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PubMed2004

[Total elbow joint allograft for long term posttraumatic osteoarticular loss. Follow-up results at twelve years].

PURPOSE OF THE STUDY: Elbow joint allograft (EJA) involving the entire joint (distal humerus, proximal radius and ulna, capsuloligament structures) is a salvage technique proposed in massive bone loss, particularly in young subjects where total elbow prosthesis is contraindicated. We report our experience with seven patients, analyzing the long-term clinical and radiological outcome. MATERIAL AND METHODS: This retrospective study included seven patients, mean age 42 years (21-70). All had experienced severe elbow trauma. Two patients had associated neuromuscular or vascular lesions. All patients underwent at least one surgical procedure on the affected elbow. The preoperative status of the skin cover was crucial. Both longitudinal and circumferential retraction were observed. We used preoperative skin expansion in one patient and a pediculated musculocutaneous latissimus dorsi flap in one other. A posterior and median approach was used conserving tricipital continuity. The ulnar nerve was transposed anteriorly. The allograft was prepared, carefully preserving the capsule and ligaments. Adaptation required cutting the extremities of the humerus and radius and total resection of the radial head except in one patient. Stable plate fixation was completed by an iliac cancellous graft screwed to the humerus and the ulna. The Morrey score was used to assess clinical outcome. The Larsen and Allieu classifications were used to assess radiological outcome. RESULTS: There was one early failure requiring revision for arthrodesis. Assessment of long-term outcome concerned six patients. Mean follow-up was 12 years (7-15 years). The Morrey score improved in six patients and five of them were satisfied. None of the patients complained of invalidating pain and elbow motion was not functional in only one (- 30 degrees - 100 degrees ). For all patients except one, instability was proportional to the duration of the graft and worsened with time. For five out of six patients, significant radiological degradation of the elbow joint was associated with bone lysis which increased with time. DISCUSSION: The allograft acts like a spacer and does not transmit pain impulses. The absence of the pain signal leads to overuse of the grafted joint and osteoarticular destruction. Despite radiological degradation, this procedure provides satisfactory and painless elbow function in most patients. The clinical and radiological features do not follow the same pattern. But we did not have any cases of disassembly or nonunion. Preoperative planning and plastic surgery have enabled us to control the cutaneous portal. We did not have any postoperative infections. Joint allograft is a salvage solution for major osteoarticular loss in young patients desiring conserved joint function and for whom a total elbow prosthesis is contraindicated. It restores bone stock, enables mid-term potential for joint function, and does not compromise surgical revision. CONCLUSION: It remains an exceptional indication which is technically difficult. Resorption of the allograft is constant at long term. Clinically, instability worsen functional outcome. The future for this technique depends on progress in immunology and cryobiology. At the present time, composite total elbow prostheses with an allograft combine the advantages of restored bone stock and arthroplasty.

Adult↗

PubMed1994

Malrotation of the humeral component of the capitellocondylar total elbow replacement is not the sole cause of dislocation.

Malrotation of the humeral component of the capitellocondylar total elbow replacement is thought but not proved to be one of the major causes of postoperative dislocation. The purpose of this study was to quantitate the effect of malrotation of the humeral component on the kinematics and laxity of the capitellocondylar total elbow prosthesis. Eleven fresh previously frozen elbows were used. With the humeral component in optimal position, external rotation, or internal rotation, movements of the elbow with neutral, valgus, and varus loading were monitored with an electromagnetic tracking device. When the humeral component was positioned in external rotation, the ulna was more valgus and supinated than when the component was in optimal position, and when the component was in internal rotation the ulna was more valgus in extension and more supinated in flexion. Malrotation in external rotation decreased valgus-varus laxity, and malrotation in internal rotation increased rotational laxity. Only one elbow became dislocated, despite constant severe maltracking between the components in all of the specimens. We concluded that although malrotation of the humeral component influences the laxity and causes maltracking, it is not the primary cause of postoperative dislocation. The contribution of other factors should be investigated.

Aged↗

PubMed2004

Systematic review of primary total elbow prostheses used for the rheumatoid elbow.

