JBJS | Article

The Journal of Bone & Joint Surgery, Volume 83, Issue 10

Scientific Article | October 01, 2001

Kudo Total Elbow Arthroplasty in Patients with Rheumatoid Arthritis : A Long-Term Follow-up Study

Nobuyuki Tanaka, MD; Hiroshi Kudo, MD; Kunio Iwano, MD; Hisashi Sakahashi, MD; Eiichi Sato, MD; Seiichi Ishii, MD

Investigation performed at Sapporo Gorinbashi Orthopedic Hospital, Sapporo, Hokkaido, Japan
Nobuyuki Tanaka, MD
Hisashi Sakahashi, MD
Eiichi Sato, MD
Sapporo Gorinbashi Orthopedic Hospital, Gorinbashi Health Care Facilities and Hospitals, 2-1, Kawazoe, Minami-ku, Sapporo, Hokkaido, 005-0802, Japan. E-mail address for N. Tanaka: nobuyuki-tanaka@hokkaido.med.or.jp
Hiroshi Kudo, MD
Kunio Iwano, MD
Department of Orthopedic Surgery, Sagamihara National Hospital, Sakuradai 18-1, Sagamihara, Kanagawa Prefecture, 228-8522, Japan

Seiichi Ishii, MD
Department of Orthopedic Surgery, School of Medicine, Sapporo Medical University, South 1 West 16, Chyou-ku, Sapporo, Hokkaido, 060-0061, Japan

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our CD-ROM (call 781-449-9780, ext. 140, to order).

The Journal of Bone & Joint Surgery. 2001; 83:1506-1513

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Abstract

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.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

As a result of modifications and improvements of elbow replacements during the last twenty years, the functional results of total elbow arthroplasty in patients with rheumatoid arthritis have become more consistent¹.

Some authors^2-4 have reported that the anterior oblique component of the ulnar collateral ligament of the elbow is the mainstay of joint stability. There is concern that complete transection of the ulnar collateral ligament will result in postoperative dislocation or instability of the replaced elbow joint. In the present study, the long-term results of implantation of a type-3 Kudo elbow prosthesis in patients with rheumatoid arthritis were examined. The differences between the results for patients who had had complete transection of the ulnar collateral ligament and those for patients who had had preservation of the anterior oblique component of the ulnar collateral ligament were evaluated.

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Fig. 1-A:: Anteroposterior and lateral photographs of a type-3 Kudo prosthesis. The humeral component is made of stainless steel, and the ulnar component is made of polyethylene. Both of the components are cemented in place.

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Fig. 1-B:: Anteroposterior and lateral photographs of a type-3 Kudo prosthesis. The humeral component is made of stainless steel, and the ulnar component is made of polyethylene. Both of the components are cemented in place.

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Fig. 2:: Graph and table showing the results of Kaplan-Meier survivorship analysis, with revision as the end point, for the fifty type-3 Kudo total elbow prostheses.

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Fig. 3-A:: Anteroposterior and lateral radiographs made sixteen years after a type-3 Kudo total elbow replacement. A 2-mm-wide, not sharply defined radiolucent line is seen at the bone-cement interface of the humeral component on the lateral radiograph.

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Fig. 3-B:: Anteroposterior and lateral radiographs made sixteen years after a type-3 Kudo total elbow replacement. A 2-mm-wide, not sharply defined radiolucent line is seen at the bone-cement interface of the humeral component on the lateral radiograph.

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TABLE I: Demographic Data

*The radiographic grading of rheumatoid arthritis of the elbow was performed with the system described by Morrey and Adams⁶.

	Total	Group I	Group II
No. of elbows (no. of patients)	50 (47)	31 (29)	19 (18)
Mean age at op. (yr)	57	57	57
Gender (M,F) (no. of patients)	7,40	4,25	3,15
Mean duration of rheumatoid arthritis (yr)7	15	15	15
Mean duration of elbow symptoms (yr)	6.0	5.9	6.1
Involved side (R,L) (no. of elbows)	25,25	16,15	9,10
Preop. radiographic grade (no. of elbows)*
Primary total elbow arthroplasty
Grade III	42	26	16
Grade IV	?5	?3	?2
Revision total elbow arthroplasty
Grade IV	?3	?2	?1
Mean (range) follow-up period (yr)	13 (11-16)	13 (11-16)	13 (11-16)

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TABLE I: Demographic Data

*The radiographic grading of rheumatoid arthritis of the elbow was performed with the system described by Morrey and Adams⁶.

