Patient Demographics
Twenty-four consecutive total elbow arthroplasties were performed from September 1982 to October 1994 at the Mayo Clinic, Rochester, Minnesota, in nineteen patients who had juvenile rheumatoid arthritis. A diagnosis of juvenile rheumatoid arthritis had been made, in accordance with the accepted criteria of the American Rheumatology Association1, if arthritis had been present in at least one joint for six weeks to three months when the patient was less than sixteen years old. There were eighteen women and one man who had an average age of thirty-six years (range, twenty-five to fifty-six years). The average age at which the juvenile rheumatoid arthritis had been diagnosed was eleven years (range, two to fifteen years).
The severity of the disease process was assessed with the classification system of the American Rheumatology Association57. Two patients (two elbows; 8 per cent) were in class II (able to perform normal activities despite a handicap, discomfort, or limited motion), sixteen patients (twenty-one elbows; 88 per cent) were in class III (unable to perform all or most duties of the patient's usual occupation or self-care), and one patient (one elbow; 4 per cent) was in class IV (largely or completely incapacitated, with little or no ability to perform self-care and confined to a bed or wheelchair)57. Fifteen patients had had an average of five (range, two to eight) previous arthroplasties or arthrodeses of other major joints. Twenty-three elbows (96 per cent) were in patients who had a symptomatic or functionally limited contralateral elbow, and nineteen (79 per cent) were in patients who had pain or limitation of motion of the ipsilateral shoulder. Fifteen patients (79 per cent) had been managed with steroids at some point in the preoperative disease process, and six of these patients were taking steroids orally at the time of the elbow arthroplasty.
The indication for the total elbow arthroplasty was refractory pain in the elbow or limited motion that interfered with function, or both, in association with concomitant destruction of the ulnohumeral joint. Pain was the primary indication for the procedure in twenty elbows (83 per cent), and ankylosis or less than 30 degrees of motion was the primary indication in four. Seven patients had had a previous synovectomy and excision of the radial head on the side of the affected elbow; two of these patients also had had a failed interposition arthroplasty.
A semiconstrained Coonrad-Morrey total elbow prosthesis (Zimmer, Warsaw, Indiana) was used in eighteen elbows (75 per cent); the design of the implant and subsequent modifications have been described previously44. An unconstrained, resurfacing prosthesis was used in six elbows (Capitellocondylar9-11 [Johnson and Johnson Products, Orthopaedic Division, New Brunswick, New Jersey] in four and Pritchard ERS48,49 [DePuy] in two) early in the study period. A resurfacing prosthesis was not used in elbows that had gross instability, severe contractures, osseous ankylosis, or severe osseous deformity. In addition, no individualized so-called custom prostheses were used.
Two systems were used for evaluation. The Mayo elbow performance score37,44 was employed to document subjective, objective, and functional characteristics before and after the total elbow arthroplasty. This system places the greatest emphasis on pain relief (45 points) and the ability of the patient to perform functional activities (25 points); assessments of motion (20 points) and stability (10 points) are also included. The results are defined as excellent (90 to 100 points), good (75 to 89 points), fair (60 to 74 points), or poor (less than 60 points). Satisfactory data were available to allow the calculation of a preoperative score for all twenty-four elbows.
The second system was used to evaluate the extent of preoperative radiographic and pathological changes in the elbow. Grade I indicates no radiographic changes with the exception of osteoporosis; grade II, narrowing of the joint space with the architecture intact; grade III, alteration of the architecture of the joint; and grade IV, gross destruction of the joint37. A grade of V was established for the present study to indicate elbows that had radiographic ankylosis, as defined by the absence of an identifiable ulnohumeral joint on the anteroposterior and lateral radiographs or by the presence of mature osseous trabeculation crossing the ulnohumeral joint (Fig. 1). Three elbows (13 per cent) had grade-II involvement, fifteen (63 per cent) had grade-III involvement, two (8 per cent) had grade-IV involvement, and four (17 per cent) had grade-V involvement.
Operative Technique
The technique of total elbow arthroplasty for the rheumatoid elbow has been well described39. In order to avoid potential complications, it is essential that the surgeon spend time planning preoperatively for the anatomical deformities and technical challenges that are common with elbows affected by juvenile rheumatoid arthritis. Emphasis is placed on ensuring that an implant is available to accommodate the small intramedullary canal.