Total elbow prosthesis (TEP) has been shown to be a viable option for treatment of the rheumatoid elbow. Many types of TEP have been studied, but the heterogeneity of the studies makes most conclusions subject to discussion. The aim of this systematic review is to show the differences between the most commonly used TEP for the destroyed rheumatoid elbow. After a search in Pubmed (NLM, Bethesda, USA) the senior author selected eight frequently used TEP: the Capitellocondylar, Coonrad-Morrey, GSB III, Kudo, Liverpool, Norway, Roper-Tuke and Souter-Strathclyde. For inclusion studies we arbitrarily formulated nine criteria, after which clearly adverse events were defined for comparison purposes. The Capitellocondylar and Souter-Strathclyde prostheses are the most-studied treatments for replacing the rheumatoid elbow. In contrast to the Capitellocondylar, the Souter-Strathclyde prosthesis showed higher loosening rates but implemented modifications of the design have reduced these rates in recent studies. Nevertheless, in relation to most other joint replacements in rheumatoid patients, all TEP still have higher complication rates. For this reason an elbow prosthesis may just be warranted in seriously disabled patients.

Arthritis, Rheumatoid↗

PubMed2001

[Endoprosthetic joint replacement of the contracted elbow joint].

In a retrospective study 14 patients were reviewed 63 months after the implantation of a semi-constrained total elbow prosthesis in fourteen stiff or ankylosed elbows with a preoperative range of elbow motion of 30 degrees or less. The result, according to the Mayo Elbow Performance score, was excellent for four elbows, good for four, fair for one, and poor for five. The average arc of flexion improved from 7 to 68 degrees postoperatively with an average increase of 34 degrees in flexion, and 27 degrees in extension. There were seven complications affecting seven of the 14 elbows and four of these seven elbows underwent a revision procedure. Replacement for a stiff elbow is the least predictable, has the lowest overall rate of success and highest complication rate, than any other procedure. Nevertheless, these disadvantages must be placed in the context of alternative intervention options. The semiconstrained total elbow arthroplasty seems to be a useful option for patients older than 50 years with intrinsic stiffness involving more than 50% of the articular surface and with an ankylosed or very stiff elbow.

Adult↗

PubMed1997

[Follow-up of Souter elbow prostheses].

27 patients (30 elbows) treated with Souter elbow prosthesis replacement were examined at a follow-up study. 26 patients had rheumatic arthritis. The mean observation time was five years (2-10 years). The indication for surgery was severe pain and reduced elbow function. Preoperative radiological examination revealed considerable pathological changes in all the elbows. Six of the elbows underwent revision with new prosthesis replacement. The indications for the re-operations were fractures, loosening of the prosthesis and luxations. 19 elbows (26%) had deteriorated and three patients had no definite opinion. Four of the six elbows replaced by a new prosthesis, became worse than before the first operation. Follow-up radiological examination showed that 80% of the humerus components showed varying degrees of radiological loosening and more than half of the humerus components showed cranial migration. All patients who suffered fractures during the operation have been, or will be, re-operated. Radiological loosening of the prosthesis makes the prognosis uncertain for the majority of the patients. Re-operation with a new prosthesis is unsatisfactory. As a consequence of the poor results, this prosthesis is no longer used at our hospital.

Adult↗

PubMed2003

[GUEPAR radial head prosthesis for recent and old fractures: a series of 22 cases].

PURPOSE OF THE STUDY: We reviewed retrospectively outcome in 22 patients with recent or old fractures of the radial head treated with a GUEPAR radial head prosthesis. This prosthesis, derived from the GUEPAR sliding total elbow prosthesis, has a cemented mobile metal cup. MATERIAL AND METHODS: Eighteen patients underwent emergency surgery, four deferred surgery. Mean age at surgery was 41 years and mean follow-up was 18 months. The Mayo Clinic score was calculated to assess clinical outcome. Static and dynamic x-rays of the elbows and wrists were analyzed. All of the fractures were total or displaced head fractures and 72% involved elbow dislocation. The coronoid process was fixed in one patient, the olecranon in one and the medial ligaments were repaired in 5. The quality of the cartilage of the humeral condyle was checked before insertion of the prosthesis. Proper position and height of the prosthesis were carefully controlled. RESULTS: There were no complications. Outcome was good in the patients who underwent emergency surgery with a mean Mayo Clinic score of 83/100, mean force 75%, good joint motion (77 degrees pronation, 79 degrees supination), stable elbow, and no wrist problems. Outcome was not as good in patients who underwent deferred implantation, particularly for joint motion (pronation 44 degrees, supination 54 degrees ). The distal radio-ulnar ratio was not perfectly restored. Finally 4 patients required arthrolysis for limited flexion/extension, proportionally more among the deferred patients. DISCUSSION: Resection of the radial head is an alternative in case of complex fractures. There are two drawbacks. The first is an unstable elbow in valgus if the medial ligaments are damaged. The second is an ascension of the radius if the interosseous membrane is damaged. Osteosynthesis is another alternative which is difficult to achieve and does not give good results (in our experience in comparison with 20 equivalent fractures, and in the literature). The GUEPAR radial head prosthesis appears to be a good solution. It stabilizes the elbow, prevents ascension of the radius, allows early rehabilitation, and provides good subjective results, particularly after emergency surgery.