	Total	Group I	Group II
No. of elbows (no. of patients)	50 (47)	31 (29)	19 (18)
Mean age at op. (yr)	57	57	57
Gender (M,F) (no. of patients)	7,40	4,25	3,15
Mean duration of rheumatoid arthritis (yr)7	15	15	15
Mean duration of elbow symptoms (yr)	6.0	5.9	6.1
Involved side (R,L) (no. of elbows)	25,25	16,15	9,10
Preop. radiographic grade (no. of elbows)*
Primary total elbow arthroplasty
Grade III	42	26	16
Grade IV	?5	?3	?2
Revision total elbow arthroplasty
Grade IV	?3	?2	?1
Mean (range) follow-up period (yr)	13 (11-16)	13 (11-16)	13 (11-16)

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TABLE II: Clinical Assessment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	?50	?47	?45	?31	?30	?29	?19	?17	?16
Pain (no. of elbows)
None	??0	?34	?23	??0	?22	?15	??0	?12	??8
Mild	??5	?13	?22	??1	??8	?14	??4	??5	??8
Moderate	?39	??0	??0	?26	??0	??0	?13	??0	??0
Severe	??6	??0	??0	??4	??0	??0	??2	??0	??0
Mean range of motion (deg)
Flexion contracture	?38	?44	?43	?38	?41	?40	?38	?49	?49
Flexion	104	133	133	104	134	133	104	132	132
Supination	?38	?58	?59	?38	?59	?59	?37	?57	?58
Pronation	?34	?42	?42	?35	?44	?44	?31	?38	?39
Stability (no. of elbows)
Stable	?11	?13	?12	??6	??7	??7	??5	??6	??5
Moderately stable	?33	?34	?33	?21	?23	?22	?12	?11	?11
Grossly unstable	??6	??0	??0	??4	??0	??0	??2	??0	??0
Daily function (no. of elbows)
25 points	??0	??1	??0	??0	??1	??0	??0	??0	??0
20 points	??0	?15	?15	??0	?10	?10	??0	??5	??5
15 points	??0	?29	?28	??0	?18	?18	??0	?11	?10
10 points	?46	??2	??2	?29	??1	??1	?17	??1	??1
5 points	??4	??0	??0	??2	??0	??0	??2	??0	??0
Mean total score (points)	?43	?81	?77	?42	?81	?77	?45	?79	?76
Grade of total score (no. of elbows)								?
Excellent (90 points)	??0	??5	??1	??0	??4	??1	??0	??0	??0
Good (75-89 points)	??0	?37	?30	??0	?23	?21	??0	?13	??9
Fair (60-74 points)	??0	??5	?14	??0	??3	??7	??0	??4	??7
Poor (£59 points)	?50	??0	??0	?31	??0	??0	?19	??0	??0

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TABLE II: Clinical Assessment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	?50	?47	?45	?31	?30	?29	?19	?17	?16
Pain (no. of elbows)
None	??0	?34	?23	??0	?22	?15	??0	?12	??8
Mild	??5	?13	?22	??1	??8	?14	??4	??5	??8
Moderate	?39	??0	??0	?26	??0	??0	?13	??0	??0
Severe	??6	??0	??0	??4	??0	??0	??2	??0	??0
Mean range of motion (deg)
Flexion contracture	?38	?44	?43	?38	?41	?40	?38	?49	?49
Flexion	104	133	133	104	134	133	104	132	132
Supination	?38	?58	?59	?38	?59	?59	?37	?57	?58
Pronation	?34	?42	?42	?35	?44	?44	?31	?38	?39
Stability (no. of elbows)
Stable	?11	?13	?12	??6	??7	??7	??5	??6	??5
Moderately stable	?33	?34	?33	?21	?23	?22	?12	?11	?11
Grossly unstable	??6	??0	??0	??4	??0	??0	??2	??0	??0
Daily function (no. of elbows)
25 points	??0	??1	??0	??0	??1	??0	??0	??0	??0
20 points	??0	?15	?15	??0	?10	?10	??0	??5	??5
15 points	??0	?29	?28	??0	?18	?18	??0	?11	?10
10 points	?46	??2	??2	?29	??1	??1	?17	??1	??1
5 points	??4	??0	??0	??2	??0	??0	??2	??0	??0
Mean total score (points)	?43	?81	?77	?42	?81	?77	?45	?79	?76
Grade of total score (no. of elbows)								?
Excellent (90 points)	??0	??5	??1	??0	??4	??1	??0	??0	??0
Good (75-89 points)	??0	?37	?30	??0	?23	?21	??0	?13	??9
Fair (60-74 points)	??0	??5	?14	??0	??3	??7	??0	??4	??7
Poor (£59 points)	?50	??0	??0	?31	??0	??0	?19	??0	??0

