaborated with Coonrad in modifying the Coonrad elbow so that better results might be obtained, adding an anterior flange to the humeral
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component to prevent loosening of the proximal component. As of 1994, 22 1 of these elbows were inserted at the Mayo Clinic for rheumatoid arthritis with very promising results (personal communication from Coonrad,8 1996). Morrey and Adams.34 reported on 54 patients with rheumatoid arthritis who were followed up for 2 to 8 years after operation. Little or no pain was had by 91% of the patients. The elbows were found to have increased extension by an average of 12”, flexion by 1 lo, pronation by lo”, and supination by 18”. The complication rate in these patients and in an additional 10 patients who were followed up for less than 2 years was 22%. Complications included 4 cases of infection, 8 condylar or ulnar fractures, 1 ulnar neuritis, and 1 acute avulsion of the triceps and fracture of the implant. No patient without infection had radiographic evidence of loosening. Excellent results were had by 69% of the patients, and good results were had by 22%. There was 1 fair and 1 poor result. lnglis and Pellicci26 reported on 36 semiconstrained elbow replacements with a minimum follow-up of 2 years. They found a 53% complication rate, but only one fourth of the complications affected the outcome. The first 17 replacements in this series were done with a semiconstrained Pritchard-Walker elbow; the rest were performed with the triaxial prosthesis. There were 22 patients with rheumatoid arthritis, who generally had better results than patients with posttraumatic problems. There were 19 complications in this series of 36 patients, including 4 wound hematomas, 2 cases of loosening, 2 fractured humeri, 2 ulnar neuropathies, 2 triceps ruptures, 2 cases of skin slough, 2 cases of bro1 fractured olecranon, 1 infection, ken components, and 1 cementophyte. Brumfield et al2 reported on the results of treatment with 2 semiconstrained prostheses, the Mayo and AHSC (Volz). Th ese are similar prostheses and both have a semiconstrained ulnohumeral articulation and a radial head component. There were 14 patients in each treatment group. All patients had rheumatoid arthritis except for 2 who had osteoarthritis. Complications included 1 case of loosening, 1 case in which the humeral ulnar joint dislocated, 1 superficial infection, and 1 case of ulnar nerve neuropathy. The triceps muscle avulsed in 2 patients. Seven cases displayed radiolucency, and 3 had fracture of the humeral condyle. In general, treatment served to decrease or abolish pain and increase motion. Although the report by Brumfield et al2 was encouraging when it appeared in 198 1, Volzsl reported in 1985 that he had stopped using the AHSC prosthesis. To obtain a lower incidence of loosening than achieved with the semiconstrained-hinged prosthesis and a lower incidence of dislocation than achieved with the nonhinged prosthesis, Pritchard40 designed a 3-piece nonconstrained surface prosthesis with a radial head. Used to treat 13 elbows (12 rheumatoid
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arthritis), the prosthesis produced satisfactory pain relief and increased motion in all cases. The only complication was a fracture/dislocation of the humeral component that occurred in 1 case as a result of a fall. In a later report, Pritchard41 presented 75 cases from a multicenter study. Although loosening, dislocation, subluxation, triceps rupture, and ulnar nerve problems were noted, he believed that the long-term results were satisfactory. Gschwend et al24 modified their original constrained GSB prosthesis to a semiconstrained device and reported on 64 patients with 71 prostheses. They believed that their complication rate was low in comparison with most reports in the world literature and even lower when the long-term complication rate was considered. In 1989 Figgie et all90 reported on total elbow arthroplasty for 19 elbows with complete ankylosis in 16 patients. Eight of the patients had juvenile rheumatoid arthritis, and 1 had rheumatoid arthritis. They used a variety of semiconstrained devices and had 15 excellent or good results. Function improved in all patients, and all had relief of preoperative pain. There was only 1 failure, this because of infection. In 1989 Figgiel*a stated that the results of total elbow arthroplasties performed with triaxial prostheses are as good as those obtained in total hip replacement but not as good as in total knee replacement. Personal experience prosthesis
with the semiconstrained
In 1989, I inserted a Coonrad-Morrey elbow to salvage a failed constrained total elbow with loosening and marked bone destruction. The next revision was with the same type of prosthesis for an unstable nonconstrained elbow. After seeing the excellent results with these difficult reconstruction problems, I started using the Coonrad-Morrey elbow for primary elbow replacement. Between 1989 and 1998, I implanted 54 of these elbows in 35 patients. Followups lasted up to 8.5 years; the average follow-up was 37 months. The minimum follow-up period was 6 months, except for 1 patient with bilateral elbow problems who died from unrelated causes that developed 10 and 4 months after the operations. No other patient was lost to follow-up. Thirty-eight replacements were followed up for at least 2 years. Of these 38 elbow replacements, 32 were performed for rheumatoid arthritis, 3 for posttraumatic arthritis, and 1 each for acute fracture, osteoarthritis, and lupus. Eight of the 38 were revisions of other types of elbows. Postoperative ranges of motion varied from 70” to 120”; average range of motion was 103”. Pronation averaged 76” and supination 73”. The elbows were graded by the Mayo total elbow criteria,36J7 with pain, motion, and stability allotted 60, 30, and 10 points, respectively. Thirty-four elbows
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Complications in my series of Coonrad-Morrey elbow arthroplasties
total
I reported the results of the first 54 Coonrad-Morrey total elbow arthroplasties that I performed in 1997.16 Of the 54 elbows, 2 failed and were removed. One failed because of bacterial infection 4 months after operation; the second failed because of mycobacteriurn avium infection 5 years after the surgery. In this latter case the prosthesis was removed, infection cleared, and the prosthesis replanted a year later. In 1 case the distal component loosened aseptically after 4 years, with the elbow becoming symptomatic a year later and then being revised (Figure 3). Another distal component loosened in an elbow with traumatic injury after 18 months. A third elbow loosened in a patient with a failed elbow, and a polyethylene fracture in this elbow was later revised with a good result. There was a case of wound infection treated with drainage, antibiotics, and a free flap over the olecranon. Condylar fractures were noted in 5 elbows, 3 of which were recognized at surgery. These fractures had no effect on the eventual outcome. One postoperative hematoma was drained. There were 2 olecranon bursae infections that were treated surgically with resolution. Eleven patients showed marked triceps weakness, although no patient described having this problem. None of the postoperative ulnar nerve problems persisted except in the 3 elbows in which this difficulty was present before operation.
Figure 3 A, Radiograph of elbow taken 5 years after arthroplast-y for rheumatoid arthritis. Elbow had become painful. Radiographs showed loosening of distal component. Lateral condyle fractured at time of initial surgery and was treated with a plate. Fracture healed. B, Revision with long-stem distal component. Revision resulted in relief of pain.
were graded as good, 2 were fair, and 2 were poor because of infection.16 Because of these encouraging results, I have been using the Coonrad-Morrey elbow as my first choice of total elbow replacement for all types of arthritis and deformity that have adequate bone stock and ligamentous stability.
