Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008

doi:10.1016/j.jse.2014.02.001

Journal of Shoulder and Elbow Surgery

Volume 23, Issue 6, June 2014, Pages 829-836

https://doi.org/10.1016/j.jse.2014.02.001 Get rights and content

Background

Total elbow arthroplasty (TEA) is an established treatment for late-stage arthritis of the elbow. Indications have expanded to osteoarthritis and nonunion in distal humeral fractures. Information on implant survival and risk factors for revision is still sparse. The aim of this study was to evaluate implant survival and risk factors for revision of TEAs inserted in patients in the eastern part of Denmark in the period from 1980 until 2008.

Material and methods

The Danish National Patient Register provided personal identification numbers for patients who underwent TEA procedures from 1980 until 2008. On the basis of a review of medical reports and linkage to the National Patient Register, we calculated revision rates and evaluated potential risk factors for revision, including, age, sex, period, indication for TEA, and implant design.

Results

We evaluated 324 primary TEA procedures in 234 patients at a mean follow-up of 8.7 years (range, 0-27 years). The overall 5-year survival was 90% (95% confidence interval [CI], 88%-94%), and 10-year survival was 81% (95% CI, 76%-86%). TEAs performed with the unlinked design had a relative risk of revision of 1.9 (95% CI, 1.1-3.2) compared with the linked design. Fracture sequelae was associated with a relative risk of revision of 1.9 (95% CI, 1.05-3.45).

Conclusions

We found acceptable implant survival rates after 5 and 10 years, with a higher revision rate for the unlinked design and primary TEA due to fracture sequelae. Patient-related outcome measures should be included in future studies for further elaboration of the outcomes after TEA.

Section snippets

Material and methods

This study was based on data provided by the Danish National Patient Register (NPR) for patients who underwent TEA procedures in eastern part of Denmark between 1980 and 2008.

Statistics

The end point for survival was defined as revision involving 1 component or the entire implant (removal or exchange). All patients were followed up from surgery to revision, death, emigration, or January 1, 2013. Kaplan-Meier survival analyses were used to calculate implant survival rates at 1, 5, 10, and 15 years. Survival data obtained in the Kaplan-Meier analysis were compared by the log-rank test (Mantel-Cox). The TEA was bilateral in 45 patients, and each replacement procedure was

Patient characteristics

Of the 324 TEA operations, 264 (81.5%) were performed in women. At the time of primary TEA, the mean age was 62 years (range, 25-91 years), and 160 (49.4%) of the TEAs were performed on the right elbow. Rheumatoid arthritis (RA) was the most frequent indication for the TEA operation, with 237 (73.1%) procedures performed. Other indications for primary TEA were fracture sequelae with 61 procedures, including 7 acute fractures (18.8%), osteoarthritis (OA) in 18 (5.6%), and other indications,

Discussion

In this retrospective study we found acceptable 5-, 10-, and 15-year implant survival rates after primary TEA. Patients receiving TEAs over time have increased, and since 2003, the choice of implant has been dominated by the linked design. Revision rates and RR estimates were higher for the unlinked design. The most common reason for revision for both the linked and unlinked design was aseptic loosening. TEA procedures performed due to fracture and fracture sequelae were associated with

Conclusions

Survival analysis on TEA is sparse as are studies comparing TEA designs. RA continues to be the most common indication, but TEA procedures due to fracture and fracture sequelae are increasing, with a higher risk for revision. The survival rates of revision TEAs are promising, which is of interest when performing primary TEA surgery on younger patients, who are more likely than older patients to live past the survival of their primary TEA. The tendency goes toward the linked design, which in

