The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 82, Issue 9

Articles | September 01, 2000

Semiconstrained Total Elbow Arthroplasty for Ankylosed and Stiff Elbows*

P. Mansat, M.D.†; B. F. Morrey, M.D.‡

Investigation performed at the Department of Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Service d'Orthopédie et Traumatologie, Hôpital Universitaire de Toulouse-Purpan, Place du Dr Baylac, 31059, Toulouse, France.
‡Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.

J Bone Joint Surg Am, 2000 Sep 01;82(9):1260-1260

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Abstract

Background: Total elbow arthroplasty can be a valuable option for the treatment of ankylosed or very stiff elbows.

Methods: A semiconstrained total elbow arthroplasty was performed in thirteen patients (fourteen elbows) with a preoperative range of elbow motion of 30 degrees or less. Nine elbows were fused or ankylosed preoperatively. The mean age at the time of the surgery was fifty years (range, twenty-four to seventy-nine years). The etiology of the stiffness was trauma for eleven elbows, juvenile rheumatoid arthritis for two, and rheumatoid arthritis for one.

Results: After a mean duration of follow-up of sixty-three months, the result was excellent for four elbows, good for four, fair for one, and poor for five, according to the Mayo elbow performance score. The mean arc of flexion improved from 7 degrees (range, 0 to 30 degrees) preoperatively to 67 degrees (range, 10 to 115 degrees) after the surgery. The most important factor that influenced the final result was the presence of ectopic bone surrounding the elbow joint. There were seven complications. Infection developed in five elbows. Three elbows had a superficial infection, which did not compromise the final result in two and which was treated with a myocutaneous flap in one with skin necrosis, with an excellent result. Deep infection developed in two other elbows. Both had an unsatisfactory result, one after implant removal and one after several dÇ¢ridements and retention of the prosthesis. Two patients sustained a fracture because of a loose component, and the prosthesis was revised. Four patients who lost motion within the first month following the surgery had a manipulation under anesthesia.

Conclusions: Semiconstrained total elbow arthroplasty is a useful option for patients with an ankylosed or a very stiff elbow and results in a considerable improvement of motion. Because of the nature of the underlying pathology, complications, including reoperation, are frequent, but the risk can be lessened by careful preoperative planning and surgical technique. Replacement is the preferred option in patients who are more than sixty years of age, but it is also a good choice in younger patients if there is no other viable option.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Contracture of the elbow is a rather common problem following elbow trauma. However, a stiff elbow can result from primary osteoarthritis, rheumatoid arthritis (especially juvenile rheumatoid arthritis), a burn, head trauma, or congenital stiffness^1,7,9,11,33.

Elbow stiffness was classified by Morrey⁴⁰ as extrinsic when only the soft tissues are involved, sparing the joint space, and as intrinsic when there is involvement of the articular surface. Chronic extrinsic stiffness is usually managed by arthroscopic^22,48,54 or surgical release^{1,3,7,11,14,16,19-21,25,32,33,39,40,51,53,55,56,58}, with good results. When less than 50 percent of the joint surface is involved in an elbow with intrinsic stiffness the same treatment can be used, although with less reliable results^39,40. However, when more than 50 percent of the articular surface is involved, an interposition arthroplasty may be the treatment of choice in young patients^{5,23,27,31,40,47}, whereas a total elbow arthroplasty has been considered the desirable option in older patients^{10,13,17,24,30}.

Little has been written about the results of total elbow arthroplasty for stiff elbows. Many studies on total elbow arthroplasty have included only a few stiff or ankylosed elbows^10,24,28,29. In 1989, Figgie et al.¹³ reported on treatment of this pathology with several regular and custom designs. They concluded that stiff elbows are difficult to treat, with a high complication rate, and that they often require a custom implant.

The purpose of the present study was to evaluate the experience at a single institution at which a semiconstrained total elbow arthroplasty was used to treat stiff or ankylosed elbows with a range of motion of 30 degrees or less.

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Fig. 1-A:: Figs. 1-A, 1-B, and 1-C: Case 5.
Fig. 1-A: Radiograph of the elbow of a twenty-four-year-old woman with spontaneous fusion in 35 degrees of extension and a one-bone forearm.

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Fig. 1-B:: Radiographs made at eight years, showing the implant to be stable. The bushings are not worn, and the patient was pleased with the result.