HYBRID ELBOW The Norway elbow is a nonconstrained prosthesis, but this elbow is unique in that it can be made into a semiconstrained device by adding a locking ring if dislocation or instability are present.42 In 1997 Risung43 reported his results with 83 of these elbows out of a total of 1 18 elbows that he implanted and followed up for 3 years. All patients except 1 with posttraumatic osteoarthritis had chronic polyarticular progressive rheumatoid arthritis. Four of the 1 18 elbows were failures. One elbow failed because of aseptic loosening of the humeral component, which was replaced; another failed because the humeral component loosened after an epicondylar fracture that was rewired. Two failed because of deep infection. Three prostheses dislocated early in the postoperative period because of humeral fractures. The use of the locking ring would have eliminated this last complication. At a mean follow-up of 4.3 years, the failure rate was 3.4%. In addition to the Norway elbow, other types are being developed that can also be inserted nonconstrained or semiconstrained. Such options are attractive insofar as they promise to prevent the most common complications associated with each type of prosthesis, namely, instability with nonconstrained elbows and loosening with semiconstrained elbows.
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INDICATIONS FOR TOTAL ELBOW ARTHROPLASTY The indications for total elbow arthroplasty in patients with rheumatoid arthritis are ARA stage IllB or IV, significant pain, and a decrease in motion that interferes with the ability to perform essential activities of daily living (Figure 4). The medullary canals of the humerus and ulna must be large enough for the prosthesis to enter. In cases of monoarticular osteoarthritis or traumatic arthritis, the patient must have a lowdemand lifestyle. If not, a high rate of early failure is not unlikely.
Traumatic arthritis The results of total elbow arthroplasties for traumatic arthritis have not been as good as the results for rheumatoid arthritis. Schneeberger et al46 reported on 41 elbows treated for posttraumatic problems with the Coonrad-Morrey elbow. Of the 41 patients, 1 1 had a major problem and 9 of these 11 needed an additional operation. The ulnar component fractured in 5 patients, the pal ethylene bushing wore out in 2, and there were 2 in 1ections. Follow-up ranged from 2 to 12 years; the average follow-up was 68 months. They concluded that this procedure was relatively contraindicated in patients who anticipate strenuous activity or who are not expected to comply with the postoperative protocol. The 24-year-old patient in Figure 5 having posttraumatic arthritis and a loosened total elbow arthroplasty is contrasted with the 85yearold patient in Figure 6 who has nonunion of an intracondylar fracture.
A
Contraindications The presence of active sepsis is an absolute contraindication. Neuropathic joints caused by diabetes, syringomyelia, or other diseases are contraindications, as are nutritional deficiencies that might delay prompt healing of the surgical wound. If total elbow arthroplasty is performed in an elbow with existing heterotopic ossification, more ossification may be stimulated, leading to a decreased range of motion.23
CONCOMITANT SHOULDERJOINT REPLACEMENT What of the patient who is in need of a shoulder replacement in the same extremity as the elbow? Friedman and Ewald22 found no contraindication to operating on 1 joint when the other had a fixed deformity. The results of an arthroplasty of either the shoulder or the elbow with respect to motion, pain, and function were not found to be compromised when the 2 arthroplasties were performed in the same extremity. When both the shoulder and the elbaw are involved,‘the joint that causes the most oain and disabilitv should be oaerated on first. If bath joints appea; to be equally involved, they recommended that the elbow be operated on first because this results in greater functional improvement and allows a longer interval between
B Figure 4 Woman, 26 years of age, with virtually fused elbows who had lost the abilitv to eat and oerform other necessarv activities of daily living wiihout adapti;e devices and help. She had great difficulty in caring for her young children. However, she had very little pain. A, Elbow flexion before operation. B, Elbow extension before operation. Almost all forward and backward motion of her arms was from shoulders.
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arthroplasties. I believe, however, that the shoulder should be done first if both joints are equally involved because there are fewer serious complications with a shoulder replacement. Also, I have found that once a shoulder has become free of pain after an arthroplasty, the affected elbow can be so protected that the patient may not feel the need for an elbow arthroplasty. Kocialkowski and Wallace** suggested that if both the elbow and shoulder need to be replaced that both might be done at the same time.
SALVAGE OF THE FAILED ELBOW ARTHROPLASTY
Figure 5 Gunshot wound to elbow of 24-year-old patient was treated with total elbow replacement. Radiographs show loosening of rosthesis. A, Lateral view of the elbow. B, Anteroposterior view o P the elbow. Failure rate in young patients with a traumatic joint such as this is very high.
Of all major total joint replacements, prosthetic elbows have had the highest complication rate. In cases of infection, Morrey and Bryan35 found that a resection arthroplasty was necessary in 10 of 14 elbows to control the infection. In 1 case, the elbow was salvaged by early debridement. In 2 cases, a new implant was reinserted after removal of the first prosthesis and control of infection. The 14th patient had a paretic upper extremity as a result of a cerebral vascular accident and her extremity was amputated. In case of failure, a reasonable backup plan for salvage must be available.9,’ II1 *,*0,*53-37 In cases of aseptic failure of a stemmed prosthesis with good bone stock, the old prosthesis can be removed and a new one reimplanted. In cases of severe bone loss, a larger stemmed prosthesis or a custom device may be necessary or even a bone graft with the implant. Morrey and Bryan37 reported 33 revisions. Of these, 22 were in patients with rheumatoid arthritis. Three of the revised elbows became infected, and 2 of the infections were in rheumatoid elbows. Only 13 of the 33 elbows were not associated with at least 1 complication. Twelve complications occurred in 10 patients who had rheumatoid arthritis. Before the 1980s they selected an implant for revision on the basis of whether any components were solid and could be left in place. Since 198 1 they have exclusively used the CoonradMorrey device for this purpose, and some of the revisions with this device failed. Eight (23%) of the revised components became loose in 7 of 30 elbows that had not become infected. Figgie et all9 reported on 10 failed elbow arthroplastics. Six of these were for dislocation after failure of the bearing mechanism. In each case, the humeral or ulnar center of rotation had been malaligned. An additional 4 elbows were revised for component loosening, and 1 was revised for malalignment. Two of these revisions failed, 1 because of sepsis. In 1990 Figgie et al*O published a report on the results of implant removal in 1 1 patients. Seven were removed because of infection, 3 because of implant fracture, and 1 because of recurrent dislocation. Treatment consisted of soft tissue arthroplasty combined with external fixation in 10 patients and attempted arthrode-
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C Figure
6 Use of Coonrad-Morrey excellent result. A, Preoperative Postoperative anteroposterior
375
D prosthesis lateral view. view.
to treat
nonunion
B, Preoperative
sis with external fixation in 1 patient. There were 4 good, 1 fair, and 2 poor results; 4 operations failed. Satisfactory results were obtained in 7 of the 8 elbows in which an anatomic arthroplasty was achieved. A later report*’ also indicated that satisfactory results can be achieved in complex cases. Dent et al11 reported on 26 failed primary total elbow arthroplasties in 25 patients with rheumatoid
of intracondylar anteroposterior
fracture in 85year-old view. C, Postoperative
woman had lateral view. D,
arthritis. Most revisions required special custom implants to treat varying bone loss and soft tissue disruption. Satisfactory function results were shown at a mean follow-up of 35 months. In cases in which it is not wise or possible to reinsert a prosthesis, resection arthroplasty is usually performed (Figure 7). The following steps are useful for obtaining stability: (1) transfer the wrist flexor and extensor mus-
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Figure 7 Resection arthroplasty resulted in painful, unstable elbow. Elbow was converted to semiconstrained prosthesis. Stability was restored, and pain was relieved.
