The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 11

Scientific Articles | November 01, 2005

Outcomes of Total Elbow Arthroplasty for Rheumatoid Arthritis: Comparative Study of Three Implants

Christopher P. Little, FRCS(Tr&Orth)¹; Alastair J. Graham, FRCS(Tr&Orth)²; Georgios Karatzas¹; David A. Woods, FRCS³; Andrew J. Carr, FRCS¹

¹ Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX2 7BD, England. E-mail address for C.P. Little: christopher.little@ndos.ox.ac.uk
² Wycombe Hospital, Queen Alexandra Road, High Wycombe, Buckinghamshire HP11 2TT, England
³ Great Western Hospital, Marlborough Road, Swindon, Wiltshire SN3 6BB, England

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Zimmer) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford, England

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Nov 01;87(11):2439-2448. doi: 10.2106/JBJS.D.02927

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Abstract

Background: As the English-language literature on prosthetic elbow arthroplasty contains only two comparative studies of implants in contemporary use, to our knowledge, comparisons of prosthetic performance is difficult. An improved knowledge of comparative outcomes would be valuable in guiding implant selection.

Methods: We identified three groups of consecutive patients who had undergone prosthetic elbow arthroplasty with the Souter-Strathclyde, Kudo, or Coonrad-Morrey implant for the treatment of rheumatoid arthritis. There were thirty-three elbows in each group. All procedures were done by or under the supervision of one surgeon. Surviving patients in whom the elbow had not been revised were followed for a mean of sixty-one months after treatment with the Souter-Strathclyde implant, sixty-seven months after treatment with the Kudo implant, and sixty-eight months after treatment with the Coonrad-Morrey implant. Clinical function was assessed on the basis of pain relief and the range of flexion. Survivorship was assessed with use of a life-table method, with revision surgery and radiographic signs of loosening as the end points.

Results: The groups were comparable in terms of age, sex, and mean duration of follow-up. All three implant procedures relieved pain. Sustained improvement in the range of flexion was comparable among the three groups, with no implant procedure dramatically changing the fixed flexion deformity and all three improving maximum flexion. Revision surgery was needed because of infection, dislocation, and aseptic loosening. Survival of the Coonrad-Morrey implant was better than that of the other two implants. The five-year survival rates, with revision and radiographic signs of loosening as the end points, were 85% and 81% for the Souter-Strathclyde implant, 93% and 82% for the Kudo implant, and 90% and 86% for the Coonrad-Morrey implant. While radiographic evidence of loosening of the Coonrad-Morrey implants was less common, we noted focal osteolysis adjacent to 16% of these ulnar components and half of these cases progressed to frank loosening.

Conclusions: The clinical function of these implants was similar in terms of pain relief and range of motion. We believe that component linkage with the Coonrad-Morrey implant prevents dislocation without increasing the risk of loosening.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Asurgeon who wishes to choose an implant for arthroplasty may look to the literature for guidance about the clinical and survivorship performances of the available devices. However, a systematic review reveals limited available information; many series are from the implant designers' institutions¹, and their results may not be applicable to other surgeons. Furthermore, the clinical outcome measures used have varied and have often not been validated, results have been heterogeneous, and formal survivorship analyses have rarely been available¹. We found only five papers comparing the performances of different implants^2-6, and only two of those dealt with implants that remain in widespread use^2,3. It is difficult to interpret apparent differences between the performances of implants on the basis of the results from different institutions because of confounding factors such as the experience of the surgeon and the rehabilitation team, particularly when a study has been conducted by the implant designer.

On the basis of the published evidence, there seems to be little difference between the revision rates of sloppy-hinge elbow replacements (those in which the humeral component is physically connected to the ulnar component, with a few degrees of varus-valgus play allowed between the components) and unlinked elbow replacements (those with no such mechanical connection between the components) after a mean of five years of follow-up¹. The functional performance of sloppy-hinge implants has been reported to be better than that of unlinked implants in terms of range of motion and the proportion of good and excellent results¹.

In order to make an informed choice, a surgeon needs to review the results of clinical series that are presented in a uniform, transparent way and in which an attempt was made to minimize the effect of confounding factors and other systematic errors. This is best achieved through prospective, randomized, controlled clinical trials, but they are often hard to conduct in surgical settings. In their absence, alternative ways of studying the effect of surgical procedures have been sought⁷.

