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PubMed2005

Revision of unstable capitellocondylar (unlinked) total elbow replacement.

BACKGROUND: Instability is a recognized complication associated with unlinked total elbow implants. The best form of treatment of this problem is uncertain as very little has been written about it. METHODS: Twelve patients underwent operative treatment of instability at the site of a capitellocondylar unlinked total elbow replacement, and the results were reviewed retrospectively. The study group included ten women and two men with an average age of fifty-eight years. Ten patients had rheumatoid arthritis. Three elbows underwent conversion to a semi-constrained hinged prosthesis. In the other nine elbows, an attempt was made to continue with an unlinked prosthesis: three had reconstruction of one or both collateral ligaments, four had component revision, and two had both ligament reconstruction and component revision. RESULTS: After an average duration of follow-up of six years (range, two to fifteen years) only three patients had retained a functioning unlinked prosthesis. Of the remaining nine patients, three had had a conversion to a semi-constrained arthroplasty at the time of the index procedure, four had had a conversion to a semi-constrained prosthesis at the time of a salvage procedure, one had had a resection arthroplasty, and one had a painfully dislocated elbow and had declined revision. Thus, seven elbows eventually underwent conversion to a semi-constrained prosthesis; these conversion procedures were technically difficult, with perforation of the humerus occurring in six patients and perforation of the ulna occurring in four. After all procedures, the average elbow flexion was 132 degrees and the average flexion contracture was 25 degrees. According to the Mayo Elbow Performance Index, there were four excellent results, three good results, three fair results, and one poor result. CONCLUSIONS: Revision of an unlinked total elbow prosthesis to a linked total elbow prosthesis is difficult, but it restores elbow function. Although the present series documents the unpredictability of attempts to salvage an unstable unlinked prosthesis, it seems reasonable to attempt at least one soft-tissue procedure before converting to a linked prosthesis.

Aged↗
PubMed2004

Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow.

BACKGROUND: The purpose of this study was to evaluate the role of the radial head and the coronoid process as posterolateral rotatory stabilizers of the elbow and to determine the stabilizing effect of radial head replacement and coronoid reconstruction. METHODS: The posterolateral rotatory displacement of the ulna was measured after application of a valgus and supinating torque (1). in seven intact elbows, (2). after radial head excision, (3). after sequential resection of the coronoid process, (4). after subsequent insertion of each of two different types of metal radial head prostheses (a rigid implant and a bipolar implant with a floating cup), and (5). after subsequent reconstruction of the coronoid with each of two different techniques in the same cadaveric elbow. RESULTS: The posterolateral rotatory laxity averaged 5.4 degrees in the intact elbows. The surgical approach used in this study insignificantly increased the mean laxity to 9 degrees. Excision of the radial head in an elbow with intact collateral ligaments caused a mean posterolateral rotatory laxity of 18.6 degrees (p < 0.0001). Additional removal of 30% of the height of the coronoid fully destabilized the elbows, always resulting in ulnohumeral dislocation despite intact ligaments. Implantation of a rigid radial head prosthesis stabilized the elbows. However, a mean laxity of 16.9 degrees persisted after insertion of a floating prosthesis (p < 0.0001). The elbows with a defect of 50% or 70% of the coronoid, loss of the radial head, and intact ligaments could not be stabilized by radial head replacement alone, but additional coronoid reconstruction restored stability. CONCLUSIONS: The results of this study suggest that the coronoid and the radial head contribute significantly to posterolateral rotatory stability.

Arthroplasty, Replacement↗
PubMed2006

Radial head prosthesis after fracture of radial head with associated elbow instability.