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TABLE III: Complications of Surgical Treatment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	50	47	45	31	30	29	19	17	16
Repetitive exuberant granulation and partial wound breakdown in the region of the tip of the olecranon	?0	?2	?2	?0	?1	?1	?0	?1	?1
Superficial wound infection	?0	?3	?0	?0	?2	?0	?0	?1	?0
Ulnar neuritis	?5	?3	?2	?3	?1	?1	?2	?2	?1

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TABLE III: Complications of Surgical Treatment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	50	47	45	31	30	29	19	17	16
Repetitive exuberant granulation and partial wound breakdown in the region of the tip of the olecranon	?0	?2	?2	?0	?1	?1	?0	?1	?1
Superficial wound infection	?0	?3	?0	?0	?2	?0	?0	?1	?0
Ulnar neuritis	?5	?3	?2	?3	?1	?1	?2	?2	?1

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TABLE IV: Radiographic Findings

*- = no radiolucent line; 1+ = partial linear translucency of £1 mm; 2+ = complete linear translucency of £1 mm; 3+ = wide translucency of £2 mm, sharply defined; 4+ = wide translucency of £2 mm, not sharply defined; and 5+ = definite endosteal cortical erosions (wide translucency of >2 mm, with or without scalloping). †- = no radiolucent line, + = radiolucent line in proximal portion only, and ++ = radiolucent line surrounding mass of cement entirely but with a width of £1 mm.

	Overall Series		Group I		Group II
	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	47	45	30	29	17	16
Humeral component* (no.)
—	26	?0	20	?0	?6	?0
1+	15	27	?9	19	?6	?8
2+	?2	11	?1	?7	?1	?4
3+	?3	?3	?0	?2	?3	?1
4+	?1	?4	?0	?1	?1	?3
5+	?0	?0	?0	?0	?0	?0
Ulnar component† (no.)
—	45	41	29	27	16	14
+	?2	?2	?1	?1	?1	?1
++	?0	?2	?0	?1	?0	?1

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TABLE IV: Radiographic Findings

	Overall Series		Group I		Group II
	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	47	45	30	29	17	16
Humeral component* (no.)
—	26	?0	20	?0	?6	?0
1+	15	27	?9	19	?6	?8
2+	?2	11	?1	?7	?1	?4
3+	?3	?3	?0	?2	?3	?1
4+	?1	?4	?0	?1	?1	?3
5+	?0	?0	?0	?0	?0	?0
Ulnar component† (no.)
—	45	41	29	27	16	14
+	?2	?2	?1	?1	?1	?1
++	?0	?2	?0	?1	?0	?1

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

The study was approved by the institutional ethics committee, and informed consent was obtained from each patient. Fifty elbows in forty-seven consecutive patients (seven men and forty women) with rheumatoid arthritis who underwent a total elbow arthroplasty with a type-3 Kudo prosthesis during the period 1983 through 1989 were enrolled in the study. All of the patients fulfilled the American Rheumatism Association 1987 revised criteria for the diagnosis of rheumatoid arthritis⁵. Their ages at the time of the operation ranged from thirty-nine to sixty-four years (mean, fifty-seven years). The average durations of rheumatoid disease and elbow symptoms were fifteen and six years, respectively. Twenty-five right elbows and twenty-five left elbows were treated. Forty-seven elbows underwent a primary total elbow arthroplasty; forty-two had grade-III rheumatoid arthritis and five had grade-IV disease⁶. Three elbows underwent revision arthroplasty in which a type-2 Kudo prosthesis was replaced with a type-3 Kudo prosthesis. All three had grade-IV disease. The average time between the operation and the final examination was thirteen years (range, eleven to sixteen years) (Table I).

The patients were randomly assigned to be treated by one of four senior surgeons. The operative techniques for the arthroplasty did not differ among the surgeons except that two surgeons routinely performed complete transection of the ulnar collateral ligament and the other two surgeons routinely preserved the anterior oblique component of the ulnar collateral ligament during the procedure. The elbows were thus divided into two groups according to whether the ulnar collateral ligament was completely transected (group I) or the anterior oblique component of the ulnar collateral ligament was preserved (group II).