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Treatment of post-traumatic complete bony ankylosed elbow using total arthroplasty and hernia patch - A case report
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The elbow is one of the most mobile joints, and its movement is very important. Bony ankylosed elbow is an uncommon condition leading to complete loss of activity of elbow, and then lead to severe disability and limitation in activities of daily living.
A 63-year-old woman sustained comminuted fracture of left distal humerus. She underwent open reduction and internal fixation by plates. After the plates were removed in 2016，stiffness developed.The elbow was stable but fixed at 90°，there was no vascular injury or deficit in sensory and motor function of the ulnar nerve. She hopes to eliminate pain and restore normal mobility compatible with ADL.
Complete bony ankylosis of the elbow joint may be caused by trauma, rheumatic disease, burns, congenital stiffness and other conditions. Even with the compensation of shoulder and wrist, it will still have a great impact on upper limb function. Whether to treat mainly depends on whether the patient has the require to improve the functionality and return to daily activities. Treatment methods are very limited, including interposition arthroplasty and TEA. Defect of soft tissue appeared was seen in our case, Hernia Patch was innovatively applied to reconstruct the defect of soft tissue and maintain continuity of elbow extension mechanism.
Patients with post-traumatic elbow joint ankylosis were suffered from severe bony abnormalities, but also soft tissue contracture or defects due to multiple operations and trauma. We present a case of complete bony ankylosed elbow treated with total elbow arthroplasty and Hernia Patch.
Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial
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Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients.
This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength.
Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of −5.6 points (95% CI: −18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group.
In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.
Analysis of 516 cases of revision total elbow arthroplasty from the Dutch Arthroplasty Registry: centralization of care is the future
2024, Seminars in Arthroplasty JSES
The number of revision total elbow arthroplasty (TEA) remains relatively low. As a result, there are relatively few orthopedic surgeons and a limited number of centers with substantial expertise in revising TEA. This study provides a comprehensive description of the current practice concerning revision TEA in a northern European Country based on the data of the Dutch National Implant Registry.
Data of all revision TEA procedures performed between 2014 and 2022 were extracted from the national registry, including cases where the primary procedure was either not recorded in the registry or was not a TEA. Descriptive statistics were used to report the current practice of revision TEA in the Netherlands.
Five hundred sixteen revision TEAs were performed in the Netherlands between 2014 and 2022. Eighty-four elbows required more than one revision during that period. The primary cause for revision was aseptic loosening 51%. The procedures were performed in 35 centers, and 21/35 centers performed 5 or less revision procedures per year. No center performed 20 or more revision procedures per year.
All types of elbow arthroplasty are associated with a considerable rate of complications, and a direct volume-outcome relationship exists in these surgical procedures. Despite the considerable complication rate, the volume of revision TEA remains low, primarily due to the infrequent occurrence of primary procedures.
The study reported that aseptic loosening was the primary reason for revision TEA. We recommend centralizing infrequent surgical procedures such as revision TEA in selected highly specialized centers to increase surgeon and center volumes, aiming to yield more favorable outcomes.
Outcomes After Acute Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures
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Compare outcomes of acute versus delayed total elbow arthroplasty (TEA) following distal humerus fractures (DHF).
This retrospective study included 39 patients who underwent primary TEA with semiconstrained implants for DHF, either within 4 weeks of their injury or after failing initial open reduction and internal fixation (ORIF) or nonsurgical management, between June 1, 2003 and February 1, 2018 with minimum 1-year follow-up. Our outcome measures included QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score, complications, reoperations, and range of motion (ROM). Demographics, clinical variables, and outcomes were compared using the Student’s t-test, Mann-Whitney U test, and Fisher’s exact test as appropriate. Kaplan-Meier curves for mortality, implant survivorship, and reoperation were created.
Our patients were categorized into acute TEA (n = 22), ORIF to TEA (n = 10), and nonsurgical to TEA (n = 7) treatment groups. Additional analysis was performed comparing acute to delayed TEA, which combined data from failed ORIF and nonsurgical cohorts. The median follow-up, average age, and median Charlson comorbility index were similar between groups. The most common fracture pattern was AO13C. At median follow-up of 5.8 years, QuickDASH differed between cohorts: mean of 31 (SD 19) in acute TEA and 52 (SD 27) in delayed TEA, which further subdivided to 44.2 (SD 25) in failed ORIF and 76 (SD 23) in failed nonsurgical management. Poorer QuickDASH scores at final follow-up were associated with delayed TEA, initial nonsurgical management, and depression. Surgical complications were associated with delayed TEA. Higher Charlson comorbidity index was associated with death. No variables were associated significantly with ROM, revision, or reoperation.
Comminuted DHFs are difficult to treat in the elderly with high rates of complication and poor function after surgery. Our study suggests TEA performed acutely result in satisfactory outcomes and should be a consideration for patients at high risk of failing ORIF or nonsurgical management.
Therapeutic, III.
Intraoperative modification of total elbow arthroplasty implants
2023, Journal of Shoulder and Elbow Surgery
