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PubMed1993

Prosthetic replacement of the arthritic elbow.

According to the recent literature, overall, results appear to be improving with elbow prosthetic surgery for severe arthritic problems, most cases being due to rheumatoid disease. However, a significant challenge remains: although data is accumulating, longer-term follow-up and greater numbers of patients need to be assessed before this area of surgical reconstruction emerges from the clinically experimental stage. It can be seen from the literature reviewed here that prosthetic loosening within bone, displacement of the articular surface of the implant, infection, and neurologic deficit, particularly of the ulnar nerve, can be unfortunate sequelae of prosthetic replacement of the elbow for severe arthritis. Osteoarthritis of the elbow is a good deal less common than rheumatoid disease of this joint, and the severe case is sometimes dealt with by prosthetic replacement; an alternative, in well selected cases, is the somewhat less challenging procedure of lower humeral fenestration arthroplasty. Revision of a failed elbow prosthesis can be a difficult challenge for the surgeon; the alternatives in this unfortunate situation are the use of an external brace, resection arthroplasty, or arthrodesis, all of them far from ideal. Many rheumatoid patients who undergo elbow prosthetic surgery have very significant shoulder involvement. Because of painful restriction of rotation of the gleno-humeral articulation, in particular, added forces are brought to bear on the elbow, making this one of the important factors in loosening of fully constrained prostheses. So far, there has been no long-term report of combined elbow and shoulder prosthetic replacement in such individuals, which is at present typically performed on separate occasions.

Arthritis↗

PubMedDate not supplied

The kinematic elbow axis as a parameter to evaluate total elbow replacement: A cadaver study of the iBP elbow system.

Malpositioning of prosthetic implants leads to biomechanical changes, often resulting in deteriorating functional outcome. This emphasizes the relevance of evaluating the surgical process of inserting the prostheses. This study tested to what extent the iBP elbow prosthesis and its alignment tools enabled a surgeon to reconstruct normal joint kinematics. It demonstrates the use of the kinematic elbow axis as an evaluation tool. An electromagnetic tracking device registered controlled passive elbow flexion of 10 embalmed upper extremities. The position and direction of the preoperative and postoperative kinematic elbow axes were established with the use of helical axes and compared. The postoperative position of the elbow axis differed from the preoperative axis because of limitations of the alignment tools. Suggestions for adjustment of the alignment tools are made. The direction of the imposed resection plane was correct; therefore, the direction of the postoperative elbow axis corresponded with the direction of the preoperative axis.

Arthroplasty, Replacement↗

PubMedDate not supplied

Semiconstrained total elbow arthroplasty.

Diminution of elbow function may be both embarrassing and severely disabling, especially in patients with multiple arthritic joints. Over the past century, multiple techniques of soft tissue reconstruction of the elbow have been advocated. In general, they do not compare well with total elbow arthroplasty. Arthrolysis has often resulted in little improvement of elbow motion and interposition arthroplasty to instability. Synovectomy may however offer satisfactory relief of disability for the rheumatoid elbow provided that initially there is little evidence of joint destruction. The major problem with rigidly linked total elbow arthroplasty has been a high incidence of prosthetic loosening. Biomechanical analysis has shown that high moments tend to disrupt the osseousmethacrylate junction in the humoral medulary canal. Development of a semi-constrained total elbow prosthesis transfers the developed stress to the collateral soft tissues and reduces prosthetic loosening to approximately 3 per cent. This is about one-tenth of the incidence of loosening of the hinge type arthroplasty. This reduction in prosthetic loosening has been coupled with excellent gains in flexion and estension. However, improvement in forearm rotation has not been predictable, especially in elbows exhibiting preoperative fusion or fibrous ankylosis. Though the semi-counstrained total elbow has only been generally available for 3 years, a review of these results justifies its continued use for elbow reconstruction.

Arthritis, Rheumatoid↗

PubMed1990

The artificial substitution of missing hands with myoelectrical prostheses.