The operative technique was the same as that reported by Kudo and Iwano⁷. Through a straight posterior midline skin incision, the fibrous arch proximal to the entry of the ulnar nerve at the cubital tunnel was released into the flexor carpi ulnaris to prevent excessive bending or kinking of the ulnar nerve when the elbow joint was fully flexed. A triangular-shaped flap with a distal base was raised in the triceps tendon. The radial head was always excised. The radial collateral ligament and capsule were transected completely to allow dislocation of the elbow joint. In cases in which complete transection was performed, the ulnar collateral ligament, including the tight anterior bundle, was cut to gain satisfactory access to the interior of the joint. In cases in which the anterior oblique component of the ulnar collateral ligament was preserved, further distraction of the humerus from the ulna, which was necessary for insertion of the ulnar component, was obtained by careful cleaning of all of the soft tissues from the inside of the ulnar collateral ligament in an effort to restore it to normal length. Both the ulnar and the humeral components (Figs.1-A and 1-B) were cemented in place.

In order to prevent postoperative dislocation or residual instability, the incised ends of the triceps tendon and the incised margins of the dorsal fascial layer on the radial side of the olecranon were sutured meticulously; however, the incised ligaments were not repaired. In the final stage of the operation, the ulnar nerve was transferred to an anterior subcutaneous position. Postoperatively, the elbow was immobilized in 90° of flexion in a posterior splint for one week. Active and active-assisted motion exercises were then begun.

Revision rates, clinical symptoms, postoperative complications, and radiographic changes were assessed at the intermediate follow-up period (four to six years after the operation) and at the time of the latest follow-up evaluation (eleven to sixteen years after the operation). The Mayo elbow performance score⁶ was used to assess pain, motion, stability, and daily function. The amount of radiolucency around the humeral and ulnar components was assessed with the method previously described by Kudo and Iwano⁷ and by Souter⁸. The clinical symptoms and radiographic changes were scored separately by two independent observers.

Survivorship analysis with revision of the bushing or removal of one or both components as the end point was performed with the method of Kaplan and Meier. Statistical analysis of the data was performed with the Wilcoxon signed-rank test and the Mann-Whitney U test.

Results

Introduction | Materials and Methods | Results | Discussion | References

Preoperative intergroup comparisons of age, duration of disease and elbow symptoms, involved side, radiographic grade, follow-up periods, pain level, range of motion, stability, and function are shown in Tables I and II. There were no apparent differences between the groups. Of the original fifty elbows, forty-seven were available at the intermediate (four-to-six-year) follow-up examination and forty-five were available at the long-term (eleven-to-sixteen-year) follow-up evaluation.

Survivorship Analysis of Surgically Treated Elbows

The overall survival rate of the prostheses was 96% (95% confidence limit, 91% to 101%) at five years after the operation and 90% (95% confidence limit, 82% to 98%) at sixteen years after the operation. No prosthesis dislocated during the follow-up period.

While the cumulative survival rates of group I (complete transection of the ulnar collateral ligament) and group II (preservation of the anterior oblique component of the ulnar collateral ligament) were similar at five years, at sixteen years the rate in group II (84% [95% confidence limit, 68% to 101%]) was worse than that in group I (94% [95% confidence limit, 85% to 102%]) (Fig. 2).

Clinical Assessment

Preoperatively, six elbows were severely painful, thirty-nine were moderately painful, and five were mildly painful. Pain decreased significantly after the operation (p < 0.001). At the intermediate point, thirty-four elbows were not painful and thirteen were mildly so. At the latest point, twenty-three elbows were not painful and twenty-two were mildly so. The mean degrees of flexion, supination, and pronation were 104°, 38°, and 34° initially; 133°, 58°, and 42° at the intermediate point; and 133°, 59°, and 42° at the latest point. There were significant (p < 0.05) improvements in the degrees of flexion, supination, and pronation at the intermediate and latest time-points compared with the preoperative values. There was not a significant difference between the degree of flexion contracture preoperatively (average, 38°) and the degrees at the intermediate and latest points (average, 44° and 43°, respectively).

Preoperative instability was significantly (p < 0.01) corrected by the total elbow arthroplasty: there were eleven stable elbows, thirty-three moderately stable elbows, and six grossly unstable elbows preoperatively and twelve stable elbows and thirty-three moderately stable elbows at the latest follow-up evaluation. With regard to daily function of the upper limb, all elbows had a score of 5 or 10 points before the operation. After the operation, the scores for daily function were significantly (p < 0.01) increased, although only one elbow at the intermediate point and no elbow at the latest point had the highest score (25 points). The mean Mayo elbow performance scores at the intermediate and latest points were 81 and 77 points, respectively, whereas all elbows had been categorized as poor (£59 points) initially. This was a significant (p < 0.01) improvement, and no elbows were categorized as poor at the time of the long-term follow-up.