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Fig. 1-C:: Radiographs made at eight years, showing the implant to be stable. The bushings are not worn, and the patient was pleased with the result.

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Fig. 2:: Drawing illustrating the aggressive anterior-posterior capsular and soft-tissue release from the condyles that is routinely carried out.

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Fig. 3-A:: Figs. 3-A and 3-B: Case 9.
Fig. 3-A: Preoperative radiograph showing complete ankylosis of the elbow at 90 degrees in a patient with severe posttraumatic arthritis.

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Fig. 3-B:: Radiograph made at five years, showing maturation of the bone graft. The result was excellent.

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TABLE I: Preoperative Data on the Patients

Case	Etiology	Additional Joints Involved	Type of Fracture	Previous Elbow Ops. (no.)	Delay Between Trauma and Arthroplasty (yrs.)
1	Rheumatoid arthritis	Wrist	None	0	-
2	Juvenile rheumatoid arthritis	Shoulder, wrist	None	0	-
3	Juvenile rheumatoid arthritis	Shoulder, wrist	None	0	-
4	Trauma		Distal humeral	2	5
5	Trauma	Forearm	Fract.-disloc., humerus and forearm	2	4
6	Trauma		Distal humeral	1	1
7	Trauma	Wrist	Distal humeral	1	1
8	Trauma		Fract.-disloc.	4	3
9	Trauma		Distal humeral	0	16
10	Trauma	Wrist, hand	Fract.-disloc., brain trauma	1	3
11	Trauma	Forearm, wrist, hand	Fract.-disloc., forearm	2	3
12	Trauma		Distal humeral	1	1
13	Trauma		Fract.-disloc.	2	1
14	Trauma	Shoulder	Proximal humeral	1	1

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TABLE I: Preoperative Data on the Patients

Case	Etiology	Additional Joints Involved	Type of Fracture	Previous Elbow Ops. (no.)	Delay Between Trauma and Arthroplasty (yrs.)
1	Rheumatoid arthritis	Wrist	None	0	-
2	Juvenile rheumatoid arthritis	Shoulder, wrist	None	0	-
3	Juvenile rheumatoid arthritis	Shoulder, wrist	None	0	-
4	Trauma		Distal humeral	2	5
5	Trauma	Forearm	Fract.-disloc., humerus and forearm	2	4
6	Trauma		Distal humeral	1	1
7	Trauma	Wrist	Distal humeral	1	1
8	Trauma		Fract.-disloc.	4	3
9	Trauma		Distal humeral	0	16
10	Trauma	Wrist, hand	Fract.-disloc., brain trauma	1	3
11	Trauma	Forearm, wrist, hand	Fract.-disloc., forearm	2	3
12	Trauma		Distal humeral	1	1
13	Trauma		Fract.-disloc.	2	1
14	Trauma	Shoulder	Proximal humeral	1	1

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TABLE II: Range of Motion and Results

*Extension/maximum flexion (global arc of flexion).†Pronation/supination (global arc of rotation).‡According to the Mayo elbow performance score⁴².

Case	Age at Op. (yrs.)	Duration of Follow-up (mos.)	Arc of Flexion* (degrees)		Arc of Rotation† (degrees)		Complications (no.)	Revision of Prosthesis	Result‡	Patient Satisfaction
Preop.	Postop.	Preop.	Postop.
1	77	58	90/90 (0)	80/100 (20)	85/50 (135)	60/60 (120)	None	0	Poor	Unsatis.
2	37	50	75/95 (20)	35/130 (95)	75/-75 (0)	70/0 (70)	None	0	Good	Satis.
3	38	35	75/95 (20)	25/130 (105)	70/-70 (0)	45/0 (45)	Superficial infection	0	Excellent	Satis.
4	31	168	85/105 (20)	25/135 (110)	60/30 (90)	60/70 (130)	Humeral fract., loosening	1	Good	Satis.
5	24	105	35/35 (0)	50/125 (75)	0/0 (0)	0/0 (0)	None	0	Excellent	Satis.
6	43	84	60/60 (0)	20/120 (100)	10/20 (30)	60/60 (120)	Superficial infection	0	Excellent	Satis.
7	54	17	80/80 (0)	50/90 (40)	-20/20 (0)	60/60 (120)	Ulnar fract., loosening	1	Poor	Satis.
8	43	67	85/115 (30)	90/115 (25)	60/60 (120)	80/80 (160)	Deep infection	1	Poor	Unsatis.
9	45	55	20/20 (0)	0/115 (115)	20/10 (30)	40/40 (80)	Superficial infection	0	Excellent	Satis.
10	41	49	80/80 (0)	50/60 (10)	10/10 (20)	10/10 (20)	None	0	Poor	Unsatis.
11	65	63	45/45 (0)	0/90 (90)	10/-10 (0)	10/-10 (0)	Deep infection	1	Fair	Satis.
12	67	35	70/70 (0)	45/95 (50)	70/80 (150)	80/80 (160)	None	0	Good	Satis.
13	79	37	80/90 (10)	60/105 (45)	20/40 (60)	60/65 (125)	None	0	Poor	Satis.
14	58	61	90/90 (0)	55/120 (65)	0/0 (0)	30/0 (30)	None	0	Good	Satis.