Adult↗

PubMed1990

Management of infection about total elbow prostheses.

Deep infection was a complication after twelve (7.3 per cent) of 164 primary total elbow replacements. Two additional patients who had an infection about an elbow prosthesis were referred for treatment after total elbow replacement elsewhere. A statistical analysis of all of these primary total elbow arthroplasties, including the two in patients who were referred from outside institutions, identified preoperative factors that placed a patient at significant risk for subsequent infection. The risk factors included a previous operation on the elbow, a previous infection in the region of the elbow, psychiatric illness, class-IV rheumatoid arthritis, drainage from the wound after operation, spontaneous drainage after ten days, and reoperation for any reason. Three modes of treatment were used for patients who had an established infection: débridement and salvage of the implant, resection arthroplasty, and arthrodesis. After early operative débridement and suppression of the infection with long-term antibiotic therapy, three patients were able to retain the prosthesis, with restoration of range of motion and function of the upper extremity. One prosthesis was reimplanted after a six-week course of intravenous administration of antibiotics.

Adolescent↗

PubMedDate not supplied

Total elbow replacement with the GSB III prosthesis.

Fourteen consecutive elbows have been treated for rheumatoid arthritis (9 elbows) and for post-traumatic osteoarthrosis (5 elbows) by total elbow replacement with the GSB III implant. The elbows were reviewed retrospectively after a mean follow-up of 6 years (2 to 9 years). Ten of 14 elbows had a functioning GSB III implant at follow-up; 7 of them were rated satisfactory and 3 unsatisfactory with the Mayo elbow performance score. In 5 of these 10 cases, the patients had significant pain relief with no or only mild pain at follow-up, whereas 5 had moderate to severe pain. With a functioning implant the range of motion averaged 140 degrees of flexion, 19 degrees of lack of extension, 65 degrees of pronation, and 84 degrees of supination. Six (43%) elbows had major complications requiring 1 to 8 additional operations. Aseptic loosening requiring revision occurred in 4 (29%) elbows. Two of them were treated by a resection arthroplasty, and 2 were revised with another hinged semiconstrained device. Three further elbows had radiolucent lines involving more than 50% of the cement-bone interface of either the humeral or the ulnar component. However, in 8 elbows the cementing technique was considered marginal or inadequate. Poor cementing (marginal or inadequate) was associated with loosening (P = .008). The GSB III total elbow prosthesis can restore function and reduce pain. The rate of aseptic loosening in this series was higher than previously reported. Based on this observation, we conclude that the GSB III implant seems to be sensitive to the insertion technique and does not tolerate suboptimal cementing.

Aged↗

PubMed1976

Comparison of an EMG-controlled prosthesis and the normal human biceps brachii muscle.

An electromyographically-controlled elbow prosthesis, the "Boston arm", was tested with constant and sinusoidally-modulated inputs under different loading conditions. These tests were used to determine the frequency response of the EMG amplifier, the range of motor speeds, the force-velocity curve, and the frequency response of the prosthesis for cyclic movements. Human biceps muscle was tested during movements under similar loads, and under isometric conditions using random, electrical stimuli to determine its frequency response. The results were compared to evaluate the performance of the prosthesis and contrast its characteristics to those of the physiological system it replaces. The prosthesis minimizes quiescent power drain, and the possibilities of instability or "tremor" by employing velocity control, an overdamped mechanical system, and an electrical "dead-band". These factors limit the ability of the prosthesis to follow rapidly changing inputs or to move rapidly and accurately to a desired position. These comparisons should provide a useful supplement to the usual clinical evaluations, and a starting point for further improvements in prosthesis design.