Except for the final amount of elbow flexion contracture, there were no significant differences between group I and group II at the long-term follow-up evaluation. The amount of elbow extension in group II was modestly, but significantly (p < 0.05), more restricted in group II (49°) than in group I (40°) (Table II).

Complications

In two patients (one in each group), necrosis of the skin edges was observed in a small area in the region of the tip of the olecranon. Exuberant granulation tissue persisted as a problem at the time of long-term follow-up in both patients. In three additional patients (two elbows in group I and one elbow in group II), superficial infection around the wound was observed at the intermediate point, but no infection was observed at the latest point. Five elbows in the overall series (three elbows in group I and two elbows in group II) had had symptoms of ulnar neuritis before the operation. These symptoms gradually resolved in three and persisted in two.

There was no difference between the complication rate in group I and that in group II (Table III).

Radiographic Assessment

The overall occurrence rate of radiolucencies about the humeral component at the intermediate point was 45% (twenty-one of the forty-seven elbows). This rate increased to 100% at the later follow-up point (p < 0.01) (Figs. 3-A and 3-B).

Radiolucent lines appeared earlier in group II than in group I, as only ten of thirty group-I elbows (compared with eleven of seventeen group-II elbows) demonstrated radiolucency about the humeral component at the intermediate point. At the latest point, all humeral components (twenty-nine in group I and sixteen in group II) had a radiolucent line. One ulnar component in group I and one in group II had a radiolucent line at the intermediate point. Only two ulnar components in each group had a radiolucent line at the latest follow-up point (Table IV).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

A variety of unlinked prostheses (such as the capitellocondylar⁹, Kudo¹⁰, Norway¹¹, and Souter-Strathclyde¹² prostheses) and semiconstrained prostheses (such as the Coonrad-Morrey¹³ and GSB¹⁴ prostheses) have been used for total elbow arthroplasty. Fully constrained hinged prostheses have demonstrated a high clinical failure rate due to aseptic loosening¹⁵. Currently, there is no agreement as to the best type of prosthesis.

There have been five different designs of the Kudo elbow replacement. A long-term follow-up study of the results of arthroplasty with the type-1 and type-2 prostheses (a stainless-steel humeral component and an ultra-high molecular weight polyethylene ulnar component with a short intramedullary stem) showed proximal subsidence of the humeral component, mainly because of the absence of an intramedullary stem for that component⁷. With the type-4 Kudo prosthesis, which has a titanium-alloy humeral component with a porous-coated stem, there was fatigue breakage of the humeral stem, metallosis, and a high rate of polyethylene wear¹⁶. The humeral component of the most recently developed (type-5) prosthesis is made of cobalt-chromium alloy, one-half of the surface of the stem is porous-coated with a plasma spray of titanium alloy, and there is reinforcement of the junction of the humeral stem to the body¹⁰. The type-3 prosthesis, used in the present study, was developed in 1980 to address the problem of subsidence of the humeral component. The humeral component is made of stainless steel and has an intramedullary stem. One of us (H.K.) previously reported that highly unstable elbows with severe bone loss due to rheumatoid arthritis can be successfully replaced with the type-3 Kudo prosthesis¹⁷. The long-term clinical results of use of this design have not been reported previously, to our knowledge.

The overall survival rate of the type-3 prosthesis was 90% at sixteen years. The mean Mayo elbow performance scores were all poor (mean overall score, 43 points) initially and were substantially improved at both the intermediate follow-up evaluation (four to six years after the operation) and the late follow-up point (eleven to sixteen years after the operation), to 81 and 77 points, respectively. The lack of improvement of the flexion contracture after the operation might be the price that has to be paid for good stability of the joint. Generally, it is difficult to consistently achieve sufficient correction of an elbow flexion contracture with any unlinked surface-replacement7 prosthesis^9,11,12, including the Kudo prosthesis. This may be because lengthening of the joint segment occurs to a variable degree after implantation of this prosthesis¹⁸. Our rehabilitation program may need to be revised to start range-of-motion exercises for extension earlier.

Neuropathy of the ulnar nerve is one of the main complications of total elbow arthroplasty^9-14. In the present series, new signs of ulnar nerve involvement did not develop in any elbow after the operation. Symptoms of ulnar neuritis due to rheumatoid involvement before the operation gradually resolved in three of five elbows. In an effort to avoid ulnar nerve problems, we release the fibrous arch at the medial epicondyle, proximal to the flexor carpi ulnaris, and leave the ulnar nerve in situ without disrupting its blood supply. We believe that release of this fibrous arch not only prevents the ulnar nerve from being excessively kinked or compressed during dislocation of the joint when the prosthesis is being implanted but also can result in the resolution of mild ulnar neuropathy due to mechanical or vascular causes.