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TABLE II: Range of Motion and Results

*Extension/maximum flexion (global arc of flexion).†Pronation/supination (global arc of rotation).‡According to the Mayo elbow performance score⁴².

Case	Age at Op. (yrs.)	Duration of Follow-up (mos.)	Arc of Flexion* (degrees)		Arc of Rotation† (degrees)		Complications (no.)	Revision of Prosthesis	Result‡	Patient Satisfaction
Preop.	Postop.	Preop.	Postop.
1	77	58	90/90 (0)	80/100 (20)	85/50 (135)	60/60 (120)	None	0	Poor	Unsatis.
2	37	50	75/95 (20)	35/130 (95)	75/-75 (0)	70/0 (70)	None	0	Good	Satis.
3	38	35	75/95 (20)	25/130 (105)	70/-70 (0)	45/0 (45)	Superficial infection	0	Excellent	Satis.
4	31	168	85/105 (20)	25/135 (110)	60/30 (90)	60/70 (130)	Humeral fract., loosening	1	Good	Satis.
5	24	105	35/35 (0)	50/125 (75)	0/0 (0)	0/0 (0)	None	0	Excellent	Satis.
6	43	84	60/60 (0)	20/120 (100)	10/20 (30)	60/60 (120)	Superficial infection	0	Excellent	Satis.
7	54	17	80/80 (0)	50/90 (40)	-20/20 (0)	60/60 (120)	Ulnar fract., loosening	1	Poor	Satis.
8	43	67	85/115 (30)	90/115 (25)	60/60 (120)	80/80 (160)	Deep infection	1	Poor	Unsatis.
9	45	55	20/20 (0)	0/115 (115)	20/10 (30)	40/40 (80)	Superficial infection	0	Excellent	Satis.
10	41	49	80/80 (0)	50/60 (10)	10/10 (20)	10/10 (20)	None	0	Poor	Unsatis.
11	65	63	45/45 (0)	0/90 (90)	10/-10 (0)	10/-10 (0)	Deep infection	1	Fair	Satis.
12	67	35	70/70 (0)	45/95 (50)	70/80 (150)	80/80 (160)	None	0	Good	Satis.
13	79	37	80/90 (10)	60/105 (45)	20/40 (60)	60/65 (125)	None	0	Poor	Satis.
14	58	61	90/90 (0)	55/120 (65)	0/0 (0)	30/0 (30)	None	0	Good	Satis.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Inclusion Criteria

Only patients with a preoperative arc of elbow motion of 30 degrees or less were included in the study. Joint replacement was selected as the treatment of choice for patients who were more than sixty years of age, and it was performed in younger patients if no other options were considered viable. A semiconstrained Coonrad-Morrey total elbow arthroplasty was done in all of the patients but one.

Patients

Thirteen patients (fourteen elbows) who satisfied the above criteria were treated between 1973 and 1994. There were six men and seven women. One woman with juvenile rheumatoid arthritis underwent a bilateral procedure. Nine right and five left elbows were operated on. The dominant arm was operated on in eight patients. The mean age at the time of the surgery was fifty years (range, twenty-four to seventy-nine years). Eight elbows were in patients younger than fifty years of age, and ten were in patients younger than sixty-five years of age (Table II). The etiology of the stiffness was trauma for eleven elbows, juvenile rheumatoid arthritis for two, and rheumatoid arthritis for one. An additional joint or joints were involved in eight of the fourteen affected limbs. The shoulder was involved in three; the forearm, in two others; the wrist, in six; and the hand, in two. Ten elbows had a mean of 1.7 procedures (range, one to four procedures) before the total elbow arthroplasty. The duration of the stiffness before the procedure ranged from six months to fifteen years (mean, 5.3 years). The data characterizing the thirteen patients (fourteen elbows) are summarized in Table I.