Since 1992, the senior author (A.J.C.) has sequentially used the Souter-Strathclyde, Kudo, and Coonrad-Morrey elbow implants to treat patients with painful elbow arthritis. The implant selection was based on the year of the surgery, not on specific patient factors. We followed prospective cohorts of patients who underwent total elbow arthroplasties for end-stage rheumatoid arthritis of the elbow with these three different implants. We present the outcomes of the initial replacements with each device in a comparative cohort series.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

We studied a consecutive series of patients who underwent elbow arthroplasty for the treatment of rheumatoid arthritis. The indication for the surgery, which remained constant throughout the study period, was pain that was not responsive to nonoperative measures and functional impairment. According to the radiographic grading system of Larsen et al., all patients had grade-5 disease⁸. Prior to the surgery, note was made of previous treatments, self-rated pain level (classified as none, mild activity-related pain that did not interfere with function, moderate activity-related pain that interfered with function, or severe), any fixed flexion deformity, the maximum active flexion that could be achieved, and whether there was clinical evidence of ulnar neuritis. The implant that was used changed during the study period without a conscious alteration in the indications for surgery. The Souter-Strathclyde implant (Stryker Howmedica Osteonics, Allendale, New Jersey) was used from 1992 through 1998; the Kudo implant (Biomet, Warsaw, Indiana), from 1993 through 1997; and a Coonrad-Morrey implant with a small ulnar component that had a collar precoated with methylmethacrylate (Zimmer, Warsaw, Indiana), from 1997 through 1999.

Surgery was performed by or under the supervision of the senior surgeon (A.J.C.) with use of a standard technique. With tourniquet control, a posterior approach was performed with use of a triceps tendon turndown. The anterior band of the medial collateral ligament was preserved when possible with use of the Souter-Strathclyde and Kudo implants, and all ligaments were released when the linked Coonrad-Morrey implant was used. The implant was fixed with antibiotic-impregnated cement, which was inserted retrograde with a cement gun but without the use of cement restrictors. The triceps tendon was carefully repaired with number-1 absorbable sutures. The ligaments were not routinely reconstructed. Joint stability was confirmed prior to tourniquet release. After hemostasis, the wound was closed in layers, routinely over a single suction drain. Postoperatively, a bulky wool-and-crepe dressing was applied; no elbow was immobilized.

Postoperative rehabilitation followed a standard protocol that was the same for all three cohorts. Mobilization commenced on the first postoperative day or as soon as discomfort allowed, with retention of the bulky dressing, and proceeded incrementally according to the patient's level of discomfort. Patients were instructed to keep the arm in a sling, except when they were exercising it, and specifically to avoid resisted extension and lifting during the first six postoperative weeks. Thereafter, they were advised to stretch the elbow into full extension and full flexion daily, progressively increasing their level of activity as discomfort decreased and returning to normal daily activities as they were able. They were advised to indefinitely refrain from strenuous manual activities, such as carrying heavy loads with the treated arm and returning to domestic or occupational construction or yard work.

Patients were followed at six weeks, six months, and one year postoperatively and annually thereafter, although they were seen more frequently if problems arose. Self-reported pain and the range of motion were recorded, and complications and symptoms were noted. The mean duration of follow-up for the patients who survived and did not have revision surgery was sixty-one months (range, twenty-nine to ninety-six months) after the twenty-one Souter-Strathclyde procedures, sixty-seven months (range, eleven to 122 months) after the twenty-six Kudo procedures, and sixty-eight months (range, fifty-seven to eighty-seven months) after the thirty Coonrad-Morrey procedures.

In order to minimize the effect of a learning curve with a given implant, the number of elbows in the three cohorts was determined by the number in the smallest cohort (those treated with the Souter-Strathclyde implant). The first thirty-three elbows treated with each device were identified, and the three cohorts were followed in a standard fashion with annual clinical and radiographic examinations. Standard anteroposterior and lateral radiographs were made at each clinic visit and were scrutinized for signs of loosening, which was defined as a complete (circumferential) radiolucent line of =2 mm in thickness, a progressive radiolucency, or component migration (either with or within the cement mantle).

An established protocol of tissue-sampling was used to rule out deep infection during all revisions of failed prostheses that had been inserted as part of the trial⁹. Paired samples from all deep tissue layers and from the membrane adjacent to each component (both at the articulation and at the stemcement interface) were acquired with fresh instruments (to minimize the potential for contamination) and sent for both histological and bacteriological analysis. Prophylactic antibiotics were withheld until these specimens had been obtained. The histological specimens were analyzed by a musculoskeletal histopathologist to determine whether infection was present and to ascertain the extent and nature of any particulate debris that was present.