The rates of radiolucency around the humeral component at the intermediate and latest follow-up points were 45% and 100%, respectively. The discrepancy between the good clinical results and the high radiolucency rate requires ongoing scrutiny.

Preservation of the anterior oblique component of the ulnar collateral ligament in total elbow arthroplasty has been recommended because the results of transection of the ulnar collateral ligament have been inconsistent^9,10,19. In the present series, patients who had complete transection of the ulnar collateral ligament had a better prosthetic survival rate, less restriction of elbow extension, and later progression of radiolucent line formation.

We speculate that the anterior oblique component of the ulnar collateral ligament of a rheumatoid elbow with severe destruction is in a state of contracture and the contracted ligament may hamper free movement of the joint and stress the implant after total elbow arthroplasty. Our results suggest that preservation of the anterior oblique component of the ulnar collateral ligament is not necessary in a total elbow arthroplasty with the Kudo prosthesis, which has a structural feature to prevent mediolateral movement (lateral subluxation) without depending upon the ulnar collateral ligament¹⁰.

This long-term follow-up study of type-3 Kudo prostheses in patients with rheumatoid arthritis showed acceptable results with regard to the revision rate and clinical findings. Preservation of the anterior oblique component of the ulnar collateral ligament does not appear to be necessary in a total elbow arthroplasty with the Kudo prosthesis.

References

Introduction | Materials and Methods | Results | Discussion | References

Ewald FC,Jacobs MA. Total elbow arthroplasty. Clin Orthop,1984;182: 137-42. 182137 1984 [PubMed]

Schwab GH, Bennett JB, Woods GW,Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orthop,1980;146: 42-52. 14642 1980 [PubMed]

Morrey BF,An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop,1985;201: 84-90. 20184 1985 [PubMed]

Sojbjerg JO, Ovesen J,Nielsen S. Experimental elbow instability after transection of the medial collateral ligament. Clin Orthop,1987;218: 186-90. 218186 1987 [PubMed]

Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS, Medsger TA Jr, Mitchell DM, Neustadt DH, Pinals RS, Schaller JG, Sharp JT, Wilder RL,Hunder G. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum,1988;31: 315-24. 31315 1988 [PubMed]

Morrey BF,Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am,1992;74: 479-90. 74479 1992 [PubMed]

Kudo H,Iwano K. Total elbow arthroplasty with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis. A long-term follow-up study. J Bone Joint Surg Am,1990;72: 355-62. 72355 1990 [PubMed]

Ruth JT,Wilde AH. Capitellocondylar total elbow replacement. A long-term follow-up study. J Bone Joint Surg Am,1992;74: 95-100. 7495 1992 [PubMed]

Ewald FC, Simmons ED Jr, Sullivan JA, Thomas WH, Scott RD, Poss R, Thornhill TS,Sledge CB. Capitellocondylar total elbow replacement in rheumatoid arthritis. Long-term results. J Bone Joint Surg Am,1993;75: 498-507. 75498 1993 [PubMed]

Kudo H, Iwano K,Nishino J. Total elbow arthroplasty with use of a nonconstrained humeral component inserted without cement in patients who have rheumatoid arthritis. J Bone Joint Surg Am,1999;81: 1268-80. 811268 1999 [PubMed]

Risung F. The Norway elbow replacement. Design, technique and results after nine years. J Bone Joint Surg Br,1997;79: 394-402. 79394 1997 [PubMed]

Trail IA, Nuttall D,Stanley JK. Survivorship and radiographic analysis of the standard Souter-Strathclyde total elbow arthroplasty. J Bone Joint Surg Br,1999;81: 80-4. 8180 1999 [PubMed]

Gill DR,Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J Bone Joint Surg Am,1998;80: 1327-35. 801327 1998 [PubMed]

Gschwend N, Scheier NH,Baehler AR. Long-term results of the GSB III elbow arthroplasty. J Bone Joint Surg Br,1999;81: 1005-12. 811005 1999 [PubMed]

Morrey BF, Bryan RS, Dobyns JH,Linscheid RL. Total elbow arthroplasty. A five-year experience at the Mayo Clinic. J Bone Joint Surg Am,1981;63: 1050-63. 631050 1981 [PubMed]