According to the radiographic classification described by Morrey and Adams⁴² and augmented by Connor and Morrey⁸, the three elbows with inflammatory arthritis had grade-V radiographic changes (joint obliteration with osseous bridging) at the joint. Secondary osteoarthritis involving the entire joint surface was seen in ten of the eleven elbows with posttraumatic stiffness. The ulnohumeral joint alone was affected in only one elbow. No loose bodies were seen on radiographic examination. Heterotopic ossification was present around ten of the fourteen joints. A radioulnar synostosis was present in three limbs. The indication for total elbow arthroplasty was refractory pain in the elbow or limited motion with impairment of daily functional activities, or both. Pain was present in eleven of the fourteen elbows: it was severe in four, moderate in one, and slight in six. Nine elbows were completely ankylosed preoperatively, with no motion, and five had an arc of motion of 30 degrees or less (range, 10 to 30 degrees). Two patients had preoperative ulnar nerve symptoms.

Assessment

All patients were successfully contacted for this study. At the time of follow-up, five elbows were evaluated at our institution and nine were examined by local physicians. Subjective and objective data were collected for calculation of the Mayo elbow performance score⁴². A handheld goniometer was used to measure the arcs of flexion and pronation, and standardized anteroposterior and lateral radiographs were made of all elbows. Clinical evaluation was done with use of the Mayo elbow performance score for pain (maximum score, 45 points), motion (maximum score, 20 points), stability (maximum score, 10 points), and daily functional activities (maximum score, 25 points)⁴³. A score of 90 to 100 points was defined as an excellent result; 75 to 89 points, as a good result; 60 to 74 points, as a fair result; and less than 60 points, as a poor result. Adequate preoperative data were available for all of the fourteen elbows to allow the calculation of a preoperative score. Radiographic evaluation, with use of anteroposterior and lateral views, was done at the time of the latest follow-up for all fourteen elbows. Three features were particularly documented: the presence and extent of any radiolucency³⁵, the presence or absence of resorption of the distal aspect of the humerus or the proximal aspect of the ulna, and the presence and incorporation of the bone graft between the anterior flange and the humerus. Wear of the bushings was assessed on the anteroposterior radiograph according to the method described by Gill and Morrey¹⁵.

Semiconstrained Device

A noncustom semiconstrained total elbow prosthesis (Coonrad-Morrey; Zimmer, Warsaw, Indiana) was used in all of the elbows but one, in which a Coonrad-I constrained implant was used.

The Mayo-modified Coonrad (Coonrad-Morrey) total elbow prosthesis is a semiconstrained device manufactured from Ti-6-Al-4-V. The presently available implant is semiconstrained, allowing 8 to 10 degrees of laxity at the articulation⁴⁵. The current prosthesis, manufactured since 1981, has a hollow cobalt-chromium pin that passes through the ultra-high molecular weight polyethylene bushings to capture the ulnar component. A second pin is inserted from the opposite side to secure the articulation. An anterior flange was incorporated in the humeral stem in 1981. It permits the insertion of a bone graft anteriorly to enhance fixation at the point where maximum stress has been found to occur³⁴. The humeral component is available in standard and small sizes and in ten, fifteen, and twenty-centimeter lengths. The ulnar component is also available in standard and small sizes, with an extra-long, small ulnar component available for revision procedures and an extra-small-diameter ulnar component used for very small medullary canals such as those in patients with juvenile rheumatoid arthritis.

Technical Considerations

The technique of total elbow arthroplasty for the treatment of posttraumatic arthritis or rheumatoid arthritis has been well described^41,42. A preoperative arteriogram is occasionally useful when there is a severe posttraumatic deformity. Radial and ulnar pulses and capillary refill must be observed following release to prevent overstretching of the brachial artery. In our study, an arteriogram was made preoperatively for two elbows, both of which were completely fused following trauma (Fig. 1-A, Fig. 1-B, and Fig. 1-C). The arteriogram showed a sufficient vascular supply at the elbow and at the arm. In both patients, a total elbow arthroplasty was done without vascular complication.