cles proximally; (2) insert a triceps flap between the bone ends; (3) advance the distal triceps; and (4) notch the bone to enhance stability if enough bone stock remains (Figure 8). An arthrodesis may be indicated, but the procedure is very difficult because of lack of bone stock. Together with Clayton, 18 I reported a series of 14 total elbows salvaged after failure, 3 for infection, 6 for asep tic loosening, 4 for instability, and 1 for a failed bearing mechanism. All the infected elbows were converted to resection arthroplasties with elimination of infection but with poor function; 2 were unstable and the third had marked limitation of motion that improved satisfactorily after fascial arthroplasty. Those that failed aseptically were all successfully salvaged with implantation of other devices, whether a longer ulnar custom implant or the Coonrad-Morrey elbow that is also used to treat nonconstrained elbows that failed because of instability. In cases without infection, all replacements were successful and pain relief and motion were comparable to or better than the same measures before revision. Failed unstemmed prostheses are easier to reconstruct. Reconstruction can be achieved by arthroplasty
B Figure 8 Resection arthroplasty was performed after total became infected. After resection, patient had motion between and 130”. Elbow was stable and painless. A, Lateral view elbow showing the prosthesis was removed and the resultant loss. B, Anteroposterior view of the elbow after the removal prosthesis.
elbow 10 of the bone of the
with tissue interpositioning, insertion of a stemmed prosthesis, or fusion. Revision for aseptic loosening or dislocation is best handled by removing the components and inserting one of the semiconstrained prostheses. The Coonrad device modified by Morrey has been useful in such cases. Reconstruction of the soft tissue restraints for dislocation has not been reliable. Dislocation or subluxa-
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and regardless I tion is likely the result of malal~ignment, * * of the type of prosthesis used tor revision, the axis ot motion needs to be corrected. Although there have been complications and failures with total elbow replacement, this operation has been very successful in relieving pain and easing disability in most patients with arthritis. Future design modifications may be useful; smaller components that save bone stock may help maintain stability in case of failure. Prostheses with an optional locking mechanism that can be converted from a nonconstrained to a semiconstrained device should help prevent loosening and instabili . Alternatives to cement fixation may also be useful. Tx e ultimate goal should be a biologic implant.
18.
Ferlic DC, Clayton plasty. J Shoulder
18a
Figgie AAOS
19.
Figgie HE Ill, lnglis AE, Ranawat of total elbow arthroplasty os‘a elbow reconstructive operations. 185-93.
190
Figgie MP, lnglis AE, Mow CS, Fi gie HE Ill. Total elbow I Bone loint arthroalastv for comolete ankvlosis o 9 the elbow. Surg i 986;71 A:5 13-20. ’ CS, Wolfe SW, Scolio TP, Figgie Figgie MP, In lis AE, Mow HE III. Results 9 or reconstruction of failed total elbow arthroplao ty. Clin Orthop 1990;253: 123-32. Fig ie MP, Gerwin M, Weiland AJ. Revision total elbow rep Pacement. Hand Clin 1994; 10:507-20.
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Burnett R, Fyfe I. Souter Strathcl toid elbow: 23 cases followed 1991;62.52-4.
Gschwend N, toehr J, IvosevieRadovanovic D, Scheier H, Munzinger U. Semiconstrained elbow prostheses with special reference to the GSB Ill prosthesis. Clin Orthop 1988;232: 104-l 1
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lnglis AE. Revision surgery following a failed total plasty. Clin Orthop 1982; 17O:Z 13-8. lnglis AE, Pellicci PM. Total elbow replacement. Surg 1980;62A: 1252-8.
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Cooney WP III, Bryan RS. Rheumatoid arthritis in the upper extremity. Treatment of the elbow and shoulder joints. American Academ of Orthopaedic Surgeons Instructional Course tectures. Vo Yume 28. St Louis: Mosby; 1979. p. 247-62.
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Coonrad Presented Meeting;
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Coonrad RP. Infection in total Surg of the Hand Correspondence
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Dhar S, Beddow H. The thesis. J Hand Surg 1994;
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Ewald FC, Jacobs MA. Total elbow arthroplasty. Clin Orthop 1984; 182: 137-42. Ewald FC, Scheinberg RD, Poss R, Thomas WH, Scott RD, Sledge CB. Copitello condylar total elbow arthroplasty. J Bone Joint Surg 1980;62A: 1259-63.
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Hoy G, Stanley JK. Revision J Bone Joint Surg 1995;778:69 Liverpool
of failed l-5.
total
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Ewald FC, Simmonds ED Jr, Sullivan SA, Thomas WH, Scott RD, Poss R, et al. Copitellocondylar total elbow replacement in rheumatoid arthritis. tong term results. J Bone Joint Surg 1993;75A:498-507. Ferlic DC. Coonrod-Morrey total elbow arthroplosty [abstract]. Orthop Trons 1997;2 1:637. Ferlic DC. tong term results of the Ewold elbow. Piedmont Orthopedic Sociev 45th Annual Meeting; Sea Island, Go, 1997 May 9. Orthop Trons 1998.
PJ. The Guildford
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Kocialkowski A, Wallace WA. One stage arthroplasty of the ipsilateral shoulder and elbow. J Bone Joint Surgery 1990;72B: 520.
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Kudo H, lwano 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:355-62.
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Kudo H, lwano rheumatoid elbow 1980;62A.277-85.
K, Watanabe with a hingeless
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Liung P, Bornmyr S, Svensson H. Wound healing after total elbow replacement in rheumatoid arthritis. Wound complications in 50 cases and laser-Doppler imaging of skin microcirculation. Acta Orthop Stand 1995;66:59-63.
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Ljung P, Jonsson K, Rydholm V. Short term complication of the lateral approach for non-constrained elbow replacement. Follow up of 50 rheumatoid elbows, J Bone Joint Surg 1995; 778:937-42.
33.
tyall MA, Cohen B, Clatworthy M, Constant CR. Results of the Souter-Strathclyde total elbow arthroplasty in patients with rheumatoid arthritis. A preliminary report, J Arthroplasty 1994; 9:279-84. Morrev BF, Adams RA. Semiconstrained arthroplastv in the treatment of rheumatoid arthritis of the elbow. J’ Bone Joint Surg 1992;74A:479-90. Morrey BF, Bryan RS. Complications of total elbow arthroplasty, Clin Orthop 1982;170:204-12.
elbow pros-
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Davis RF, Weiland AJ, Hungerford DS, Moore JR, Volenec-DowC ing S. Non-constrained total elbow replacement [abstract]. Orthop Trons 1982;6:34 l-2. Dee R. Reconstructive surgery following total elbow endoprosthesis. Clin Orthop 1982; 170: 196-201. KW. Dennis DA, Clayton Ml, Ferlic DC, Strin er EA, Bramlett Capitello-condylar total elbow arthrop 7asty for rheumatoid arthritis. J Arthroplasty 1990;5 Suppl:S83-8.