Kudo H, Iwano K,Nishino J. Cementless or hybrid total elbow arthroplasty with titanium-alloy implants. A study of interim clinical results and specific complications. J Arthroplasty,1994;9: 269-78. 9269 1994 [PubMed]

Kudo H. Non-constrained elbow arthroplasty for mutilans deformity in rheumatoid arthritis: a report of six cases. J Bone Joint Surg Br,1998;80: 234-9. 80234 1998 [PubMed]

Blewitt N,Pooley J. Elbow lengthening after total prosthetic arthroplasty: observations and clinical implications. J Shoulder Elbow Surg,1994;3: 200-6. 3200 1994

Davis RF, Weiland AJ, Hungerford DS, Moore JR,Volenec-Dowling S. Non-constrained total elbow arthroplasty. Clin Orthop,1982;171: 156-60. 171156 1982 [PubMed]

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Fig. 2:: Graph and table showing the results of Kaplan-Meier survivorship analysis, with revision as the end point, for the fifty type-3 Kudo total elbow prostheses.

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TABLE I: Demographic Data

*The radiographic grading of rheumatoid arthritis of the elbow was performed with the system described by Morrey and Adams⁶.

	Total	Group I	Group II
No. of elbows (no. of patients)	50 (47)	31 (29)	19 (18)
Mean age at op. (yr)	57	57	57
Gender (M,F) (no. of patients)	7,40	4,25	3,15
Mean duration of rheumatoid arthritis (yr)7	15	15	15
Mean duration of elbow symptoms (yr)	6.0	5.9	6.1
Involved side (R,L) (no. of elbows)	25,25	16,15	9,10
Preop. radiographic grade (no. of elbows)*
Primary total elbow arthroplasty
Grade III	42	26	16
Grade IV	?5	?3	?2
Revision total elbow arthroplasty
Grade IV	?3	?2	?1
Mean (range) follow-up period (yr)	13 (11-16)	13 (11-16)	13 (11-16)

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TABLE I: Demographic Data

*The radiographic grading of rheumatoid arthritis of the elbow was performed with the system described by Morrey and Adams⁶.

	Total	Group I	Group II
No. of elbows (no. of patients)	50 (47)	31 (29)	19 (18)
Mean age at op. (yr)	57	57	57
Gender (M,F) (no. of patients)	7,40	4,25	3,15
Mean duration of rheumatoid arthritis (yr)7	15	15	15
Mean duration of elbow symptoms (yr)	6.0	5.9	6.1
Involved side (R,L) (no. of elbows)	25,25	16,15	9,10
Preop. radiographic grade (no. of elbows)*
Primary total elbow arthroplasty
Grade III	42	26	16
Grade IV	?5	?3	?2
Revision total elbow arthroplasty
Grade IV	?3	?2	?1
Mean (range) follow-up period (yr)	13 (11-16)	13 (11-16)	13 (11-16)

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TABLE II: Clinical Assessment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	?50	?47	?45	?31	?30	?29	?19	?17	?16
Pain (no. of elbows)
None	??0	?34	?23	??0	?22	?15	??0	?12	??8
Mild	??5	?13	?22	??1	??8	?14	??4	??5	??8
Moderate	?39	??0	??0	?26	??0	??0	?13	??0	??0
Severe	??6	??0	??0	??4	??0	??0	??2	??0	??0
Mean range of motion (deg)
Flexion contracture	?38	?44	?43	?38	?41	?40	?38	?49	?49
Flexion	104	133	133	104	134	133	104	132	132
Supination	?38	?58	?59	?38	?59	?59	?37	?57	?58
Pronation	?34	?42	?42	?35	?44	?44	?31	?38	?39
Stability (no. of elbows)
Stable	?11	?13	?12	??6	??7	??7	??5	??6	??5
Moderately stable	?33	?34	?33	?21	?23	?22	?12	?11	?11
Grossly unstable	??6	??0	??0	??4	??0	??0	??2	??0	??0
Daily function (no. of elbows)
25 points	??0	??1	??0	??0	??1	??0	??0	??0	??0
20 points	??0	?15	?15	??0	?10	?10	??0	??5	??5
15 points	??0	?29	?28	??0	?18	?18	??0	?11	?10
10 points	?46	??2	??2	?29	??1	??1	?17	??1	??1
5 points	??4	??0	??0	??2	??0	??0	??2	??0	??0
Mean total score (points)	?43	?81	?77	?42	?81	?77	?45	?79	?76
Grade of total score (no. of elbows)								?
Excellent (90 points)	??0	??5	??1	??0	??4	??1	??0	??0	??0
Good (75-89 points)	??0	?37	?30	??0	?23	?21	??0	?13	??9
Fair (60-74 points)	??0	??5	?14	??0	??3	??7	??0	??4	??7
Poor (£59 points)	?50	??0	??0	?31	??0	??0	?19	??0	??0