The operation is performed with the patient supine and a sandbag under the scapula. The Mayo (Bryan-Morrey) approach is used⁴, and a posterior incision is performed. The ulnar nerve is carefully isolated and translocated with use of ocular magnification and a bipolar cautery. The triceps is then released from the olecranon and reflected laterally in continuity with the anconeus. Circumferential capsular and collateral ligaments are released to expose the distal aspect of the humerus and to maximize postoperative motion and function. The anterior aspect of the capsule is completely excised and further reflected from the distal aspect of the humerus with a blunt periosteal elevator. The attachments of the flexors and extensors are released if they are contracted (Fig. 2). When there is osseous ankylosis, a circular microsagittal saw or a small osteotome is used to reestablish the joint line. Care is taken to create the osteotomy as close as possible to the center of rotation of the ulnohumeral joint to maximize the biomechanical function of the prosthetic elbow and to preserve a site for triceps attachment.

A radial head resection was performed in thirteen limbs. Ectopic bone was excised in ten limbs during the surgical exposure. In one limb affected by juvenile rheumatoid arthritis with a proximal radioulnar synostosis, the radial nerve was explored before the synostosis was removed.

When an elbow is grossly deformed, care must be taken during preparation of the medullary canal. If the canal has been narrowed or obliterated by bone formation or because of malunion, it is necessary to recreate a new canal with use of a small burr or cannulated flexible reamers. After the medullary canal has been prepared, a trial reduction allows resection of soft-tissue contracture, which may include the flexor and extensor muscle origins. Tobramycin-impregnated cement is inserted with an intramedullary injection system. A bone graft is placed behind the anterior flange on the distal aspect of the humerus, and the components are articulated.

The length of the humeral component was ten centimeters in four limbs, fifteen centimeters in nine, and twenty centimeters in one. A small ulnar component was used in thirteen limbs, and a standard size was used in one. No custom devices were employed. After careful hemostasis, the triceps is secured, usually at 90 degrees of flexion, with number-5 nonabsorbable sutures placed through drill-holes in the proximal aspect of the ulna.

The elbow is placed in full extension with a cold compressive dressing (Cryocuff; Aircast, Summit, New Jersey) and an extension splint, and then it is elevated in a vertical position for twenty-four hours. The dressing is changed at two to three days, and the patient is allowed to move the elbow as tolerated. No formal physical therapy is required. Strength exercises are avoided. A system of flexion and extension braces is used if motion remains limited or was difficult to obtain at surgery³². After the replacement, the patient is advised not to lift more than one kilogram on a repetitive basis or five kilograms as a single event.

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.

Results

Introduction | Materials and Methods | Results | Discussion | References

All patients were followed for a minimum of two years (mean, sixty-three months; maximum, 168 months). One patient had a revision at seventeen months; the duration of follow-up after the revision was nine years. The result was excellent for four elbows, good for four, fair for one, and poor for five. The patient who had both elbows replaced because of juvenile rheumatoid arthritis had a good result on one side and an excellent result on the other. The mean preoperative score was 39 points (range, 5 to 64 points), and the mean postoperative score was 73 points (range, 45 to 100 points). The data characterizing each patient and the subjective satisfaction of each patient are summarized in Table II. The patients were satisfied with eleven of the fourteen elbows.

Pain

Preoperatively, four elbows (in three patients) were severely painful, one was moderately painful, six were mildly painful, and three were not painful. At the most recent follow-up evaluation, none of the elbows were severely painful, one was moderately painful, seven were mildly painful, and six were not painful. The mean score for the pain component of the elbow performance score improved from 23 points preoperatively to 35 points at the most recent follow-up evaluation.

Range of Motion

The mean preoperative arc of flexion was 7 degrees (range, 0 to 30 degrees), which was positioned from 69 degrees (range, 20 to 90 degrees) to 76 degrees (range, 20 to 115 degrees) in the flexion arc. Postoperatively, the arc of flexion was 67 degrees (range, 10 to 115 degrees), which was between 42 degrees (range, 0 to 90 degrees) and 109 degrees (range, 60 to 135 degrees) in the flexion arc. The mean increase in the arc of flexion was 60 degrees (range, -5 to 115 degrees), with a mean increase of 33 degrees in flexion and 27 degrees in extension.