The fitting of upper-extremity amputees requires special efforts, and its significance has been increased by the development of myoelectrically controlled prosthetic arm. Although an artificial hand only represents a relatively modest substitute for the missing hand of human beings, the efforts of designers and the achievements of manufacturers should not go unnoticed. Because of the development of myoelectrically controlled prosthetic arm, the amputee's standard of function can be improved and a cosmetic and functional solution provided. For control of the electromechanical hand, muscular potentials are received from the residual limb surface, amplified in the electrodes, and transmitted as control signals to the distal area. An important factor in providing a successful fitting is a reliable man-machine connection. This article summarizes the historic development and state of the art of the myoelectrically controlled arm prosthesis. The components and technical evaluations of the Myobock system as well as the procedures for fitting and fabricating a below-elbow prosthesis have been improved recently. A critical analysis of adaptive hands suggests that the prospects for the future are good.

Adult↗

PubMed1994

Total elbow allograft for twice-failed total elbow arthroplasty. A case report.

A successful case of total elbow allograft after removal of a twice-failed total elbow prosthesis is reported. The patient, a disabled 63 year old at the time of allograft implantation, can now perform all activities of daily living, including household chores. Both the humeral and ulnar allografts have incorporated, and there is no evidence of degenerative changes or allograft resorption two years nine months postoperatively.

Bone Transplantation↗

PubMed1998

[In vivo study of kinematics of the elbow using electromagnetic goniometer].

We used an electromagnetic goniometer to study the angular and translations displacements between the humerus and the 2 bones of the forearm. The electromagnetic gionometer allows acquisition of the coordinates and analysis of the 6 degrees of motion. To validate our external fixation apparatus, we used a fresh body upper limb. At first, a series of measurements was conducted with the apparatus. We then performed a series of measurements, by fixing the transmitter and receiver with external fixation pins directly inserted into the bones of the arm and forearm. To assess the reproducibility of our method, we chose a healthy subject. We performed 20 measurements over his right and left elbows. In order to study normal elbow kinematics, we performed measurements on 10 healthy subjects. The study of rotation showed that the apparatus was adapted to measure flexion-extension. It limited pronation-supination movement to about 26.7 degrees. Abduction was increased by 19.7 degrees by our apparatus during flexion-extension, but abduction was reliable within a 2 degrees range for pronation-supination. The sliding movements recorded during flexion-extension were reliable within approximately 3 mm for frontal translations, 6 mm for fitting, and 1 mm for external translations. For the sliding movements recorded in pronation-supination, frontal translations were reliable within about 7 mm, fitting was reliable within 1.9 mm and external translations were reliable within about 2.9 mm. During flexion-extension of the elbow, flexion-extension, frontal translations and external translations were reproducible. The reproducibility test showed that only 6 measurements were reproducible. The kinematic elbow study of a healthy subject showed that the average amplitude of flexion-extension was close to the measurement observed with the manual goniometer. The results in the healthy subject showed that the elbow is more stable during pronation-supination than during flexion-extension. This preliminary study should allow us, in the near future, to study elbow prosthesis kinematics.

Cadaver↗

PubMed2005

Polyethylene wear after total elbow arthroplasty.

BACKGROUND: Articular wear is considered to be a possible long-term complication of the use of stemmed, coupled elbow replacements with the capacity to correct deformity and restore function. There have been no reports on this topic, to our knowledge. METHODS: A review of the results of 919 replacements with the semi-constrained linked Coonrad-Morrey total elbow implant, performed between 1981 and 2000, revealed that twelve patients (1.3%) had undergone an isolated exchange of the articular bushings as a result of polyethylene wear. The status of these patients was assessed clinically and radiographically. RESULTS: The mean age of the twelve patients at the time of the initial total elbow replacement was forty-four years compared with a mean age of sixty-two years in the overall group (p < 0.001). Seven of the twelve patients had posttraumatic arthritis, and five had rheumatoid arthritis. Nine patients had extensive deformity. The group consisted of seven women and five men, and ten patients had involvement of the right dominant elbow. The mean age at the bushing revision was fifty-two years, and the bushings were revised at an average of 7.9 years after implantation. All twelve patients reported pain, and five reported crepitus or a squeaking sound. None had extensive osteolysis. The mean duration of follow-up after the bushing exchange was sixty-five months. The mean arc of motion improved from 89 degrees before the surgery to 109 degrees after it. Three of the twelve patients underwent an additional articular revision at fifty-three, fifty-four, and 136 months after the initial bushing exchange. At the time of final follow-up, all twelve patients had functioning elbows. CONCLUSIONS: Isolated bushing exchange can be a successful revision procedure in patients with a semi-constrained linked total elbow prosthesis. Younger patients with a posttraumatic condition and/or severe pre-existing deformity are at greater risk for the development of excessive bushing wear. Patients should be cautioned against exceeding the recommended activity and lifting restrictions.