INTRODUCTION: Fractures of the radial head and associated elbow instability can be treated with operation with radial head prosthesis. In this study, we evaluate function 1-7 years after implantation and also function after removal of five prostheses. MATERIAL AND METHODS: Eighteen patients with radial head fracture and associated elbow instability were evaluated 3.7 years (1-7) after implantation of a radial head prosthesis. Pain at rest and during activity was measured with a visual analogue scale (VAS). Test of stability and neurological examination was done manually as well as measurement of the range of motion, using a goniometer. Activity of daily living (ADL) was estimated using five questions where the answers were graded between 1 and 3. The patients were asked to grade their general satisfaction according to the following scale; very satisfied, satisfied, not satisfied, disappointed. Plain X-rays were taken and 14 patients agreed to have their elbow strength evaluated using the validated BTE work simulator. RESULTS: Five prostheses had been extracted due to poor range of motion. All these patients improved after extraction. All elbows were stable. No patient with extracted prosthesis had VAS score >2. The mean extension defect for this group was 15 degrees (5-25) compared to the mean extension defect for the 13 patients with the prosthesis still in place 15 degrees (0-40). The highest VAS score for the patients with prosthesis was five but the mean as low as 0.8. In the whole group, 13 patients were pain free. ADL function was good in general. The X-rays of the prostheses, still in place, showed radiolucent lines in 7 of the 13 patients. In the whole group, there was a significant decrease in supination, flexion and extension strength (P<0.01, P<0.01, P<0.05). DISCUSSION: Radial head prosthesis works as a spacer after fracture of the radial head and associated instability. If range of motion is much restricted post-operatively, the prosthesis can be removed with improved function as result.

Adult↗
PubMed2006

Total elbow replacement with the Souter-Strathclyde prosthesis in rheumatoid arthritis. Long-term follow-up.

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.

Adult↗
PubMed2002

[Endoprosthesis implantation in the elbow joint].

Previously used total elbow prostheses were mainly constrained hinged implants. Their early clinical results were favourable but they failed due to a high rate of loosening already a few years after implantation. The cause for the early loosening was the great forces across the elbow joint which were directly transmitted to the prosthesis-bone interface in these implants. Therefore, these implants were abandoned. Afterwards, unlinked, semiconstrained or non-constrained resurfacing devices were introduced. In these devices, the soft tissues constrain the joint and therefore absorb part of the transmitted forces. The rates of loosening were significantly improved and rarely the cause of early failure. But resurfacing implants require intact condyles and collateral ligaments. These implants can, therefore, only be used in a limited number of indications, and postoperative instabilities are known complications. The currently most frequently used device is the semiconstrained Coonrad-Morrey prosthesis. It is a floppy hinge which allows valgus-varus and rotational laxities. Therefore, a part of the forces across the elbow joint are absorbed by the soft tissues. The loosening rate is not a clinical problem any more, and is with 4% 10 years after implantation (rheumatoid arthritis) similar to that of total hip or knee replacement. Furthermore, this device is stabilised with a small anterior flange to the anterior cortex of the humeral shaft. Condyles and collateral ligaments are therefore not necessary neither for short nor for long-term stability. The Coonrad-Morrey total elbow prosthesis can therefore be used for almost every indication, such as severe destruction of the elbow joint and even in case of complete loss of the distal humerus. The long-term outcome with this prosthesis for the treatment of rheumatoid arthritis is favourable with 96% of very good and good results. Function is restored with an average flexion of 131 degrees, a mean loss of extension of 28 degrees, and an unrestricted pronation and supination. The rate of complications for patients with rheumatoid arthritis is 10%. Similarly, the results for Coonrad-Morrey total elbow replacement for posttraumatic arthrosis are favourable with 83% of satisfactory results. Most patients consider their elbow as improved compared to preoperatively, but pain relief is obtained only in three quarters of the patients. The rate of complications is high with 30%, indicating the total elbow replacement is contraindicated for strenuous labour and sports activities.

Arthritis, Rheumatoid↗
PubMed1979

The derivation of elbow joint forces, and their relation to prosthesis design.

A literature review showed a lack of accurate data for upper limb joint forces. After discussing methods to determine muscle forces, the physiological cross-sections of muscles were used to estimate their strengths. Elbow joint forces were predicted for isometric actions which gave severe loading conditions. The predicted forces were discussed in relation to prosthesis design, and the use of a radial head replacement was recommended.

Biomechanical Phenomena↗
PubMed2004

Allograft-prosthesis composite for revision of catastrophic failure of total elbow arthroplasty.