The mean preoperative arc of rotation was 45 degrees (range, 0 to 150 degrees), which was between 34 degrees (range, -20 to 85 degrees) of pronation and 12 degrees (range, -75 to 80 degrees) of supination. Postoperatively, the mean arc of forearm rotation was 84 degrees (range, 0 to 160 degrees), with a mean pronation of 48 degrees (range, 0 to 80 degrees) and a mean supination of 37 degrees (range, -10 to 80 degrees).

Stability

Thirteen of the fourteen elbows were stable at the final follow-up evaluation. One elbow, the only one with a constrained Coonrad-I device, was moderately unstable because of a loose humeral component.

Daily Function

Preoperatively, the ability to perform activities of daily living was severely limited by the restricted arc of motion and by pain. The mean preoperative score for the function component of the Mayo elbow performance score was 2 points (range, 0 to 19 points). Postoperatively, the mean score was 15 points (range, 0 to 25 points). At the latest follow-up evaluation, four elbows were noted by the patients to cause no difficulties with any of the activities of daily living.

Radiographic Findings

Ten elbows had no progressive radiolucency around either the humeral or the ulnar component (Fig. 3-A and Fig. 3-B). Two elbows had a progressive two-millimeter-thick radiolucent line around the humeral component. One had an excellent result (91 points) at the latest follow-up evaluation (at thirty-five months), and one had symptomatic aseptic loosening and sustained a supracondylar fracture of the lateral osseous column. This was the elbow that had been treated, in 1973, with a rigid Coonrad-I implant. A revision with a Coonrad-Morrey semiconstrained total elbow arthroplasty was performed fourteen years after the first procedure. The patient had a satisfactory result two years after the revision. Two other elbows had a complete radiolucent line around both the humeral and the ulnar component. One had a good result (87 points) at the latest follow-up evaluation (at fifty months), and one was revised because of ulnar component loosening one year after the first procedure.

The bone graft behind the anterior flange of the Coonrad-Morrey prosthesis was not seen in three elbows, and it had matured with complete incorporation in the ten other elbows (Fig. 3-B). None of these elbows showed radiographic evidence of bushing wear.

Complications and Revisions

There were seven complications affecting seven of the fourteen elbows, and four of these seven elbows subsequently had a revision procedure²⁶. Two elbows had a minor complication, persistent wound drainage, that did not compromise the result of the arthroplasty. Both elbows were treated with irrigation and dÇ¢ridement, and one had a manipulation under anesthesia at the same time. A third elbow had a superficial infection with skin necrosis. The elbow had been ankylosed preoperatively following trauma, and a range of motion of 140 degrees was obtained during the surgery. The wound was debrided one month following the surgery, and a brachioradialis muscle flap procedure was performed. A week later this flap became necrotic, and a latissimus dorsi myocutaneous flap procedure was successfully performed. At seven years, the wound was healed, the range of flexion was 20 to 120 degrees, and the patient had an excellent result.

Deep infection developed in two elbows with posttraumatic stiffness. In both cases, Staphylococcus aureus was isolated on culture of articular specimens. One patient had had two previous operations before the arthroplasty, and the other had had four. In the first patient, the elbow was debrided, the bushings were removed, and vancomycin beads were left in the joint. Six days later, another dÇ¢ridement was done, the antibiotic beads were removed, and the joint was rearticulated. Five years later, there was no recurrent infection and the clinical result was fair, with a range of flexion of 0 to 90 degrees and no radiographic evidence of loosening. In the other patient, a total elbow arthroplasty had been done because of posttraumatic avascular necrosis of the distal aspect of the humerus and the proximal aspect of the ulna. The total elbow prosthesis was removed during the first dÇ¢ridement, and a cement spacer in combination with antibiotic beads was left in the joint. A second dÇ¢ridement was performed six days later, and the beads were removed. The patient had a resection arthroplasty and had a poor result at the time of writing.