Survivorship analysis with use of the life-table method¹⁰ was performed for each type of implant, with revision surgery as the primary end point, and then again with revision surgery or radiographic signs of loosening (defined as component migration, progressive radiolucency, or a complete radiolucent line of =2 mm in thickness around either component) as the end point. Patients who had undergone revision surgery (component revision, soft-tissue stabilization, or débridement with retention of the component for the treatment of infection) were considered to have had a failure of the index operation and thus were excluded from the functional analyses. However, elbows that had dislocated only once and were successfully treated with closed reduction and rehabilitation and those that had subluxation of components but good function were treated as successes and included in the functional analyses. The change in flexion and extension within a given implant cohort was analyzed with use of the paired-samples t test, with SPSS software (SPSS, Chicago, Illinois). The level of significance was set at p < 0.05.

Results

Materials and Methods | Results | Discussion | Appendix | References

Demographic details of the groups are presented in Table I. There were more men in the group treated with the Kudo implant than in the two other groups, and more patients treated with the Coonrad-Morrey implant had undergone previous elbow surgery (open radial head excision and synovectomy).

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TABLE I Demographic Data

	Souter-Strathclyde	Kudo	Coonrad-Morrey
No. of elbows (patients)	33 (33)	33 (29)	33 (30)
Male:female ratio	6:27	11:22	8:25
Mean age (yr)	63	60	65
Percent with previous elbow surgery	15	21	30
Mean duration of follow-up (range) for surviving elbow implants (mo)	61 (29-96)	67 (11-122)	68 (57-87)

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TABLE I Demographic Data

	Souter-Strathclyde	Kudo	Coonrad-Morrey
No. of elbows (patients)	33 (33)	33 (29)	33 (30)
Male:female ratio	6:27	11:22	8:25
Mean age (yr)	63	60	65
Percent with previous elbow surgery	15	21	30
Mean duration of follow-up (range) for surviving elbow implants (mo)	61 (29-96)	67 (11-122)	68 (57-87)

Pain relief was achieved in the majority of patients in all three implant groups (Table II). At the time of the latest follow-up, only one patient with a surviving implant had more than mild activity-related pain. This patient had a loose Souter-Strathclyde ulnar component.

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TABLE II Self-Reported Pain at the Time of the Latest Follow-up in Patients with Surviving Implants

	Souter-Strathclyde			Kudo			Coonrad-Morrey
Pain	Preop.	Follow-up	Preop.	Follow-up	Preop.	Follow-up
None/mild (% of elbows)	-	95	-	100	-	100
Moderate/severe (% of elbows)	100	5	100	-	100	-

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TABLE II Self-Reported Pain at the Time of the Latest Follow-up in Patients with Surviving Implants

	Souter-Strathclyde			Kudo			Coonrad-Morrey
Pain	Preop.	Follow-up	Preop.	Follow-up	Preop.	Follow-up
None/mild (% of elbows)	-	95	-	100	-	100
Moderate/severe (% of elbows)	100	5	100	-	100	-

With the numbers available, the fixed flexion deformity was not significantly decreased by any of the three implant procedures (p = 0.46 for the Souter-Strathclyde implant, p = 0.53 for the Kudo implant, and p = 0.60 for the Coonrad-Morrey implant) (Table III). The range of flexion was, however, improved by a mean of 20° with the Souter-Strathclyde implant (p = 0.000), 14° with the Kudo implant (p = 0.002), and 10° with the Coonrad-Morreyimplant (p = 0.001).

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TABLE III Range of Motion^*

	Souter-Strathclyde	Kudo	Coonrad-Morrey
Preop. extension-flexion for all patients	35 ± 13 to 120 ± 13	39 ± 14 to 115 ± 20	38 ± 16 to 115 ± 18
Latest extension-flexion for patients with surviving implants	36 ± 13 to 134 ± 9	34 ± 13 to 129 ± 12	38 ± 17 to 128 ± 12
Change in fixed flexion deformity for patients with surviving implants	+4	-2	-2
Change in flexion for patients with surviving implants	+20	+14	+10

The values are given, in degrees, as the mean and the standard deviation.

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TABLE III Range of Motion^*

	Souter-Strathclyde	Kudo	Coonrad-Morrey
Preop. extension-flexion for all patients	35 ± 13 to 120 ± 13	39 ± 14 to 115 ± 20	38 ± 16 to 115 ± 18
Latest extension-flexion for patients with surviving implants	36 ± 13 to 134 ± 9	34 ± 13 to 129 ± 12	38 ± 17 to 128 ± 12
Change in fixed flexion deformity for patients with surviving implants	+4	-2	-2
Change in flexion for patients with surviving implants	+20	+14	+10

The values are given, in degrees, as the mean and the standard deviation.