BACKGROUND: Revision of a failed total elbow arthroplasty is a challenging procedure, often associated with bone deficiency. The purpose of this investigation was to review our experience with a composite allograft-implant reconstruction for patients with a failed total elbow arthroplasty. METHODS: Thirteen patients (thirteen elbows) in whom a total elbow arthroplasty had failed, primarily as a result of loosening of the humeral or ulnar component, were operated on with use of an allograft-prosthesis composite; the composite was placed on the humeral side in four of these patients and on the ulnar side in nine. The delay between the last total elbow arthroplasty and the allograft-prosthesis-composite procedure averaged eight years. RESULTS: At an average of forty-two months after the revision, the Mayo Elbow Performance Score was excellent for four elbows, good for three, fair for one, and poor for five. Nine of the thirteen patients had no or only slight pain in the elbow. The mean arc of flexion was 97 degrees, with an average of 28 degrees (range, 0 degrees to 60 degrees ) of extension to 125 degrees (range, 100 degrees to 140 degrees ) of flexion. There were seven complications affecting seven elbows, and five of the seven required a revision procedure. Deep infection developed in four elbows, and the allograft-prosthesis composite had to be removed from three. Two nonunions occurred at the allograft-humeral junction. CONCLUSIONS: An allograft-prosthesis composite can be a valuable option in selected patients with a failed total elbow arthroplasty with massive bone loss. The union and implant survival rates are high. Deep infection remains the main complication. Hence, we recommend the pursuit of other revision options, such as strut graft reconstruction, whenever possible before resorting to the use of an allograft-prosthesis composite in the surgical treatment of a failed total elbow arthroplasty with massive bone loss.

Adult↗
PubMed1982

Silastic radial head prosthesis in rheumatoid arthritis.

This paper reports our experience of using the Silastic radial head prosthesis in 18 elbow joints affected by rheumatoid arthritis. There was a varying degree of severity of involvement in 15 of the elbows, and in a further 3 cases replacement was carried out at an early stage of the disease. The 3 cases in whom early replacement was carried out had the best results at follow-up and 11 of the remaining 15 were considered to have a satisfactory overall result. The major benefit of operation has been the relief of pain, even in the late cases, whilst preserving stability of the elbow in all but 3 cases.

Adult↗
PubMed1993

Kinematic and stability of the Norway elbow. A cadaveric study.

We investigated the effect of simulated muscle loading and the contribution of the radial head to stability of the Norway elbow in 6 cadavers using an electromagnetic tracking device. The kinematics of the elbow after implantation of the prosthesis were similar to the intact elbow in their valgus-varus orientation, however, the forearms were slightly externally rotated, probably due to a small amount of external rotation of the humeral components at the time of implantation. The valgus-varus laxity limit of the implants were greater than in the intact specimens averaging 8.0 and 5.6 degrees, respectively. Simulated muscle loading stabilized both the intact and the Norway elbows. Excision of the radial head after implant arthroplasty increased their valgus-varus laxity, suggesting that preservation of the radial head may be indicated if it is not too severely involved by the underlying disease process. The laxity permitted by the prosthesis articulation is greater than that measured after implantation of the Norway arthroplasty. This suggests that the prosthesis may behave as an unconstrained arthroplasty. This should minimize the stress experienced by the bone-cement interface and may reduce the incidence of loosening. The laxity of the elbows after joint arthroplasty were only slightly greater than normal, possibly explaining the low incidence of prosthesis dislocation which has been observed with clinical use.

Aged↗
PubMedDate not supplied

The effects of static friction and backlash on extended physiological proprioception control of a powered prosthesis.

In general, externally powered prostheses do not provide proprioceptive feedback and thus require the user to rely on cognitively expensive visual feedback to effectively control the prosthesis. Applying the concept of extended physiological proprioception (EPP) to externally powered prostheses provides direct feedback to the user's proprioceptive system regarding the position, velocity, and forces applied to the prosthesis. However, electric elbows with EPP controllers developed at the Northwestern University Prosthetics Research Laboratory have exhibited unexplained "jerky" behavior in both clinical fittings and bench-top operation. In addition, the development of limit cycles, a specific type of constant-amplitude oscillation, had been observed in bench-top use of these elbows. Backlash and static friction within the EPP system were found to be primarily responsible for the development of limit cycles. Reducing static friction and backlash improved the system's performance. These results suggest that to most effectively implement EPP, prosthesis manufacturers should design prosthetic components that minimize static friction and backlash.