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Morrey BF, Bryon RS. Infection Bone Joint Surg 1983;65A:330-8. Morrey BF, Bryan RS. Revision Joint Surg 1987;69A:523-32.
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Peterson LFA, Jones JM. Surgery of the rheumatoid elbow. Orthop Clin North Am 1971;2:667-77. Poll RG, Rozing PM. Use of the Souter-Strothclyde total elbow prosthesis in patients who have rheumatoid arthritis. J Bone Joint Sura 199 1.73A: 1227-33. Pritghard RW. Anatomic nary report. Clin Orthop
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Pritchard RW: Personal experience using a three piece surface elbow replacement. American Academy of Orthopaedic Surgeons Summer Institute. Course Syllabus. Sept 1989. Chico o 42. Risung CF. Characteristics, design, and preliminary resu 9ts of the Norwav elbow svstem. Rheumatoloav 199 1 : 15:68-72. Risung CF. T6e Norwiy Elbow Reploce%ent. niaue. and results after nine vears. I -I Bone 76B:j94-402. Rosenberg GM, Turner RH. Nonconstrained plasty. Clin Orthop 1984; 187: 154-62.
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G, Blomgren
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Schemitsch EH, Ewold FC, Thornhill TS. Results of total elbow arthroplasties after excision of the radial head and synovectomy in patients who have had rheumatoid arthritis. J Bone Joint Surg 1996;78A: 154 l-7. Schneeberger AG, Adams R, Morrey BF. Semiconstrained total elbow replacement for the treatment of posttraumatic osteoarthrosis. J Bone Joint Surg 1997;79A: 12 1 l-22. Sioden
ment years.
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in rheumatoid Acta Orthop
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13 patient follow-up 1992;73:3 15-7.
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Sioden G, Lundberg A, Blomgren G. Late results of the SouterStrathclyde total elbow prosthesis in rheumatoid arthritis. 6/l 9 implants loose after 5 years. Acta Orthop Stand 1995;66: 391-4. Street DM, Stevens PS. A humeral replacement prosthesis for the elbow. Results in ten elbows. I Bone loint Sura ” 197456A: 1 147-58. Troncik T, Wilde AH, Borden LS. Capitello-condylar total elbow arthroplasty. Two- to eight-year experience. Clin Orthop 1987;223: 175-80. Volz RE. Total elbow arthroplasty, current status. Presented to the 52nd Annual Meeting of the American Academy of Orthope die Surgeons; Jan 24-29,1985; Las Vegas. Weiland AJ, Weiss A-PC, Wils RP, Moore JR. Capitello lar total elbow replacement. A long-term follow-up study. Joint Surg 1989;71 A:2 17-22.
condyJ Bone
arthroplasty
Donald
Denver,
C. Ferlic, MD,
for treatment
Th
HEMIARTHROPLASTY
In 1971 Peterson and Janes38 reported on 2 Vitalliurn-mold arthroplasties of the olecranon notch. One had excellent results, the other fair results. In 1974 Street and Stevens@ reported on their use of a metallic distal humeral resurfacing device in 10 patients. Three of the patients had rheumatoid arthritis, and results in 2 of the 3 were unsatisfactory. One patient had complete elbow ankylosis and a transient ulnar neuropathy develop; the other patient’s case was complicated by elbow dislocation. HINGES
The results with the disappointing. Cooney a combination of 1 1 1 and Coonrad elbows,
arthritis
Co/o
ere are 3 basic types of elbow prostheses: constrained, semiconstrained, and nonconstrained. The constrained hinge is constructed with either metal-tometal or metal-to-high-density polyethylene, with the aid of a bushing or a separate polyethylene piece. The semiconstrained elbow (the so-called “sloppy hinge”) is designed to link the components together with an axle and-bushing arrangement but is less constrained in the varus/valgus plane than the constrained design. This type of prosthesis was designed to help correct some of the loosening problems associated with the constrained hinges. The unconstrained design consists of separate units of metal-to-high-density polyethylene components. This design relies on the soft tissue envelope, muscle tendon, and muscle ligament to maintain the articulation rather than an axle-bushing linkage. Some unconstrained prostheses are designed for use in tandem with a radial head replacement.
RIGID
of elbow
rigid hinges have likewise been and Bryan5 tabulated results on Schiers, Dee, McKee-Dee, GSB, with 24% associated with poor
From Denver Orthopedic Specialists, PC Reprint requests: Donald Cl Ferlic, MD, 1601 E 19th Ave, Suite 5000, Denver, CO 802 18. J Shoulder Elbow Surg 1999;8:367-78. Copyright 0 1999 by Journal of Shoulder and E/bow Surgery Board of Trustees. 1058-2746/99/$8.00 + 0 32/l/94890
Table
Types of elbow
Constrained
Coonrad Schiers Dee GSB McKee Mazas Stanmore
prostheses Semiconstrained
1
Nonconstrained
AHSC (Volz) Pritchard-Walker Pritchard Mark II Triaxial Coonrad II Schlein Silva St George-Bucholz Swanson Coonrad-Morrey GSB Ill Dee IV Norway Mayo
Kudo London Pritchard ERS Capitellocondylar (Ewald) Wadsworth Covendish Gunston Stevens-Street Souter-Strathclyde Guildford Liverpool Norway
results (Table). Cofield et al4 tabulated the complications in 346 hinged total elbow replacements of both constrained and semiconstrained types and found loosening in 13% of cases. Other complications in their series included fracture in 9%, wound problems in 9%, infection in 5%, ankylosis in 4%, neuropathy in 6%, and triceps rupture in 2%. Twelve cases required revision. personal
experience
with
the
rigid
hinge
The first 4 total elbow replacements that I participated in were performed with rigid hinge in patients with rheumatic elbow (3 GSB, 1 Coonrad I). The first of these procedures was in 1971. My team10 chose the GSB initially because we believed that its small size would preserve bone stock so that if the device necessitated removal, a stable fascial arthroplasty would still be possible. Two of the 4 elbows loosened with a marked amount of bone resorption (Figure 1). In light of these results, we started using nonconstrained resurfacing devices, including the Ewald, London, and Wadsworth. There is no place for the rigid hinge today. NONCONSTRAINED
DESIGNS
Nonconstrained elbow protheses were introduced to alleviate the loosening problem, but these have also been plagued with a high complication rate. Kudo et
367
368
Ferlic
Figure 1 A, Radiograph of GSB hinge 1 year after operation shows solid fixation. B, Same hinge 18 years later with marked loosening and bone resorption.