Modification of total elbow arthroplasty (TEA) implants may be necessary in selected patients with substantial anatomic bone deformity or those undergoing revision surgery. The purpose of this study was to investigate the prevalence and consequences of implant modifications during TEA at our institution. We hypothesized that TEA implant modification would be more common in revisions than in primary replacements, and that it would not be associated with worse clinical outcomes or increased rates of radiographic or surgical complications directly related to the implant modification.
Elbows that had undergone TEA by any of 3 surgeons at our institution with use of intraoperative implant modification between January 1992 and October 2019 were retrospectively reviewed for the type of modification and complications. Complications were classified as definitely related, probably related, possibly related, or nonrelated to the implant’s modification according to the consensus review by the 3 senior surgeons. A survey was sent out to surgeons outside of our institution to investigate whether intraoperative modification to TEA implants is a common clinical practice.
A total of 106 implant components were modified during 94 of 731 TEA procedures (13%) in 84 of 560 patients. Implant modifications were performed in 60 of 285 revision cases (21%) compared with 34 of 446 (8%) primary cases (P < .0001). These included shortening the stem in 40 (44%), bending the stem in 16 (15%), notching the stem in 16 (15%), tapering the stem in 9 (9%), and a combination of 2 or more of these modifications in 19 implants (17%). Among the 55 index surgeries available for complication analysis, 40 complications occurred in 28 index surgeries (11 primary and 17 revisions; 25 patients), making the overall complication rate 51%. Of these 40 complications, 23 were considered independent of any implant modification. Of the remaining 17 complications, 9 were considered nonrelated to the implant modification, 6 were possibly related, and 2 were probably related to the implant modification. Therefore, the complication rate possibly related or probably related to implant modification was 15% (8 of 55). No complication was classified as definitely related to the implant modification. No implant breakage or malfunction occurred after any modification. A total of 442 survey responses were received representing 29 countries, of which 144 surgeons (39%) performed modification to implants during TEA procedures.
This study confirmed our hypothesis that modification of TEA implants is not uncommon at our institution, particularly in revision arthroplasty. Surgeons should keep in mind that complications possibly related or probably related to implant modification were at minimum 15% and could have been as high as 30% if the patients lost to follow-up had all had complications. Implant modification may be necessary in some cases but should be exercised with thoughtful consideration and caution.
Testing of Novel Total Elbow Prostheses Using Active Motion Experimental Setup
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Citation Excerpt :
We are testing this novel total elbow arthroplasty (TEA) in different degrees of abduction because in the dependent position the elbow does not experience substantial varus or valgus laxity and total elbow arthroplasty designs do not reach the laxity limits of the linkage mechanism.5,14,15 Our experimental setup aims to reproduce the in vivo situation by abducting and adducting the arm and recreating varus and valgus forces, which have been implicated in the creation of polyethylene edge loading that is identified in explanted, semiconstrained total elbow replacement bearings (Fig. 6).16–19 This experimental setup reproduces active muscle forces that both move and dynamically stabilize the elbow and can offload the stabilizing ligaments by increasing osseous stability.20
The goal of this study was to test a novel uncemented and unconstrained total elbow arthroplasty (Kaufmann total elbow) design that is stabilized through a ligament reconstruction.
We quantified the implant stability after 25,000 cycles, which represents the time between implantation and when ligament and bone healing has occurred. We used an active motion experimental setup that applies tendon loads via pneumatic cylinders and reproduces the forearm-originating dynamic stabilizers of the elbow. The novel total elbow arthroplasty was actuated for 5,000 full flexion-extension cycles at 5 different shoulder positions. Four Sawbones and 4 cadaver elbows were employed. Angular laxity and implant stability were recorded prior to testing and after each 5,000-loading cycle.
Four Sawbones and 4 cadaver elbows were implanted with the uncemented total elbow arthroplasty and did not demonstrate fixation failure or substantial laxity after 25,000 cycles of loading imparted at different shoulder positions.
Our findings demonstrate that the Kaufmann total elbow replacement implanted into cadaver and Sawbones specimens did not exhibit fixation failure or excessive laxity after 25,000 cycles.
An uncemented, nonmechanically linked total elbow arthroplasty that gains component fixation using intramedullary screws and employs a ligament reconstruction to stabilize the elbow has the potential to be a valuable management option, particularly in younger patients.

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: The Scientific Ethics Committee for the Hovedstaden Region approved this study.

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ElbowImplant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008

Background

Material and methods

Results

Conclusions

Section snippets

Material and methods

Statistics

Patient characteristics

Discussion

Conclusions

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Orthop Traumatol Surg Res

J Shoulder Elbow Surg

J Shoulder Elbow Surg

The Danish National Hospital Register. A valuable source of data for modern health sciences

Dan Med Bull

Total elbow arthroplasty: history, current concepts, and future

Clin Rheumatol

Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients

J Bone Joint Surg Am

Total replacement arthroplasty of the elbow for rheumatoid arthritis

J Bone Joint Surg Br

Reconstructive surgery following total elbow endoprosthesis

Clin Orthop Relat Res

Early results of the Souter-Strathclyde unlinked total elbow arthroplasty in patients with osteoarthritis

J Bone Joint Surg Br

Radial head, radiocapitellar and total elbow arthroplasties: a review of recent literature

Injury

Elbow
Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008