Arm↗

PubMed1997

The Norway elbow replacement. Design, technique and results after nine years.

The Norway elbow prosthesis is a non-constrained cemented total replacement. It depends on intact collateral ligaments for stability, and allows a full range of movement. The system includes several sizes of components, all freely interchangeable, and semi-constraint can be provided by a locking ring if damaged collateral ligaments make dislocation possible. The prosthesis has been used in more than 350 elbows in Norway and the detailed results for 118 elbows studied prospectively since 1987 are reported. It is inserted through a posterolateral triceps-splitting incision with minimal muscle disruption and bone resection, preserving the collateral ligaments. The results as regards pain relief and range of movement were comparable with those of other elbow prostheses, but there were fewer serious complications. At a mean follow-up of 4.3 years, the failure rate was 3.4%.

Adult↗

PubMed1984

Design and evaluation of a prosthesis control system based on the concept of extended physiological proprioception.

This paper describes the design and evaluation of an experimental prosthesis-control system based on the concept of extended physiological proprioception (EPP). It was originally hypothesized that EPP control effected by residual shoulder motion could be effectively applied in multifunctional prostheses for shoulder disarticulation amputees. The experimental system developed for this study utilized a force-driven control scheme and a shoulder motion transduction system in which direct cable linkages to the prosthesis components were used to implement EPP position-servo relationships between shoulder elevation-depression and prosthesis elbow flexion, and between shoulder protraction-retraction and prosthesis wrist rotation. The results of experiments performed with this prosthesis (and with an experimental velocity-controlled prosthesis implemented for comparison purposes) clearly demonstrated the superior performance provided by EPP control of prosthesis function.

Arm↗

PubMed2001

Elbow load during pushup at various forearm rotations.

OBJECTIVE: Elbow joint loading was evaluated during pushup exercises at various forearm rotations. DESIGN: Subjects were asked to perform pushup in various forearm rotations: neutral, 90 degrees internal rotation, and 90 degrees external rotation. BACKGROUND: Training with pushup exercise is good for the muscles and joints of the upper extremities. However, excessive shear forces on the elbow might lead to injuries to either normal trainees or to handicapped people, especially for those who rely on elbow prosthesis. METHODS: The kinematics and kinetics of the elbow joint were investigated under various forearm rotations. RESULTS: The loading biomechanics of the elbow joint differed with various forearm rotations. It was noted that greater posterior and varus forces of the elbow are encountered with internal rotation of the hand position and, consequently, full forearm pronation. CONCLUSIONS: Pushup with hands in internally rotated position should be prevented so as to avoid excessive shear forces or moments. RELEVANCE: Knowledge of elbow kinematics and kinetics may be helpful in preventing injuries by reducing the elbow shear force with changes of forearm rotation.

Adult↗

PubMed1979

Learning patterns of young children with above-elbow prostheses.

In order to develop an improved method of teaching young child amputees to operate the forearm lift and elbow lock of a conventional above-elbow prosthesis, learning patterns of 12 young above-elbow amputees were observed and described by occupational therapists. From these observations, signs of readiness for learning were identified and a method was proposed for teaching these controls to children. The therapist gave the child physical assistance as well as verbal instruction and a demonstration for each part of the operation and then for the combined motion. Application to activities required development of new habit patterns and appeared to be related to cognitive abilities beyond the sensorimotor level. Mechanical features of the double cycle lock tended to complicate learning and demonstrated the need to develop an elbow lock mechanism that better meets the needs of children.

Amputees↗

PubMed1995

Use of a pattern recognition technique to control a multifunctional prosthesis.

Various kinds of command source can be used to control an above-elbow prosthesis. But none of them can be used to perform a specified task easily. The research is devoted to investigation of the potential effectiveness of applying the kinematic data of the shoulder joint to control an upper-limb prosthesis. Using these data as input signals, an appropriate signal processing technique, pattern recognition, is utilised to derive control commands. The purpose of the investigation is to use these commands to control a multifunctional prosthesis so that an amputee can perform a few tasks. For testing performance accuracy, a goniometer is worn by a subject with intact arm. It is also interfaced to a digital computer. Next, he is asked to do one of the predefined tasks for which the joint angle trajectories have already been derived and stored. Almost as soon as the shoulder joint angles are sampled and sent to the computer, the program calculates the elbow and wrist angles. These values are compared with actual elbow and wrist angles, which are monitored by the goniometer.