A posterior incision is used, and the ulnar nerve is routinely transferred anteriorly to a subcutaneous position. The triceps is then released in a subperiosteal manner from the olecranon, in continuity with the ulnar periosteum and the fascia of the forearm along with the anconeus3. Elbows affected by juvenile rheumatoid arthritis are characterized by very small, fragile bones; thus, care should be taken during the exposure to avoid excessive forces about the elbow that could cause a fracture. If there is osseous ankylosis, a microsagittal saw or a small osteotome is used to reestablish the joint line after osseous landmarks have been identified. Care is taken to create the osteotomy at the proper center of rotation of the ulnohumeral joint to maximize the biomechanical function of the prosthetic elbow14,16,31.
In elbows with severe soft-tissue contractures or osseous ankylosis, or both, circumferential capsular and collateral ligament releases are necessary to maximize postoperative motion and function. As the stability of unconstrained, resurfacing prostheses depends on functional collateral ligaments and proper soft-tissue balancing, these prostheses are not typically indicated in this clinical situation. Rather, a semiconstrained prosthesis is used, the collateral ligaments are released, and the anterior aspect of the capsule is completely excised (Figs. 2-A and 2-B) and further reflected from the distal aspect of the humerus with an osteotome or a blunt periosteal elevator. These maneuvers and this prosthesis allow the greatest possible motion and stability for patients who have severe preoperative stiffness.
When a resurfacing prosthesis is to be implanted, the treatment of the radial head depends on the particular prosthesis being used. For the semiconstrained Coonrad-Morrey prosthesis, the periphery of the radial head is excised with a small rongeur to create a resection arthroplasty of the proximal radioulnar joint in patients who have perioperative pain with rotation of the forearm. The radius is not routinely shortened.
The intramedullary canals of the humerus and the ulna characteristically are very narrow or are completely obliterated in patients who have severe juvenile rheumatoid arthritis (Figs. 3-A and 3-B). Thus, care must be taken in the identification and preparation of these canals. Occasionally, if the canal has been obliterated by cortical bone, it is necessary to use a small burr to create a new canal, especially in the ulna. If this is done, it is important to stay centered on the ulna and to remain within the confines of the cortical bone. A small (four-millimeter) cannulated flexible reamer that employs a guide-pin is used for this purpose. The Coonrad-Morrey implant system includes an extra-small ulnar component with an intramedullary circumference of only 1.5 centimeters (Fig. 4). This component is often used in elbows affected by juvenile rheumatoid arthritis that have tiny bones. Although the use of individualized custom prostheses was not necessary in the elbows in our study, it is important to have an appropriate inventory of prosthetic sizes available to address the small intramedullary canal. In four of the eighteen elbows treated with a Coonrad-Morrey prosthesis, the stem was slightly modified further with a cam-lever bending device because an angular change was needed.
The cementing technique used in patients who have juvenile rheumatoid arthritis differs little from standard techniques. Tobramycin-impregnated cement is routinely used in an effort to lessen the likelihood of infection, and the cement for both the humeral and the ulnar component is inserted with an intramedullary injection system. As many patients who have juvenile rheumatoid arthritis have involvement of the ipsilateral shoulder, which may eventually necessitate prosthetic replacement, care is taken to limit the level of the cement injected in the humerus by placing bone graft down the canal; also, a short, ten-centimeter humeral component is typically used.
After repair of the extensor mechanism, as described by one of us (B. F. M.) and Bryan3, and routine closure, the elbow is placed in a compressive dressing and elevated in a vertical elbow sling for twenty-four hours. The patient is then allowed to use the extremity as tolerated for activities of daily living. Although patients who have juvenile rheumatoid arthritis are encouraged to use the elbow in the extremes of flexion and extension to enhance postoperative motion, as is the case for all patients who have an elbow replacement, no formal physical therapy is provided.
Follow-up Evaluation
One patient, a forty-three-year-old woman who had a thirty-one-year history of juvenile rheumatoid arthritis and a twenty-year history of steroid use, died on the first postoperative day of an acute cardiac embolism. This left eighteen patients (twenty-three elbows) who were followed for a minimum of two years. Six elbows (26 per cent) were most recently assessed at our institution and seventeen (74 per cent) were most recently assessed by a local orthopaedic surgeon (nine elbows) or on the basis of a questionnaire and radiographs (eight elbows). The mean duration of follow-up was 7.4 years (range, two to fourteen years).