J Shoulder Elbow Surg July/August I999
aI30 reported 24 cases of rheumatoid arthritis treated with a resurfacing prosthesis. Results were excellent in 14 cases and poor in 3. Two elbows failed to regain functional motion. Proximal migration of the humeral component occurred in 1 of the 2 elbows; the other had persistent sub1 uxation with pain and instability. In 1990 Kudo and lwano29 reported on 37 elbows in 36 patients. Because of a high incidence of proximal migration of the humeral component, they now use a humeral component with an intramedullary stem. Ewald et al14 reported on 60 prosthetic replacements for rheumatoid arthritis. Although the results were excellent or good in 87% of the cases, they encountered a 39% complication rate. Eight cases required revision of the arthroplasty: 4 for dislocation, 2 for sepsis, 1 for loosening, and 1 for fracture. Five patients had recurrent dislocation, and 5 had permanent and 6 had transient ulnar nerve palsy. There were 3 fractures, 2 of the olecranon and 1 of the humeral shaft. Three wounds demonstrated some degree of breakdown and skin loss. In a later report, Ewald and Jacobs13 described a lateral surgical approach that they used in an attempt to reduce the incidence of soft tissue problems in 54 elbows. The results were good or excellent in 90% of the cases. Complications included dislocation in 7% of the cases and permanent sensory ulnar nerve palsy in 4%. There was 1 deep and 1 superficial wound infection. Transient ulnar nerve palsy developed in 14% of the cases. Thus the lateral surgical approach did not change the rate of serious complications. They used a cemented radial head prosthesis in 8 elbows, but in 4 of these there was a radiolucent line at the cement/bone interface of the humeral component and at the radial head. By comparison, only 1 prosthesis without a radial head implant had a radiolucent line. In 1993 Ewald et al15 evaluated long-term results in 202 capitellocondylar elbows in 172 patients with rheumatoid arthritis with an average follow-up of 69 months (range 24 to 178 months). The greatest improvements were in terms of pain, function, and range of motion. Range of motion improved in all planes except extension and was not reversed with time. Roentgenograms showed a radiolucent line adiacent to 8 humeral and 19 ulnar components; most of the lines were incomplete and 11 mm. Revision was necessary in 3 (1.5%) elbows because of aseptic loosening and in another 3 (1.5%) because of dislocation. Complications included deep space infection in 3 (1.5%) elbows, wound problems in 15 (7%), permanent partial sensory ulnar nerve palsy in 5 (2.5%), permanent partial motor ulnar nerve palsy in 1 (O.S%), and dislocation in 7 (3.5%). Rosenberg and Turner44 reported on 28 Ewald cap itellocondylar arthroplasties for rheumatoid arthritis. Satisfactory results were obtain in 86% of the elbows. There was 1 failure from loosening, 2 remote infec-
J Shoulder Elbow Surg Volume 8, Number 4
tions, and 4 dislocations, 1 of which required additional surgery. Davis et aI*0 reported on 30 Ewald arthroplasties for rheumatoid arthritis that resulted in excellent relief of pain. Wound infections developed in 2 cases that ultimately required removal of the prosthesis. There were 4 cases of subluxation, 1 of which required additional surgery. Ulnar neuropathy developed in 3 cases, 2 of which required neurolysis and rerouting of the nerve. Weiland et aI52 reported on 40 capitellocondylar arthroplasties in 35 patients, 32 of whom had rheumatoid arthritis. Malarticulation or dislocations occurred in 10 (29%). Deep infection necessitating removal of the prosthesis developed in 2 patients, and transient nerve palsy developed in 7. Adoption of the lateral Kocher approach was associated with a reduced incidence of nerve palsy. Trancik et aI50 reported a 57% complication rate in 35 capitellocondylar arthroplasties in 29 patients. There were 3 infections, 3 dislocations, 2 intraoperative fractures, 9 transient nerve palsies, 2 postoperative hematomas, and 1 intraoperative perforation of the ulna. Despite these problems, pain relief was achieved in all but 1 patient. There were no unstable elbows. Ljung et aI32 reviewed 50 capitellocondylar elbow replants performed with the lateral approach in 42 patients with rheumatoid arthritis who were followed up for a median of 3 years. Eight elbows required reoperation. Soft tissue problems developed in 7 elbows, and 1 prosthesis was removed because of deep infection. There was 1 case of traumatic disla cation that was stabilized after ligament reconstruction. Wound healing was delayed in 2 elbows. Transient ulnar nerve palsy developed in 1 1 patients; permanent palsy developed in 3. At follow-up, all elbows were either free of pain or only slightly painful; 49 of the elbows were stable and 43 had a range of motion sufficient for activities of daily living. Radiologic loosening of the humeral component was suspected in 1 asymptomatic elbow. Ljung et ,131 reported no wound problems and no loss of function in 42 capitellocondylar elbow replants that were immobilized for 12 days after operation. In 5 such elbows that were immobilized for only 5 days, however, they reported 2 cases of wound problems. Schemitsch et aI45 compared the results of capitellocondylar arthroplasties in patients previously operated on for rheumatic elbow with the results of the same procedure in patients with the same condition who had not undergone such an operation. They concluded that conversion to a capitellocondylar elbow is not onl more difficult after a previous operation has been per Yormed but that the results in such cases are inferior. Six of 23 patients who had the total elbow done as a secondary procedure had instability develop, whereas none of a similarly matched group with primary elbows did. Sjoden and Blomgren47 reported in 1992 on 13
Feriic
369
SouterStrathclyde elbows for rheumatoid arthritis. There were no cases of infection. Three humeral components became loose but remained asymptomatic. Sioden et aI48 later reported that 6 of 19 Souter-StrathClyde implants became loose after 5 years; complications included 1 intraoperative fracture of the medial epicondyle, 3 cases of neuropathy, and 1 dislocation. Burnett and Fyfe3 reported on 23 elbows in 17 patients with rheumatoid arthritis who were followed up for 3 years. A deep wound infection developed in 1 patient, and temporary ulnar nerve paresis developed in 4. Arcs of motion were moderately improved. Three elbows required revision, 2 for recurrent dislocation and the third after loosening caused by a humeral fracture. Lyall et al33 reported on 19 elbow arthroplasties for rheumatoid arthritis in 17 patients. Relief of pain was obtained in all cases but with a 32% complication rate. Complications included 2 temporary nerve palsies, 1 permanent palsy, 3 dislocations, and 2 cases of loosening. The mean follow-up was 41 months. Poll and Rozing39 reported on 34 elbow arthroplasties in 33 patients with a minimal follow-up of 2 years, Four of the arthroplasties were revised, 3 because of irreversible dislocation and 1 because of loosening. One prothesis was removed because of infection. In the remaining cases, pain either decreased markedly or resolved completely; function was greatly improved. Recent results of other total arthroplasties have also been reported.lll2J7 Personal
experience
with
nonconstrained
prostheses
I was part of a team 10 that implanted 21 unconstrained capitellocondylar elbows for rheumatoid arthritis. With an average follow-up of 48 months, the average elbow scored an 89.5 points on a loo-point scale; the pain and function ratings were excellent. We saw moderate gains in motion; however, the gains were less in patients with juvenile rheumatoid arthritis. There was 1 failure because of infection; this implant was removed 6 months after operation. The patient in question died 6 years after the index operation. In a later report17 on the same patients, we noted that 1 other patient had died whose elbow had been unstable at the last follow-up. The elbow of a third patient was revised at 9 years, 7 months after the index procedure because of instability (Figure 2). Follow-ups of the remaining 1 1 patients ranged from 9 years, 9 months to 14 years, 10 months (average 12.5 years). Of these patients, 1 sustained a fracture of the proximal ulna as a result of a fall. The ulnar component loosened and was removed; the fracture was plated and bone was grafted. The result for the patient was a hemiarthroplastic elbow that was free of pain and that had motion restored to the degree before fracture. The other 10 elbows have had satisfactory results with no evidence of loosening, rare or minimal pain, and no instability.