Arm↗
PubMed2000

The Roper-Tuke total elbow arthroplasty. 4- to 10-year results of an unconstrained prosthesis.

We report the results of a series of 59 unconstrained total arthroplasties of the elbow after a mean follow-up of 6.5 years (4 to 10). All the patients had rheumatoid arthritis. The indication for surgery was pain in all but one. Outcome was assessed by the Mayo Elbow Performance Index (MEPI). Of the 59 arthroplasties, two were lost to follow-up. Ten patients died, but as two of their arthroplasties were failures we included them in the results. The outcome in the remaining 49 was excellent in 26 (53%), good in 15 (31%), fair in one (2%) and poor or a failure in seven (14%). There was an improvement in the pain score (p < 0.001), movement (p < 0.001) and function (p < 0.001). Two patients developed instability, but neither required further surgery. There was a mean increase of 21 degrees in flexion and of 7 degrees in extension. The overall rate of complications was 33.9%. Lesions of the ulnar nerve, one of which did not recover, occurred in four patients, deep infection in two and stiffness in five. The rates of complications were similar to those in recent reports of other elbow arthroplasties. We carried out a radiological analysis of 39 arthroplasties which showed radiolucent lines around the humeral component in 22 and the ulnar component in 15. There were lower scores on the MEPI for those with radiolucent lines around the humeral component.

Arthroplasty, Replacement↗
PubMed1990

Total elbow arthroplasty with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis. A long-term follow-up study.

Thirty-seven elbows in thirty-six patients who had rheumatoid arthritis had a total elbow arthroplasty with insertion of a non-constrained surface-replacement prosthesis. The patients were followed for an average of nine years and six months, the longest follow-up being seventeen years. A good result was seen in twenty-nine elbows; a fair result, in one; and a poor result, in seven. The reasons for the poor results were gross posterior displacement of the humeral component in five elbows, persistent subluxation with pain in one, and recurrent ankylosis in one. Of the five elbows that had gross posterior displacement, four had a revision operation with a new humeral component, and a satisfactory result was eventually achieved. Radiographic examination revealed various degrees of proximal subsidence of the humeral component in 70 per cent of the elbows. However, in most of the elbows the subsidence was not progressive and was compatible with a good clinical result. In contrast, the rate of loosening of the ulnar component was low; loosening was seen in only 5 per cent of the elbows. Seventeen elbows were followed for ten years or more, and comparison of the clinical results in the intermediate period with those at the most recent review revealed that the results improved with time. Because of the number of elbows in which subsidence of the humeral component developed, we now use a humeral component with an intramedullary stem, and were no longer recommend the use of our Type-1 and Type-2 prostheses.

Adult↗
PubMed2003

Complex segmental elbow reconstruction after tumor resection.

Twenty-three patients were reviewed retrospectively to determine their oncologic and functional outcomes after resection of 15 primary or eight metastatic tumors about the elbow between 1985 and 2000. The indications for resection were dictated by the histologic features of the tumor, location of the lesion, and extent of bone destruction. A total humeral reconstruction was done in 12 patients. Of this group, an endoprosthesis was used in seven patients and a total humeral allograft with a proximal humeral prosthesis and osteoarticular elbow reconstruction (allograft-prosthetic composite) was used in five patients. Eleven additional patients had a segmental total elbow replacement after resection of the distal humerus or proximal ulna. Local disease control was achieved in 17 patients (74%). Fourteen patients presented with (48%) or had (13%) distant metastasis develop, but only eight (35%) died of their disease. Periprosthetic lysis or allograft resorption was present in five patients (22%), and two (18%) humeral components of total elbow prostheses required revision for loosening. The mean Musculoskeletal Tumor Society functional score was 23 of 30 points (77%) in the 12 living patients followed up for a mean of 46 months (range, 24-124 months). It was 83% in patients with a segmental total elbow reconstruction and 71% in patients with a total humeral reconstruction. Aggressive limb salvage of the humerus or elbow or both provides a satisfactory functional outcome without jeopardizing overall survival.

Activities of Daily Living↗