All elbows were evaluated with anteroposterior and lateral radiographs, at an average of 6.1 years (minimum, two years) postoperatively. The radiographs were assessed for progressive radiolucent lines as well as for the presence and incorporation of bone graft that had been placed between the anterior flange of the Coonrad-Morrey prosthesis and the distal aspect of the humerus.
Statistical Analysis
A one-tailed t test was used to determine the significance of both discrete and continuous variables. Significance was assigned when the probability that the difference was due to chance was less than 0.05.
Clinical Results
The result at the latest follow-up evaluation was excellent for twelve elbows (52 per cent), good for eight (35 per cent), and poor for three (13 per cent), according to the Mayo elbow performance score. The average preoperative score was 31 points (range, 5 to 55 points) and the average postoperative score was 90 points (range, 55 to 100 points) (p < 0.001). All three elbows that had a poor result had a late complication that necessitated a major revision procedure. The marked improvement in the score was primarily due to the relief of pain.
Pain
Preoperatively, eighteen (78 per cent) of the twenty-three elbows caused severe pain, four (17 per cent) caused moderate pain, and one (4 per cent) caused mild pain. At the most recent follow-up evaluation, seventeen elbows (74 per cent) caused no pain, five (22 per cent) caused mild pain, and one (4 per cent) caused moderate pain. None of the elbows caused severe pain postoperatively. The average score for the pain component of the elbow performance score (maximum, 45 points) improved from 4 points preoperatively to 41 points at the most recent follow-up evaluation (p < 0.001).
Range of Motion
The average preoperative arc of flexion was 63 degrees (range, 0 to 125 degrees) and began at an average of 44 degrees (range, 0 to 90 degrees), with additional flexion to an average of 107 degrees (range, 75 to 150 degrees). Postoperatively, the arc of flexion was 90 degrees (range, 45 to 150 degrees), beginning at 35 degrees (range, 5 to 70 degrees) with additional flexion to 125 degrees (range, 90 to 150 degrees). The average increase in the arc of flexion was 27 degrees (an average increase of 9 degrees of extension and 18 degrees of flexion). With the numbers available for study, we could not detect a significant improvement in postoperative motion.
The average postoperative arc of flexion of the four elbows that had been ankylosed preoperatively was 73 degrees (range, 45 to 95 degrees). For the seventeen elbows that had had an arc of flexion of less than 100 degrees preoperatively (average, 45 degrees; range, 0 to 85 degrees), the arc improved 32 degrees, to 77 degrees (range, 45 to 110 degrees), postoperatively. Only ten elbows (43 per cent), however, had a postoperative arc of 100 degrees or more. As a result of the operation, seventeen elbows (74 per cent) had an improvement in motion, one elbow had the same motion, and five (22 per cent) lost motion.
The elbows that were treated with a semiconstrained prosthesis had had an average preoperative arc of flexion of 57 degrees (range, 0 to 120 degrees), which began at an average of 48 degrees with additional flexion to 105 degrees. Postoperatively, the average arc of flexion improved to 85 degrees (range, 45 to 120 degrees), beginning at an average of 36 degrees with additional flexion to 121 degrees. The average preoperative arc of flexion of the elbows that were treated with a resurfacing arthroplasty had been 88 degrees (range, 50 to 125 degrees), beginning at an average of 27 degrees with additional flexion to 115 degrees. Postoperatively, the average arc improved to 107 degrees (range, 70 to 150 degrees), beginning at an average of 30 degrees with additional flexion to 137 degrees. Thus, the average arc of flexion improved 28 degrees for the elbows that had been treated with a semiconstrained prosthesis and 19 degrees for those that had been treated with a resurfacing prosthesis (p < 0.02). The fourteen elbows that had had an arc of flexion of less than 100 degrees before treatment with a semiconstrained implant had an average improvement of 36 degrees (range, 0 to 95 degrees). The three elbows that had had an arc of less than 100 degrees before treatment with a resurfacing implant had an average improvement of 15 degrees (range, 0 to 35 degrees).
Three extremities had severe concomitant disease in the ipsilateral wrist that precluded improvement in pronation and supination after the elbow arthroplasty. When these three elbows were excluded, the average preoperative arc was 52 degrees (range, 0 to 80 degrees) of pronation to 36 degrees (range, 0 to 70 degrees) of supination. Postoperatively, the average arc was 61 degrees (range, 30 to 80 degrees) of pronation to 53 degrees (range, 10 to 80 degrees) of supination.