370
Figure revised
Ferlic
2 Dislocation of nonconstrained with semiconstrained device.
J Shoulder Elbow Surg July/August I999
elbow.
Complications in my series of capitellocondylar total elbow arthroplasties
Elbow
was
(Ewald)
Eight (40%) of 20 Ewald total elbow arthroplasties had some type of complication.10 A total of 12 complications occurred in these 8 patients. There were 3 cases of postoperative ulnar neuropathy. All resolved completely, but 1 required anterior transposition of the ulnar nerve. A posterior interosseous neuropathy requiring surgical decompression developed in 1 patient 4 months after operation. Skin sloughs developed in 2 patients. Lateral subluxation of the implant developed in 1 of these patients during the early postoperative period, possibly contributing to the complication. An abdominal pedicle flap was required to obtain skin coverage after 2 unsuccessful rotational skin flaps were performed. The postoperative course of the other patient with a skin slough was complicated by acute renal failure, gramnegative septicemia, and acute cholecystitis requiring a prolonged stay in the intensive care unit. The routine postoperative therapy program was delayed, and on removal of the splint an area of pressure necrosis was noted over the olecranon. Skin coverage was obtained with a rotational skin flap.
A dislocation with hemarthrosis was noted in 1 case during the immediate postoperative period. This condition was treated successfully with open reduction and hematoma drainage; there were no further problems in the next 12 years. There were 2 cases of implant sub luxation. One of these cases resolved after 4 weeks of cast immobilization. In the other case, the patient was able to control the subluxation by avoiding external rotation of the shoulder and desired no further surgery. Two triceps ruptures occurred, 1 in the previously mentioned patient with the skin slough. Initial triceps repair was unsuccessful, requiring a second repair with palmaris longus reinforcement. In the second case, a 70-year-old patient debilitated by rheumatoid arthritis, the triceps ruptured 8 years after total elbow arthroplasty while the patient was using her elbow to get out of a wheelchair. She desired no further surgical treatment. A deep infection in 1 patient (the same patient who had acute renal failure and a skin slough) resulted in the only clinical failure. Six months after primary wound healing had been obtained, she had sepsis of the greater trochanteric bursa and ankle develop. Deep sepsis of her total elbow arthroplasty ensued, presumably of hematogenous origin. This case required permanent removal of the prosthesis for salvage. The patient died of sepsis several years after the prosthesis had been removed. To treat the numerous complications discussed, 11 additional operations were required on 5 of the patients. The nonconstrained elbows were introduced to alle viate the loosening problem. Treatment with these elbows is indicated most often in cases of rheumatoid arthritis and other types of arthritis in which there is ligamentous stability and adequate bone stock. THE SEMICONSTRAINED, “SLOPPY HINGE” DESIGN At about the same time as the nonconstrained prostheses were being developed, “sloppy hinges” were adopted in place of the rigid-hinged elbow in an attempt to control loosening. Coonrad6 performed a multicenter study on 150 semiconstrained elbows in patients with rheumatoid arthritis. He reported that the results were good in 95% of the cases. There were only 6 failures, 4 because of loosening and 2 because of infection. However, in 12% of the cases the humeral stems became loose. He concluded that semiconstrained elbow arthroplasties were well suited for cases with rheumatoid arthritis but not for cases with posttraumatic problems. However, of the first 14 semiconstrained elbow arthroplasfies that he personally performed, Coonrad7 reported 2 cases in which deep infections developed. Both were posttraumatic cases. Morrey collaborated with Coonrad in modifying the Coonrad elbow so that better results might be obtained, adding an anterior flange to the humeral
Ferlic
J Shoulder Elbow Surg Volume 8, Number 4
component to prevent loosening of the proximal component. As of 1994, 22 1 of these elbows were inserted at the Mayo Clinic for rheumatoid arthritis with very promising results (personal communication from Coonrad,8 1996). Morrey and Adams.34 reported on 54 patients with rheumatoid arthritis who were followed up for 2 to 8 years after operation. Little or no pain was had by 91% of the patients. The elbows were found to have increased extension by an average of 12”, flexion by 1 lo, pronation by lo”, and supination by 18”. The complication rate in these patients and in an additional 10 patients who were followed up for less than 2 years was 22%. Complications included 4 cases of infection, 8 condylar or ulnar fractures, 1 ulnar neuritis, and 1 acute avulsion of the triceps and fracture of the implant. No patient without infection had radiographic evidence of loosening. Excellent results were had by 69% of the patients, and good results were had by 22%. There was 1 fair and 1 poor result. lnglis and Pellicci26 reported on 36 semiconstrained elbow replacements with a minimum follow-up of 2 years. They found a 53% complication rate, but only one fourth of the complications affected the outcome. The first 17 replacements in this series were done with a semiconstrained Pritchard-Walker elbow; the rest were performed with the triaxial prosthesis. There were 22 patients with rheumatoid arthritis, who generally had better results than patients with posttraumatic problems. There were 19 complications in this series of 36 patients, including 4 wound hematomas, 2 cases of loosening, 2 fractured humeri, 2 ulnar neuropathies, 2 triceps ruptures, 2 cases of skin slough, 2 cases of bro1 fractured olecranon, 1 infection, ken components, and 1 cementophyte. Brumfield et al2 reported on the results of treatment with 2 semiconstrained prostheses, the Mayo and AHSC (Volz). Th ese are similar prostheses and both have a semiconstrained ulnohumeral articulation and a radial head component. There were 14 patients in each treatment group. All patients had rheumatoid arthritis except for 2 who had osteoarthritis. Complications included 1 case of loosening, 1 case in which the humeral ulnar joint dislocated, 1 superficial infection, and 1 case of ulnar nerve neuropathy. The triceps muscle avulsed in 2 patients. Seven cases displayed radiolucency, and 3 had fracture of the humeral condyle. In general, treatment served to decrease or abolish pain and increase motion. Although the report by Brumfield et al2 was encouraging when it appeared in 198 1, Volzsl reported in 1985 that he had stopped using the AHSC prosthesis. To obtain a lower incidence of loosening than achieved with the semiconstrained-hinged prosthesis and a lower incidence of dislocation than achieved with the nonhinged prosthesis, Pritchard40 designed a 3-piece nonconstrained surface prosthesis with a radial head. Used to treat 13 elbows (12 rheumatoid
371