Two patients sustained a fracture associated with a loose component. In one, a supracondylar fracture of the lateral osseous column occurred because of loosening of the humeral component of a Coonrad-I constrained prosthesis that had been implanted fourteen years before. The elbow was revised, and a Coonrad-Morrey total elbow arthroplasty was performed. Two years later, the clinical result was good, with 110 degrees of motion (from 25 to 135 degrees). The other patient sustained a fracture of the proximal aspect of the ulna one year following the initial procedure, and the ulnar component became loose. The elbow was revised, and a new ulnar implant was inserted. Nine years following the revision, the patient had some pain following activity but better function than before the initial surgery and had a range of motion of 50 to 90 degrees. Radiographic evaluation showed ulnar osteolysis with evidence of a loose ulnar component. The patient refused additional surgery.

Four elbows that did not regain adequate motion within the first month after the surgery had a manipulation under anesthesia. Generally, manipulation was performed when the range of motion at the time of the surgery was 90 degrees but decreased to less than 30 degrees during the postoperative period without recent improvement. These four elbows had a mean arc of motion of 100 degrees (range, 70 to 135 degrees) after the manipulation. At the time of the latest follow-up, the mean arc of motion of these elbows had again decreased, to 61 degrees (range, 20 to 115 degrees), but this was an improvement of 35 degrees compared with the preoperative state.

Statistical Analysis

The final result was not found to be influenced by gender, involved side, diagnosis, or duration of the symptoms prior to the total elbow arthroplasty, with the numbers available. Age influenced postoperative function (p < 0.05) as well as the final score (p < 0.05). Manipulation under anesthesia following the total elbow arthroplasty was more frequent in the older patients than in the younger patients (p < 0.05). The severity of the deficit in extension preoperatively was associated with the final score (p < 0.05) as well as with the final gain in flexion (p < 0.01) and flexion-extension (p < 0.02). Preoperative flexion was also associated with the final gain in flexion and flexion-extension (p < 0.05).

The most important factor that influenced the final result was the presence of ectopic bone surrounding the elbow joint. The elbows with ectopic bone before the surgery had less postoperative flexion than those without ectopic bone (p < 0.02). Preoperative radioulnar synostosis influenced the final arcs of pronation (p < 0.05), supination (p < 0.02), and rotation (p < 0.02).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Total elbow arthroplasty is a valuable option for the treatment of ankylosed or very stiff elbows in patients more than sixty years of age with involvement of more than 50 percent of the articular surface. Initially performed for patients with rheumatoid arthritis^8,15,35,42, semiconstrained elbow replacement has also been performed for the treatment of acute fractures of the distal aspect of the humerus in elderly patients⁶, distal humeral nonunions⁴⁴, and posttraumatic osteoarthritis^41,52 . The results for patients with rheumatoid arthritis are usually better than those for patients with a traumatic or posttraumatic condition. Ramsey et al.⁵⁰ recently reported their experience with this device used for the treatment of gross instability, the antithesis of the pathology discussed in the current study. On the basis of the findings of the cited reports, we concluded that when the replacement is used to treat a stiff elbow it has the least predictable results, the lowest overall rate of success, and the highest complication rate. Nonetheless, this experience must be placed in the context of alternative intervention options.

Only a few reports in the literature describe the results of total elbow arthroplasty for the treatment of ankylosed or stiff elbows. Figgie et al.¹³ reported the results of total elbow arthroplasty in nineteen completely ankylosed elbows. The diagnoses varied, and three different types of semiconstrained prostheses as well as eight custom prostheses were used. The mean arc of motion improved from 0 degrees preoperatively to 80 degrees (35 to 115 degrees of flexion) at a mean of five and three-quarter years. There were five complications. A deep infection that led to removal of the elbow prosthesis developed in one patient, wound problems occurred in three, and a fracture of the tip of the olecranon occurred in one. Five elbows were manipulated postoperatively, with the patient under anesthesia, to increase the range of motion. The patients with juvenile rheumatoid arthritis had the least motion postoperatively.

Katsen and Skinner²⁴ performed a semiconstrained total elbow arthroplasty in three of thirty ankylosed or very stiff elbows. There was one good result, with a range of flexion of 15 to 135 degrees; one fair result; and one poor result. Postoperative instability was common in the series. Kudo and Iwano²⁹ implanted an unconstrained implant in four elbows with a range of motion of 30 degrees or less. They reported a mean improvement of motion of 61 degrees, with improvement of only 10 degrees in extension. After that study, the implant was modified to add an intramedullary stem on the humeral component because of a high rate of loosening. Engelbrecht and Zippel¹⁰ implanted a hinged elbow prosthesis in fourteen elbows with ankylosis due to juvenile rheumatoid arthritis (eight elbows) or trauma (six). Better results were obtained in the group with juvenile rheumatoid arthritis, who had a mean postoperative arc of 80 degrees.