Arm↗

PubMed2001

Kudo total elbow arthroplasty in patients with rheumatoid arthritis: a long-term follow-up study.

BACKGROUND: Improvements in the design of total elbow prostheses over the last two decades have led to better and more consistent results. The type-3 Kudo total elbow prosthesis was developed in 1980. The long-term results of use of this implant have not been reported. Because it is an unlinked prosthesis, it is not known whether preservation of the anterior oblique component of the ulnar collateral ligament at the time of implantation is important. METHODS: A type-3 Kudo total elbow arthroplasty with cement was performed in forty-seven patients (fifty elbows) with rheumatoid arthritis. Revision rates, clinical symptoms, postoperative complications, and radiographic changes were assessed eleven to sixteen years (mean, thirteen years) postoperatively. RESULTS: The overall survival rate of the prosthesis was 90% at sixteen years. The mean Mayo elbow performance scores were all poor (mean overall score, 43 points) initially. The overall score was substantially improved at both the intermediate follow-up examination (four to six years after the operation) and the late follow-up examination (eleven to sixteen years after the operation), to 81 and 77 points, respectively. The overall rate of radiolucency about the humeral component was 45% at the intermediate follow-up examination and 100% at the long-term follow-up examination. The rate of radiolucency about the ulnar component at the intermediate and late follow-up examinations was 4.3% and 8.9%, respectively. No great differences in results were found with preservation of the anterior oblique component of the ulnar collateral ligament. CONCLUSIONS: This long-term follow-up study showed acceptable results of the type-3 Kudo total elbow arthroplasty in patients with rheumatoid arthritis. Preservation of the ulnar collateral ligament does not seem to be necessary when performing this procedure.

Arthritis, Rheumatoid↗

PubMed2004

[Elbow reconstruction with massive total osteoarticular allograft: early failure due to instability].

Total elbow allografts were implanted for the treatment of trauma-induced bone defects in three patients between 1986 and 1990. Six allografts were implanted and finally explanted. The longest follow-up for an implanted allograft was five years. Allografts had to be removed because of nonunion in one patient and gross instability in the others. A constrained elbow prosthesis was implanted in all three patients. This short series illustrates mid-term failure to be expected with total elbow allografts, mainly due to instability. Accordingly, we no longer recommend the use of total elbow allografts alone as a salvage procedure for bony defects. If an allograft is needed, it should be implanted with a prosthesis.

Aged↗

PubMedDate not supplied

Late complications in elbow arthroplasty.

The world literature (1986 to 92) reports an amazingly high complication rate of elbow arthroplasty, amounting to 43%. Accordingly, we also find a high revision rate (18% on average) and a considerable rate (15%) of permanent complications. These figures do not correspond to our own experience with the GSB III (Gschwend/Scheier/Bähler) elbow prosthesis, a sloppy hinge with flanges on the lower and anterior part of the distal humerus. Our respective figures of complications are two to four times lower for rheumatoid elbows. When complications are discussed, a clear distinction of the type of prosthesis is mandatory, because linked or nonlinked and nonconstrained or semiconstrained prostheses have specific complications. The following complications are discussed separately: loosening (radiologic and clinical), ulnar neuropathy, infection, dislocation and subluxation, uncoupling, intraoperative bone fractures, and failure of the implant. The possible causes are analyzed, and means to avoid or treat these complications are discussed. We conclude that even in the long term ( > 10 years), results obtained with elbow arthroplasty are approaching those of hip and knee arthroplasty.

Adult↗

PubMed1992

Kinematics of semi-constrained total elbow arthroplasty.

We used 11 cadaver elbows and a three-dimensional electromagnetic tracking device to record elbow movements before and after implantation of a 'loose-hinged' elbow prosthesis (modified Coonrad). During simulated active motion there was a maximum of 2.7 degrees (+/- 1.5 degrees) varus/valgus laxity in the cadaver joints. This increased slightly after total elbow arthroplasty to 3.8 degrees (+/- 1.4 degrees). These values are lower than those recorded for the cadaver joints and for the prostheses at the limits of their varus/valgus displacements, indicating that both behave as 'semi-constrained' joints under physiological conditions. They suggest that the muscles absorb some of the forces and moments that in a constrained prosthesis would be transferred to the prosthesis-bone interface.

Biomechanical Phenomena↗