Stability
Preoperatively, two elbows (9 per cent) were grossly unstable and eight (35 per cent) were moderately unstable, as defined by 5 to 10 degrees of varus-valgus laxity. Four of the five elbows that had been treated with a resurfacing prosthesis were stable at the most recent follow-up evaluation; the fifth elbow, which had been moderately unstable preoperatively, was found to be grossly unstable after the resurfacing arthroplasty. No elbow that had been treated with a semiconstrained prosthesis was unstable, as ensured by the prosthetic design. The average overall score for the stability component of the Mayo elbow performance score (maximum, 10 points) improved from 7 points preoperatively to 10 points at the most recent follow-up evaluation.
Daily Function
Preoperatively, the ability to perform activities of daily living (such as combing the hair, feeding oneself, personal hygiene, putting on a shirt, and putting on shoes) was severely limited by pain and restricted motion. The average preoperative score for the function component of the Mayo elbow performance score (maximum, 25 points) was 9 points (range, 0 to 25 points). Postoperatively, the average score was 23 points (range, 15 to 25 points) (p < 0.001). At the latest follow-up evaluation, eighteen elbows (78 per cent) were noted by the patient to cause no difficulties with any of the aforementioned activities.
Radiographic Results
Twenty elbows (87 per cent) had no progressive radiolucency (other than the normal radiolucency seen immediately postoperatively) around either the humeral or the ulnar component (Figs. 5-A and 5-B). Two elbows had a progressive one-millimeter-thick radiolucent line around less than 50 per cent of the humeral component at 5.3 and 10.4 years postoperatively. Both were clinically asymptomatic at the time of the most recent follow-up. One elbow had a complete radiolucent line around the humeral component with distal humeral osteolysis at five years postoperatively, and a revision was performed for symptomatic aseptic loosening.
The bone graft that was placed behind the anterior flange of the Coonrad-Morrey prosthesis had matured, as seen radiographically, in fifteen of eighteen elbows. In three elbows, the graft was present but did not show signs of trabeculation. In no elbow had the bone graft been completely resorbed.
Complications and Reoperations
There were thirteen complications affecting twelve (50 per cent) of the twenty-four elbows. One patient died in the immediate postoperative period, as mentioned previously. The remaining complications were divided into two groups: early, which although sometimes serious had no adverse effect on the long-term outcome after proper treatment, and late. There were nine early complications and three late complications; one elbow had both an early and a late complication. Of the twenty-three elbows that were followed for at least two years, nine (three of the five that were treated with a resurfacing prosthesis and six of the eighteen that were treated with a semiconstrained prosthesis) needed a reoperation; one of these elbows had two procedures.
All of the early complications occurred either at the time of the procedure or within six weeks postoperatively. One elbow had an intraoperative fracture of the olecranon, which was treated with immediate fixation with a tension band; the hardware was removed at two years postoperatively. One resurfacing prosthesis was noted to be subluxated on the immediate postoperative radiographs. The patient was returned to the operating room for reduction of the prosthesis and additional soft-tissue balancing; the instability did not recur. One patient who had pain that was difficult to manage postoperatively and who did not regain adequate motion by the seventh postoperative day was returned to the operating room for examination under anesthesia. The arc of flexion at that time was 15 to 135 degrees. The patient continued to have reduced motion, however; the most recent arc of flexion was 45 to 100 degrees. One elbow sustained an avulsion of the extensor mechanism two weeks postoperatively; this necessitated reoperation and repair. Two elbows that had a semiconstrained prosthesis were noted to have a stress fracture, which involved the medial and lateral supracondylar columns in one each. Although both fractures progressed to non-union, neither led to a reoperation or adversely affected the outcome. Two elbows had persistent wound drainage and one had an abscess at the site of a subcutaneous suture; all three elbows were treated with irrigation and débridement. No elbow had a deep infection.
The average postoperative arc of flexion of the seven elbows that had an early complication that led to a reoperation was 75 degrees (range, 45 to 110 degrees) compared with the overall average of 90 degrees (range, 45 to 150 degrees). Although the number of elbows in this subset is too small to reflect significance, the presence of an early complication that led to a reoperation showed a trend toward adversely affecting the postoperative range of motion. Overall, of the nine elbows that had an early complication, five had an excellent result, three had a good result, and one had a poor result. The elbow that had a poor result also sustained a late complication.