Adult↗

PubMedDate not supplied

Semiconstrained total elbow arthroplasty in the context of treated previous infection.

Previous infection has been considered a strict contraindication to implantation or reimplantation of an elbow prosthesis. The purpose of this study was to investigate whether these patients can in fact be successfully treated with a prosthetic arthroplasty given previous treatment of the infection. Ten consecutive prosthetic arthroplasties performed in patients with documented infections in the elbow were retrospectively reviewed. Seven of the patients had infectious complications of total elbow arthroplasties that led to resection. Two patients had previous infections from septic joints and 1 from open reduction internal fixation. The median interval of time from infection treatment to final implant was 45 months (3.8 years). All arthroplasties were performed by the same surgeon with a modified Coonrad-Morrey, semiconstrained prosthesis. Patients were monitored for clinical signs of infection including radiographic and serologic studies and clinical evaluation based on the Mayo Elbow Performance Score. Mean surveillance was 4 years (range 2.8 to 5.4 years). Eight of the 10 cases have not shown signs of infection at the latest assessment. Two have had recurrent infections. The time interval from the original infection to latest implantation did not correlate with infection recurrence. Among those 8 without recurrent infection, 7 had excellent and 1 had satisfactory results according to the Mayo Elbow Performance Score. The recurrent infections were rated as failures. The average score was 32 before and 81 after surgery. The average pain score was 15 before surgery, and the average postoperative pain score was 40. Salvage of previously infected elbows with prosthetic arthroplasty can provide excellent results in a significant proportion of patients. Although the procedure offers superior functional outcomes compared with the alternative treatment options, it is technically demanding.

Aged↗

PubMed2005

Limited influence of prosthetic position on aseptic loosening of elbow replacements: 125 elbows followed for an average period of 5.6 years.

BACKGROUND: Aseptic loosening of elbow replacements, seen in long-term follow-up, remains a problem. In this study, we attempted to determine the influence of cementing technique, prosthetic position, different component sizes, use of a bone plug, and intraoperative fractures on the development and progression of radiolucent lines and aseptic loosening. METHODS: We studied standard radiographs of 125 primary Souter-Strathclyde total elbow prostheses using the Wrightington method. Additionally, 104 preoperative radiographs were available for analysis. We used a Markow statistical model to detect relationships between all factors described above. RESULTS: After a mean follow-up time of 5.5 (2-19) years, 21 (17%) prostheses had loosened radiographically (10-year survival: 65%). When the humeral component was tilted more medially or more anteriorly, we found development of radiolucent lines at the medial condyle and at the posterior side of the humeral component. However, the progression of these lines was not influenced by these positions. No other prognostic factors for radiolucent lines or aseptic loosening were found. INTERPRETATION: Despite the small number of elbows studied, the weak influence of prosthetic position on aseptic loosening gives more ground for a multifactorial cause for aseptic loosening of the Souter-Strathclyde total elbow prosthesis.

Adult↗

PubMed1997

Semiconstrained total elbow replacement for the treatment of post-traumatic osteoarthrosis.