arthritis), the prosthesis produced satisfactory pain relief and increased motion in all cases. The only complication was a fracture/dislocation of the humeral component that occurred in 1 case as a result of a fall. In a later report, Pritchard41 presented 75 cases from a multicenter study. Although loosening, dislocation, subluxation, triceps rupture, and ulnar nerve problems were noted, he believed that the long-term results were satisfactory. Gschwend et al24 modified their original constrained GSB prosthesis to a semiconstrained device and reported on 64 patients with 71 prostheses. They believed that their complication rate was low in comparison with most reports in the world literature and even lower when the long-term complication rate was considered. In 1989 Figgie et all90 reported on total elbow arthroplasty for 19 elbows with complete ankylosis in 16 patients. Eight of the patients had juvenile rheumatoid arthritis, and 1 had rheumatoid arthritis. They used a variety of semiconstrained devices and had 15 excellent or good results. Function improved in all patients, and all had relief of preoperative pain. There was only 1 failure, this because of infection. In 1989 Figgiel*a stated that the results of total elbow arthroplasties performed with triaxial prostheses are as good as those obtained in total hip replacement but not as good as in total knee replacement. Personal experience prosthesis
with the semiconstrained
In 1989, I inserted a Coonrad-Morrey elbow to salvage a failed constrained total elbow with loosening and marked bone destruction. The next revision was with the same type of prosthesis for an unstable nonconstrained elbow. After seeing the excellent results with these difficult reconstruction problems, I started using the Coonrad-Morrey elbow for primary elbow replacement. Between 1989 and 1998, I implanted 54 of these elbows in 35 patients. Followups lasted up to 8.5 years; the average follow-up was 37 months. The minimum follow-up period was 6 months, except for 1 patient with bilateral elbow problems who died from unrelated causes that developed 10 and 4 months after the operations. No other patient was lost to follow-up. Thirty-eight replacements were followed up for at least 2 years. Of these 38 elbow replacements, 32 were performed for rheumatoid arthritis, 3 for posttraumatic arthritis, and 1 each for acute fracture, osteoarthritis, and lupus. Eight of the 38 were revisions of other types of elbows. Postoperative ranges of motion varied from 70” to 120”; average range of motion was 103”. Pronation averaged 76” and supination 73”. The elbows were graded by the Mayo total elbow criteria,36J7 with pain, motion, and stability allotted 60, 30, and 10 points, respectively. Thirty-four elbows
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J Shoulder Elbow Surg July/August I999
Complications in my series of Coonrad-Morrey elbow arthroplasties
total
I reported the results of the first 54 Coonrad-Morrey total elbow arthroplasties that I performed in 1997.16 Of the 54 elbows, 2 failed and were removed. One failed because of bacterial infection 4 months after operation; the second failed because of mycobacteriurn avium infection 5 years after the surgery. In this latter case the prosthesis was removed, infection cleared, and the prosthesis replanted a year later. In 1 case the distal component loosened aseptically after 4 years, with the elbow becoming symptomatic a year later and then being revised (Figure 3). Another distal component loosened in an elbow with traumatic injury after 18 months. A third elbow loosened in a patient with a failed elbow, and a polyethylene fracture in this elbow was later revised with a good result. There was a case of wound infection treated with drainage, antibiotics, and a free flap over the olecranon. Condylar fractures were noted in 5 elbows, 3 of which were recognized at surgery. These fractures had no effect on the eventual outcome. One postoperative hematoma was drained. There were 2 olecranon bursae infections that were treated surgically with resolution. Eleven patients showed marked triceps weakness, although no patient described having this problem. None of the postoperative ulnar nerve problems persisted except in the 3 elbows in which this difficulty was present before operation.
Figure 3 A, Radiograph of elbow taken 5 years after arthroplast-y for rheumatoid arthritis. Elbow had become painful. Radiographs showed loosening of distal component. Lateral condyle fractured at time of initial surgery and was treated with a plate. Fracture healed. B, Revision with long-stem distal component. Revision resulted in relief of pain.
were graded as good, 2 were fair, and 2 were poor because of infection.16 Because of these encouraging results, I have been using the Coonrad-Morrey elbow as my first choice of total elbow replacement for all types of arthritis and deformity that have adequate bone stock and ligamentous stability.
HYBRID ELBOW The Norway elbow is a nonconstrained prosthesis, but this elbow is unique in that it can be made into a semiconstrained device by adding a locking ring if dislocation or instability are present.42 In 1997 Risung43 reported his results with 83 of these elbows out of a total of 1 18 elbows that he implanted and followed up for 3 years. All patients except 1 with posttraumatic osteoarthritis had chronic polyarticular progressive rheumatoid arthritis. Four of the 1 18 elbows were failures. One elbow failed because of aseptic loosening of the humeral component, which was replaced; another failed because the humeral component loosened after an epicondylar fracture that was rewired. Two failed because of deep infection. Three prostheses dislocated early in the postoperative period because of humeral fractures. The use of the locking ring would have eliminated this last complication. At a mean follow-up of 4.3 years, the failure rate was 3.4%. In addition to the Norway elbow, other types are being developed that can also be inserted nonconstrained or semiconstrained. Such options are attractive insofar as they promise to prevent the most common complications associated with each type of prosthesis, namely, instability with nonconstrained elbows and loosening with semiconstrained elbows.
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INDICATIONS FOR TOTAL ELBOW ARTHROPLASTY The indications for total elbow arthroplasty in patients with rheumatoid arthritis are ARA stage IllB or IV, significant pain, and a decrease in motion that interferes with the ability to perform essential activities of daily living (Figure 4). The medullary canals of the humerus and ulna must be large enough for the prosthesis to enter. In cases of monoarticular osteoarthritis or traumatic arthritis, the patient must have a lowdemand lifestyle. If not, a high rate of early failure is not unlikely.
Traumatic arthritis The results of total elbow arthroplasties for traumatic arthritis have not been as good as the results for rheumatoid arthritis. Schneeberger et al46 reported on 41 elbows treated for posttraumatic problems with the Coonrad-Morrey elbow. Of the 41 patients, 1 1 had a major problem and 9 of these 11 needed an additional operation. The ulnar component fractured in 5 patients, the pal ethylene bushing wore out in 2, and there were 2 in 1ections. Follow-up ranged from 2 to 12 years; the average follow-up was 68 months. They concluded that this procedure was relatively contraindicated in patients who anticipate strenuous activity or who are not expected to comply with the postoperative protocol. The 24-year-old patient in Figure 5 having posttraumatic arthritis and a loosened total elbow arthroplasty is contrasted with the 85yearold patient in Figure 6 who has nonunion of an intracondylar fracture.