The late complications led to the three poor results. One elbow that was treated early in the study period had aseptic loosening of a Pritchard ERS resurfacing prosthesis. Because of the small size of the intramedullary canals, it was thought at the time of the index operation that press-fit fixation of the components was adequate and cement was not used. Although the patient had an excellent clinical result for five years, a progressive radiolucent line developed around the entire humeral component and the proximal aspect of the ulnar component, and severe distal humeral osteolysis developed as well. A successful revision arthroplasty was performed with insertion of a modified Coonrad-Morrey prosthesis with cement six years postoperatively. Another late complication occurred in a patient who had had moderate instability preoperatively and who had been managed with a Capitellocondylar resurfacing prosthesis. Six months postoperatively, the elbow was symptomatically unstable. A revision procedure was performed in an attempt to balance the soft-tissues; however, instability persisted. At the time of writing, the patient was considering revision to a semiconstrained prosthesis. The third late complication was in a patient who had an excellent result for three years and then was seen because of swelling of the elbow and a gradually decreasing range of motion. Radiographs revealed asymmetry of the ulnohumeral articulation suggestive of wear of the polyethylene bushings but no evidence of loosening of the components. At the time of the revision, the bushings were worn and there was polyethylene-induced synovitis and wear of the articulating titanium pin; the humeral and ulnar components, however, remained well fixed. The polyethylene bushings were replaced and the titanium pin was exchanged for a stainless-steel one. Although the patient was doing well at the time of the most recent follow-up, the result was considered poor because of the need for a late revision procedure.
Juvenile rheumatoid arthritis is a debilitating condition that affects nearly a quarter of a million children in the United States1,55. The severe nature of this disease is evidenced by the fact that fifteen patients in the present study had had an average of five previous arthroplasties or arthrodeses involving a major joint by an average age of thirty-six years. The hip and knee are the joints most frequently affected by juvenile rheumatoid arthritis; however, the elbow and shoulder often become involved in young adulthood35. At the time of presentation, 96 per cent of the elbows in the present study were in patients who had a symptomatic or functionally limited contralateral elbow and 79 per cent were in patients who had a symptomatic or functionally limited ipsilateral shoulder.
The arthritic elbows of patients who have juvenile rheumatoid arthritis differ in several important aspects from those of patients who have adult rheumatoid arthritis. Although pain is the most common symptom in both groups, elbows affected by juvenile rheumatoid arthritis have a distinct predilection for stiffness. In two recent large studies of total elbow arthroplasty in patients who had adult rheumatoid arthritis11,37, the average preoperative arc of flexion was 35 to 118 degrees (an 83-degree arc). In the current study, the average preoperative arc was only 44 to 107 degrees (a 63-degree arc). In addition, seventeen elbows (71 per cent) in the current study had a preoperative arc of flexion of less than 100 degrees and four had complete ankylosis. For this reason, we added a grade-V radiographic classification, indicating ankylosis, to the system described previously37.
In elbows affected by juvenile rheumatoid arthritis, the underdeveloped bones, which have an extremely narrow or completely obliterated intramedullary canal, present one of several obvious technical difficulties involved in the performance of a total elbow arthroplasty in these patients. Forcing a typically sized implant into these bones either causes an intraoperative fracture or prevents the component from being completely seated; if the component is not completely seated, the anatomical center of rotation cannot be re-created and the opportunity for improved motion is decreased14,16,31. Although individualized custom prostheses have been advocated for elbows with similar anatomical deformities11,16,25,27, they were not found to be necessary in the present series; thus, issues involving very high cost were avoided. The modified Coonrad-Morrey prosthesis provides a small humeral component and an extra-small ulnar component that can easily be shortened during the operation, thus enabling adequate sizing in these patients (Fig. 4). Regardless of the prosthesis that is used, however, the importance of thorough preoperative planning for elbow arthroplasty in patients who have juvenile rheumatoid arthritis cannot be overemphasized.
Satisfactory pain relief was nearly universal in the present study. Twenty-two (96 per cent) of the twenty-three elbows had no or mild pain at the time of the most recent follow-up. Two of the three patients who eventually needed a revision arthroplasty had had a painless elbow for three and five years. These results with regard to pain relief compare favorably with or are better than those reported in published series of elbow arthroplasty for adults who had rheumatoid arthritis2,10,11,20,30,33,34,37,46,51-53,56 or another diagnosis15,17,24,38,42. The reliable achievement of satisfactory pain relief should be considered when other potential operative options are reviewed for an elbow that is severely affected by juvenile rheumatoid arthritis12,19,29,36,54.