Forty-one consecutive patients were managed for post-traumatic osteoarthrosis or dysfunction of the elbow with use of a non-customized semiconstrained Coonrad-Morrey total elbow prosthesis. The average age at the time of the operation was fifty-seven years (range, thirty-two to eighty-two years). The patients were followed for an average of five years and eight months (range, two to twelve years). Radiographs were made at least two years postoperatively (average, five years and one month; range, two to twelve years) for thirty-nine of the forty-one patients. According to the Mayo elbow performance score, sixteen patients (39 per cent) had an excellent result, eighteen (44 per cent) had a good result, five (12 per cent) had a fair result, and two (5 per cent) had a poor result. Thirty-six (95 per cent) of the thirty-eight patients who had a functioning implant at the time of follow-up considered the outcome to be satisfactory. Preoperatively, thirty-seven patients (90 per cent) had moderate or severe pain; postoperatively, thirty (73 per cent) had no or only mild discomfort. Motion improved from an average arc of flexion of 40 to 118 degrees preoperatively to an average arc of flexion of 27 to 131 degrees postoperatively. All thirty-eight functioning implants rendered the elbow stable. Eleven patients (27 per cent) had a major complication. Nine of them (22 per cent of the series) needed an additional operation. There was no aseptic loosening, and most of the complications were primarily due to so-called mechanical failure. The ulnar component fractured in five patients (12 per cent), and the polyethylene bushings wore out in two (5 per cent). These complications were attributed principally to the performance of strenuous physical labor, such as lifting more than ten kilograms on a regular basis, against the advice of the surgeon; excessive preoperative deformity of the joint; or an unstable traumatic injury. Two patients (5 per cent) had an infection. Semiconstrained joint replacement of the elbow can be a reliable form of treatment, and frequently is the only viable option, for the difficult problems encountered with post-traumatic destruction of a joint. Restoration of function, relief of pain, and patient satisfaction can be achieved even when a patient is less than sixty years old if that patient has low demands and a low level of activity. However, the mechanical failures underscore the fact that this procedure is relatively contraindicated in patients who anticipate strenuous physical activity or who are not expected to comply with the postoperative protocol. This observation reflects the tendency for increased and excessive use of a previously functionless joint, after it has been rendered stable and pain-free, to lead to mechanical failure.

Adult↗

PubMed2003

Souter-Strathclyde total elbow arthroplasty: medium-term results.

The Souter-Strathclyde unconstrained elbow prosthesis was prospectively studied in 36 patients (45 prostheses) with rheumatoid arthritis (Larsen grade 4 and grade 5). The mean age of the patients at the time of operation was 63 years (range: 39 to 75 years). Eight patients (9 prostheses) died within five years of implantation, from causes unrelated to the elbow arthroplasty. One patient was lost to follow-up, leaving 27 patients (35 prostheses) for review. The mean length of follow-up was 98 months (range: 60 to 174 months). At 8.2 years follow-up, the prosthesis showed a probability of survival of 76% (SD 9%) with revision of the humeral component as an end point; the percentage dropped to 67% (SD 9%) when radiographic loosening was taken as an end-point. Survival of the ulnar component was 98%. Loosening of the humeral component seems to be related to both the short humeral stem and a persistent extension deficit.

Aged↗

PubMed1991

Constrained total elbow arthroplasty.

In 1972, the senior author designed a condylar-sparing constrained hinge elbow prosthesis with a high-density polyethylene bushing. The condylar-sparing design allows both intercondylar and intramedullary fixation of the humeral component with methylmethacrylate cement. Reattachment of the muscles and collateral ligaments to the preserved condyles provides further stability. The clinical experience spans more than 16 years in 42 elbows with a relatively low loosening rate of 7%. The implant was removed and not replaced in three elbows: one for late infection, one for posttraumatic comminuted fracture of the distal humerus, and one for loosening of a humeral component. A series of 27 patients (31 elbows) with 24-204 months of follow-up study (average, 77 months) had excellent pain relief and an average range of motion of 129 degrees flexion, -44 degrees extension, 69 degrees pronation, and 61 degrees supination.

Bone Cements↗

PubMed2000

Souter-Strathclyde total elbow arthroplasty.

We have reviewed 66 consecutive Souter-Strathclyde arthroplasties of the elbow implanted in 59 patients between 1982 and 1993. Thirteen patients (15 elbows) (19.6%) died. Sixteen elbows (24.2%) were revised, six for aseptic loosening (9%), four (6%) because of fracture or loosening after a fracture, three (4.5%) for infection and three (4.5%) for dislocation. Four patients refused to attend for review. In 33 elbows with a follow-up of 93 months (60 to 167) complete relief of pain was achieved in 22 (67%) when seen at one year. After ten years or more 36% of the elbows were painfree and 64% had occasional slight pain especially under loading or stress. The mean gain in the arc of movement was 16 degrees, but a mean flexion contracture of 33 degrees remained. The main early complications were intraoperative fractures of the epicondyles (9%), postoperative dislocation (4.5%) and ulnar neuropathy. The incidence of ulnar neuropathy before operation was 19%. After operation 20 patients (33%) had an ulnar neuropathy, in seven of which it had been present before operation, and of these weakness of the hypothenar muscle occurred in two. The probability of survival of the Souter-Strathclyde elbow prosthesis based on the Kaplan-Meier calculation is 69% at ten years.