A
Contraindications The presence of active sepsis is an absolute contraindication. Neuropathic joints caused by diabetes, syringomyelia, or other diseases are contraindications, as are nutritional deficiencies that might delay prompt healing of the surgical wound. If total elbow arthroplasty is performed in an elbow with existing heterotopic ossification, more ossification may be stimulated, leading to a decreased range of motion.23
CONCOMITANT SHOULDERJOINT REPLACEMENT What of the patient who is in need of a shoulder replacement in the same extremity as the elbow? Friedman and Ewald22 found no contraindication to operating on 1 joint when the other had a fixed deformity. The results of an arthroplasty of either the shoulder or the elbow with respect to motion, pain, and function were not found to be compromised when the 2 arthroplasties were performed in the same extremity. When both the shoulder and the elbaw are involved,‘the joint that causes the most oain and disabilitv should be oaerated on first. If bath joints appea; to be equally involved, they recommended that the elbow be operated on first because this results in greater functional improvement and allows a longer interval between
B Figure 4 Woman, 26 years of age, with virtually fused elbows who had lost the abilitv to eat and oerform other necessarv activities of daily living wiihout adapti;e devices and help. She had great difficulty in caring for her young children. However, she had very little pain. A, Elbow flexion before operation. B, Elbow extension before operation. Almost all forward and backward motion of her arms was from shoulders.
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arthroplasties. I believe, however, that the shoulder should be done first if both joints are equally involved because there are fewer serious complications with a shoulder replacement. Also, I have found that once a shoulder has become free of pain after an arthroplasty, the affected elbow can be so protected that the patient may not feel the need for an elbow arthroplasty. Kocialkowski and Wallace** suggested that if both the elbow and shoulder need to be replaced that both might be done at the same time.
SALVAGE OF THE FAILED ELBOW ARTHROPLASTY
Figure 5 Gunshot wound to elbow of 24-year-old patient was treated with total elbow replacement. Radiographs show loosening of rosthesis. A, Lateral view of the elbow. B, Anteroposterior view o P the elbow. Failure rate in young patients with a traumatic joint such as this is very high.
Of all major total joint replacements, prosthetic elbows have had the highest complication rate. In cases of infection, Morrey and Bryan35 found that a resection arthroplasty was necessary in 10 of 14 elbows to control the infection. In 1 case, the elbow was salvaged by early debridement. In 2 cases, a new implant was reinserted after removal of the first prosthesis and control of infection. The 14th patient had a paretic upper extremity as a result of a cerebral vascular accident and her extremity was amputated. In case of failure, a reasonable backup plan for salvage must be available.9,’ II1 *,*0,*53-37 In cases of aseptic failure of a stemmed prosthesis with good bone stock, the old prosthesis can be removed and a new one reimplanted. In cases of severe bone loss, a larger stemmed prosthesis or a custom device may be necessary or even a bone graft with the implant. Morrey and Bryan37 reported 33 revisions. Of these, 22 were in patients with rheumatoid arthritis. Three of the revised elbows became infected, and 2 of the infections were in rheumatoid elbows. Only 13 of the 33 elbows were not associated with at least 1 complication. Twelve complications occurred in 10 patients who had rheumatoid arthritis. Before the 1980s they selected an implant for revision on the basis of whether any components were solid and could be left in place. Since 198 1 they have exclusively used the CoonradMorrey device for this purpose, and some of the revisions with this device failed. Eight (23%) of the revised components became loose in 7 of 30 elbows that had not become infected. Figgie et all9 reported on 10 failed elbow arthroplastics. Six of these were for dislocation after failure of the bearing mechanism. In each case, the humeral or ulnar center of rotation had been malaligned. An additional 4 elbows were revised for component loosening, and 1 was revised for malalignment. Two of these revisions failed, 1 because of sepsis. In 1990 Figgie et al*O published a report on the results of implant removal in 1 1 patients. Seven were removed because of infection, 3 because of implant fracture, and 1 because of recurrent dislocation. Treatment consisted of soft tissue arthroplasty combined with external fixation in 10 patients and attempted arthrode-
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C Figure
6 Use of Coonrad-Morrey excellent result. A, Preoperative Postoperative anteroposterior
375
D prosthesis lateral view. view.
to treat
nonunion
B, Preoperative
sis with external fixation in 1 patient. There were 4 good, 1 fair, and 2 poor results; 4 operations failed. Satisfactory results were obtained in 7 of the 8 elbows in which an anatomic arthroplasty was achieved. A later report*’ also indicated that satisfactory results can be achieved in complex cases. Dent et al11 reported on 26 failed primary total elbow arthroplasties in 25 patients with rheumatoid
of intracondylar anteroposterior
fracture in 85year-old view. C, Postoperative
woman had lateral view. D,
arthritis. Most revisions required special custom implants to treat varying bone loss and soft tissue disruption. Satisfactory function results were shown at a mean follow-up of 35 months. In cases in which it is not wise or possible to reinsert a prosthesis, resection arthroplasty is usually performed (Figure 7). The following steps are useful for obtaining stability: (1) transfer the wrist flexor and extensor mus-
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Figure 7 Resection arthroplasty resulted in painful, unstable elbow. Elbow was converted to semiconstrained prosthesis. Stability was restored, and pain was relieved.
cles proximally; (2) insert a triceps flap between the bone ends; (3) advance the distal triceps; and (4) notch the bone to enhance stability if enough bone stock remains (Figure 8). An arthrodesis may be indicated, but the procedure is very difficult because of lack of bone stock. Together with Clayton, 18 I reported a series of 14 total elbows salvaged after failure, 3 for infection, 6 for asep tic loosening, 4 for instability, and 1 for a failed bearing mechanism. All the infected elbows were converted to resection arthroplasties with elimination of infection but with poor function; 2 were unstable and the third had marked limitation of motion that improved satisfactorily after fascial arthroplasty. Those that failed aseptically were all successfully salvaged with implantation of other devices, whether a longer ulnar custom implant or the Coonrad-Morrey elbow that is also used to treat nonconstrained elbows that failed because of instability. In cases without infection, all replacements were successful and pain relief and motion were comparable to or better than the same measures before revision. Failed unstemmed prostheses are easier to reconstruct. Reconstruction can be achieved by arthroplasty
B Figure 8 Resection arthroplasty was performed after total became infected. After resection, patient had motion between and 130”. Elbow was stable and painless. A, Lateral view elbow showing the prosthesis was removed and the resultant loss. B, Anteroposterior view of the elbow after the removal prosthesis.
elbow 10 of the bone of the
with tissue interpositioning, insertion of a stemmed prosthesis, or fusion. Revision for aseptic loosening or dislocation is best handled by removing the components and inserting one of the semiconstrained prostheses. The Coonrad device modified by Morrey has been useful in such cases. Reconstruction of the soft tissue restraints for dislocation has not been reliable. Dislocation or subluxa-
I Shoulder Volume
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and regardless I tion is likely the result of malal~ignment, * * of the type of prosthesis used tor revision, the axis ot motion needs to be corrected. Although there have been complications and failures with total elbow replacement, this operation has been very successful in relieving pain and easing disability in most patients with arthritis. Future design modifications may be useful; smaller components that save bone stock may help maintain stability in case of failure. Prostheses with an optional locking mechanism that can be converted from a nonconstrained to a semiconstrained device should help prevent loosening and instabili . Alternatives to cement fixation may also be useful. Tx e ultimate goal should be a biologic implant.
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