However, marked improvement in the range of motion after elbow arthroplasty in patients who have juvenile rheumatoid arthritis is not as reliable. Overall, seventeen elbows (74 per cent) had an improvement in the range of motion and five (22 per cent) had less motion postoperatively than they had had preoperatively. The average 90-degree postoperative arc of flexion represents an improvement of only 27 degrees compared with the preoperative average. These results are not as favorable as the expected improvements in motion following arthroplasty of an elbow affected by adult rheumatoid arthritis11,37. Although some authors have not noted less improvement in postoperative motion after elbow arthroplasty in patients who have juvenile rheumatoid arthritis11, others8,16,26,27, including us, have reported such a finding.
Although the gains in postoperative motion were modest, functional ability was consistently enhanced. It has been shown that most daily activities require approximately 100 degrees of flexion of the elbow (from 30 to 130 degrees) and 100 degrees of rotation of the forearm (from 50 degrees of pronation to 50 degrees of supination)43. Despite maintenance of adequate rotation of the forearm, less than half of the elbows in the present series had a postoperative arc of flexion of 100 degrees or more. Eighteen elbows (78 per cent), however, did not limit the performance of any activities of daily living. This somewhat unexpected result may be attributable to the excellent postoperative relief of pain, which allowed uninhibited use of the extremity.
A relatively high overall prevalence of complications and reoperations has been associated with total elbow arthroplasty5,10,14,18,23,29,34,40,41, with the prevalence depending on the severity of the condition being treated and the experience of the surgeon40. In recent years, however, rates of complications have decreased coincident with modifications in prosthetic design and improvements in operative technique37-39. Most of the complications reported in the present study were diagnosed and treated in the early postoperative period and had no adverse effect on the long-term outcome. An error in judgment involving resurfacing implants contributed to two of the three late complications. One of these complications involved aseptic loosening, after five years, of a humeral component that had been inserted without cement and the other involved an elbow with moderate preoperative instability that, in retrospect, did not have the ligamentous support necessary for an unconstrained implant. To avoid these complications, the humeral and ulnar components should routinely be inserted with cement and a semiconstrained prosthesis should be used when there is preoperative instability or when extensive soft-tissue releases are needed to gain motion.
No definitive comparison of resurfacing and semiconstrained elbow arthroplasties can or should be made on the basis of this study. Resurfacing prostheses depend on adequate bone stock and ligamentous integrity for stability and function11,28,31,32,39. In elbows that are severely affected by juvenile rheumatoid arthritis, with fibrous or osseous ankylosis, the need for extensive, circumferential capsular and ligamentous releases is tempered by concern about instability. However, if there are adequate bone stock, ligamentous support, and preoperative motion, a resurfacing prosthesis can provide satisfactory results.
As stability is an inherent aspect of the semiconstrained prosthetic design, the capsule and ligaments can be released extensively in a stiff or ankylosed elbow without concern regarding postoperative stability16. In fact, use of the semiconstrained device resulted in a significantly greater improvement in motion (p < 0.02) in this study. In addition, the semiconstrained elbow arthroplasty reliably restores both stability and function if there is gross osseous destruction and a flail extremity13,50. O'Driscoll et al.47 showed that the functional laxity of the Coonrad-Morrey prosthesis is consistently less than its inherent structural laxity, thus explaining the low rate of aseptic loosening of this implant when it is used to treat rheumatoid arthritis37, traumatic conditions38, and other diagnoses39. This observation is supported by our finding of no clinical or radiographic evidence of loosening of the semiconstrained prostheses at the most recent follow-up evaluation. Furthermore, as the present study has, to our knowledge, the longest duration of follow-up (average, 7.4 years) of any series of total elbow arthroplasties in the current literature, the implications are particularly relevant for patients with juvenile rheumatoid arthritis who have an elbow arthroplasty when they are young.
Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis provides rewarding pain relief and improvements in function. However, the favorable restoration of motion that is seen after elbow arthroplasty in patients who have adult rheumatoid arthritis cannot be expected. As many elbows affected by juvenile rheumatoid arthritis have preexisting anatomical deformities, there are complex and challenging technical considerations and thorough preoperative planning must be emphasized. This is particularly relevant with regard to determining the size and type of the prosthetic implant. Finally, experience with operations on the elbow, and with prosthetic replacement in particular, will increase the likelihood of a satisfactory outcome.