Activities of Daily Living↗

PubMed1980

Total replacement of the rheumatoid elbow with a hingeless prosthesis.

Twenty-four elbows with rheumatoid arthritis underwent total replacement arthroplasty with insertion of a hingeless surface-replacement prosthesis. These were followed for an average of three years and ten months. Excellent results were seen in fourteen elbows; fair, in seven; and poor, in three. Satisfactory pain relief as well as good stability were obtained in all but one elbow. Two elbows did not regain a useful range of motion. Proximal migration of the humeral component was seen in one elbow, and persistent subluxation with pain and instability was seen in another. No other major complications were encountered. The very low incidence of loosening in this series seems to substantiate the sound principle of the use of this type of hingeless prosthesis.

Adult↗

PubMedDate not supplied

Endoprosthetic elbow replacement in patients with solitary metastasis resulting from renal cell carcinoma.

Renal cell carcinoma is one of the most common cancers, and solitary metastasis to bone occurs in 2.5% of these patients. Localization of solitary metastasis to the elbow joint is rarer still, and data about these patients are limited. Because, in these cases, metastasis presents with osteolytic bone destruction, radical removal of solitary lesions should be considered. The aim of this treatment is to control the tumor locally, to reduce pain, and to restore function. We describe 4 patients with a solitary metastasis to the elbow from renal cell carcinoma who had the tumor resected and were then fitted with a custom-made elbow prosthesis. After surgical reconstruction, all patients reported markedly reduced pain and had a good functional outcome. The literature and our experience indicate that the prognosis for patients with just a solitary metastasis is sufficiently encouraging to warrant the use of all surgical and oncologic treatment options, especially if the interval between the diagnosis of the primary tumor and the development of the metastasis is lengthy.

Aged↗

PubMed2004

Forearm musculofasciocutaneous flap to cover glenohumeral arthrodesis hardware during reconstruction of the flail upper extremity.

SUMMARY: For selected patients with flail upper extremities after brachial plexus injury, glenohumeral arthrodesis, above-the-elbow amputation, and fitting of an above-the-elbow prosthesis are effective reconstructive options. In such situations, soft-tissue thinning at the shoulder, especially deltoid atrophy, presents the potential problem of shoulder fusion hardware causing pain or even eroding overlying soft tissue. The authors have used a pedicled forearm musculofasciocutaneous flap, elevated just before above-the-elbow amputation and subsequently transposed to the shoulder, to provide high-quality soft-tissue coverage of the arthrodesis hardware. Preliminary results with three patients suggest that this procedure may be useful for preventing tenderness and breakdown of tissue overlying glenohumeral arthrodesis hardware. In all three patients, the forearm flap remained well perfused, and all wounds healed fully with no subsequent problems with skin breakdown. All three patients had long-term benefit from prosthesis fitting.

Adult↗

PubMedDate not supplied

Total elbow arthroplasty.

In the eight-year experience at the authors' institution (1974-1981) with an unlinked resurfacing elbow prosthesis, one failure occurred due to loosening of an ulnar component (1 of 153; 0.6%). The authors concluded that loosening of the prosthetic components in bone is not a serious problem, but other problems remain. Postoperative dislocation continued after a lateral approach was adopted but improved with the use of components of variable sizes. Ulnar nerve palsies are an unsolved problem and require special investigation in the rheumatoid patient. Other soft tissue problems have been relieved by the more physiologic lateral approach. Indications have been expanded to include posttraumatic or osteoarthritic conditions in relatively inactive elderly patients.

Arthritis, Rheumatoid↗

PubMed1994

Ilizarov lengthening of a posttraumatic below elbow amputation stump. A case report.

Lengthening of a nonfunctional posttraumatic below elbow stump via Ilizarov technique is described. Preoperatively, the 5 cm ulna in the residual forearm provided an insufficient lever arm for practical use of a standard below elbow prosthesis. An additional 5 cm of ulnar length was achieved (100% increase) by distraction histogenesis, ultimately limited by impending necrosis of adherent skin covering the tip of the residual limb. Utilizing the Ilizarov technique, ulnar lengthening converted the functional level of the patient's amputation from elbow disarticulation to below elbow status.

Adult↗