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TABLE II: Clinical Assessment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	?50	?47	?45	?31	?30	?29	?19	?17	?16
Pain (no. of elbows)
None	??0	?34	?23	??0	?22	?15	??0	?12	??8
Mild	??5	?13	?22	??1	??8	?14	??4	??5	??8
Moderate	?39	??0	??0	?26	??0	??0	?13	??0	??0
Severe	??6	??0	??0	??4	??0	??0	??2	??0	??0
Mean range of motion (deg)
Flexion contracture	?38	?44	?43	?38	?41	?40	?38	?49	?49
Flexion	104	133	133	104	134	133	104	132	132
Supination	?38	?58	?59	?38	?59	?59	?37	?57	?58
Pronation	?34	?42	?42	?35	?44	?44	?31	?38	?39
Stability (no. of elbows)
Stable	?11	?13	?12	??6	??7	??7	??5	??6	??5
Moderately stable	?33	?34	?33	?21	?23	?22	?12	?11	?11
Grossly unstable	??6	??0	??0	??4	??0	??0	??2	??0	??0
Daily function (no. of elbows)
25 points	??0	??1	??0	??0	??1	??0	??0	??0	??0
20 points	??0	?15	?15	??0	?10	?10	??0	??5	??5
15 points	??0	?29	?28	??0	?18	?18	??0	?11	?10
10 points	?46	??2	??2	?29	??1	??1	?17	??1	??1
5 points	??4	??0	??0	??2	??0	??0	??2	??0	??0
Mean total score (points)	?43	?81	?77	?42	?81	?77	?45	?79	?76
Grade of total score (no. of elbows)								?
Excellent (90 points)	??0	??5	??1	??0	??4	??1	??0	??0	??0
Good (75-89 points)	??0	?37	?30	??0	?23	?21	??0	?13	??9
Fair (60-74 points)	??0	??5	?14	??0	??3	??7	??0	??4	??7
Poor (£59 points)	?50	??0	??0	?31	??0	??0	?19	??0	??0

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TABLE III: Complications of Surgical Treatment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	50	47	45	31	30	29	19	17	16
Repetitive exuberant granulation and partial wound breakdown in the region of the tip of the olecranon	?0	?2	?2	?0	?1	?1	?0	?1	?1
Superficial wound infection	?0	?3	?0	?0	?2	?0	?0	?1	?0
Ulnar neuritis	?5	?3	?2	?3	?1	?1	?2	?2	?1

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TABLE III: Complications of Surgical Treatment

	Overall Series			Group I			Group II
Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)	Preop.	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	50	47	45	31	30	29	19	17	16
Repetitive exuberant granulation and partial wound breakdown in the region of the tip of the olecranon	?0	?2	?2	?0	?1	?1	?0	?1	?1
Superficial wound infection	?0	?3	?0	?0	?2	?0	?0	?1	?0
Ulnar neuritis	?5	?3	?2	?3	?1	?1	?2	?2	?1

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TABLE IV: Radiographic Findings

	Overall Series		Group I		Group II
	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	47	45	30	29	17	16
Humeral component* (no.)
—	26	?0	20	?0	?6	?0
1+	15	27	?9	19	?6	?8
2+	?2	11	?1	?7	?1	?4
3+	?3	?3	?0	?2	?3	?1
4+	?1	?4	?0	?1	?1	?3
5+	?0	?0	?0	?0	?0	?0
Ulnar component† (no.)
—	45	41	29	27	16	14
+	?2	?2	?1	?1	?1	?1
++	?0	?2	?0	?1	?0	?1

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TABLE IV: Radiographic Findings

	Overall Series		Group I		Group II
	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)	Postop. (4-6 yr)	Postop. (11-16 yr)
No. of elbows	47	45	30	29	17	16
Humeral component* (no.)
—	26	?0	20	?0	?6	?0
1+	15	27	?9	19	?6	?8
2+	?2	11	?1	?7	?1	?4
3+	?3	?3	?0	?2	?3	?1
4+	?1	?4	?0	?1	?1	?3
5+	?0	?0	?0	?0	?0	?0
Ulnar component† (no.)
—	45	41	29	27	16	14
+	?2	?2	?1	?1	?1	?1
++	?0	?2	?0	?1	?0	?1