At a mean of sixty-three months, our patients had a mean postoperative Mayo elbow performance score of 73 points (range, 45 to 100 points), which is lower than that reported for patients with juvenile rheumatoid arthritis (90 points)⁸, posttraumatic osteoarthritis (82 points)⁵², or rheumatoid arthritis (87 points)¹⁵. However, the overall mean improvement in motion (60 degrees) in our study would be anticipated to be better than the mean improvement reported after treatment of juvenile rheumatoid arthritis (18 degrees)⁸, posttraumatic arthritis (26 degrees)⁵², or rheumatoid arthritis (13 degrees)¹⁵. The greatest improvement in our series was in the patients' ability to perform daily functional activities. Our patients had more limited function (mean Mayo elbow performance score, 15 points) than patients with juvenile rheumatoid arthritis (23 points)⁸, posttraumatic osteoarthritis (24 points)⁵², or rheumatoid arthritis (21 points)¹⁵. Furthermore, eight of the fourteen elbows in our series were associated with involvement of one or more other joints in the ipsilateral limb. This impairment may have compromised the functional results, especially with regard to daily activities⁴⁶. At the latest follow-up evaluation, four elbows were noted by the patients to cause no difficulties with any daily activities. The elbow was the only joint involved in these patients.

We observed high complication and revision rates. Of the seven complications, only three - two deep infections and a loose ulnar component with a fracture of the ulna - affected the final result³⁶. All three elbows with a superficial infection had an excellent result at the final follow-up evaluation, and the revision of the loose humeral component led to a good result. In a review of the world literature, Gschwend et al.¹⁸ surveyed eight series representing 828 total elbow arthroplasties and reported a rate of complications of 43 percent with a rate of revision of 18 percent. The rate of complications varied according to the etiology leading to the arthroplasty. The best results were usually obtained in patients with rheumatoid arthritis, who had complication rates ranging from 15.2 percent¹⁸ to 20 percent¹⁵ at the time of long-term follow-up. Patients with juvenile rheumatoid arthritis had fewer good results and a rate of complications of 54 percent⁸. Elbows affected by posttraumatic arthritis typically have been operated on several times before the arthroplasty is done. This increases the risk of wound complications or infection⁵⁹. Also, patients with posttraumatic arthritis are usually more active than patients with rheumatoid arthritis, so the components are exposed to more stress. In recent series of patients with posttraumatic arthritis, the rates of complications have ranged from 27 to 38 percent^41,52.

In ankylosed or severely contracted joints, arthrolysis may be necessary to improve the arc of motion intraoperatively. Usually, a circumferential capsular release and an excision of the collateral ligaments is done. This step cannot be performed without compromising elbow stability, so the use of resurfacing devices is generally discouraged^{2,12,13,29,49,57}. The semiconstrained implant used in this study is designed to deal with this problem. If there is osseous ankylosis, the joint line is reestablished, with a microsagittal saw or a small osteotome, to create a space as close as possible to the center of rotation of the ulnohumeral joint in order to offer the best biomechanical and functional condition for the implant. Although the use of individualized custom prostheses has been advocated for ankylosed elbows¹³, they were not found to be necessary in the present study.

The Coonrad-Morrey semiconstrained total elbow arthroplasty may be considered a viable option for patients with various forms of stiffness of the articulation. Substantial improvement of motion and satisfactory pain relief can be obtained with this procedure. Complications are frequent but can be minimized by careful selection of the patients and by preoperative planning. Expensive custom implants are not necessary to treat these patients.

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Introduction | Materials and Methods | Results | Discussion | References

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Topics

rheumatoid arthritis ; fracture ; arthritis, juvenile rheumatoid ; elbow region ; humerus ; pain ; range of motion ; wounds and injuries ; elbow replacement arthroplasty

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P. Mansat, B. F. Morrey; Semiconstrained Total Elbow Arthroplasty for Ankylosed and Stiff Elbows*. The Journal of Bone & Joint Surgery. 2000 Sep;82(9):1260-1260.

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