The mode of failure differed among the implants (Table IV). Component linkage with the Coonrad-Morrey implant successfully prevented instability, but this was not associated with an increased need for revision due to aseptic loosening; indeed, there was less medium-term failure by aseptic loosening with the Coonrad-Morrey implant than with the other implants, although the confidence intervals for the survival analyses were wide and overlapped (Figs. 1, 2, and 3, and Appendix).

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TABLE IV Modes of Failure of the Different Components

Implant	Infection	Instability^*	Aseptic Loosening Requiring Revision (Component Involved)
Souter-Strathclyde	1	1 (1 reduced)	5 (4 humeral; 1 both)
Kudo	-	2 (1 subluxated)	4 (2 humeral; 2 both)
Coonrad-Morrey	2	-	1 (both)

The information in parentheses refers to patients who were treated with closed means for a single episode of dislocation or who showed radiographic subluxation; they were not considered to have had a failure.

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TABLE IV Modes of Failure of the Different Components

Implant	Infection	Instability^*	Aseptic Loosening Requiring Revision (Component Involved)
Souter-Strathclyde	1	1 (1 reduced)	5 (4 humeral; 1 both)
Kudo	-	2 (1 subluxated)	4 (2 humeral; 2 both)
Coonrad-Morrey	2	-	1 (both)

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Fig. 1: Survival curves for the Souter-Strathclyde implant, with revision as the end point and with revision or radiographic loosening as the end point. The 95% confidence intervals are given only for the curve with revision as the sole end point. The life tables for these curves are presented in the Appendix.

Survivorship analyses were performed with the method of Murray et al.¹⁰, with revision surgery (implant revision, soft-tissue reconstruction, or débridement with retention of the component for the treatment of infection) as an end point. The curves are shown in Figures 1, 2, and 3, with the life tables for these curves presented in the Appendix. While the confidence intervals were wide, the survival of the Souter-Strathclyde prosthesis appeared to be worse than that of the other two implants at five years. No implant broke in any of the cohorts during the study period.

Two different lengths of humeral stem (standard, used in sixteen elbows, and long, used in seventeen elbows) were used with the Souter-Strathclyde implant, and three of the long stems had a "snap-fit" articulation. The modes of loosening differed, with four of the sixteen standard-stemmed humeral components loosening aseptically and requiring revision compared with one of the seventeen long-stemmed implants (one of the three snap-fit components). The pattern of loosening of the standard-stemmed humeral components was anterior tilt of the stem tip (Fig. 4). One additional standard-stemmed humeral implant had radiographic signs of loosening. No additional long-stemmed humeral implants had radiographic loosening, but two ulnar components showed radiographic loosening.

Loosening of the Kudo implants was less predictable. We noted a trend for loosening of implants in which the ulnar component was able to tilt with the forearm going into valgus, causing tilting at the articular surface as seen on the postoperative and follow-up radiographs. Tilting was observed in six implants, with four going on to loosen clinically and requiring revision. Both the ulnar and the humeral components were subject to loosening (Fig. 5). At revision, uneven wear of the polyethylene was noted, sometimes with complete loss of one edge of the polyethylene and wear of the exposed metal backing of the ulnar component (Fig. 6).

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Fig. 2: Survival curves for the Kudo implant, with revision as the end point and with revision or radiographic loosening as the end point. The 95% confidence intervals are given only for the curve with revision as the sole end point. The life tables for these curves are presented in the Appendix.

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Fig. 3: Survival curves for the Coonrad-Morrey implant, with revision as the end point and with revision or radiographic loosening as the end point. The 95% confidence intervals are given only for the curve with revision as the sole end point. The life tables for these curves are presented in the Appendix.

Although only one Coonrad-Morrey implant required revision because of loosening, we detected initially occult ulnar osteolysis in four of the twenty-five surviving patients who did not require surgery for infection (Fig. 7). This osteolysis progressed to frank, symptomatic loosening in two elbows, with one requiring revision after forty-nine months and the second awaiting revision surgery at the time of writing. In the elbow that was revised, much metallic debris was seen but no microbiological or histological evidence of infection was found.

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Fig. 4: A loose Souter-Strathclyde total elbow implant. There is a complete radiolucent line at the cement-bone interface of the humeral component. The stem is tilted, with the tip moved anteriorly in the characteristic pattern. The anterior cortex of the humerus has expanded to accommodate this anterior translation of the humeral stem.

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Fig. 5: Loose Kudo total elbow components. The cement mantle around the humeral component is broken, with endosteal scalloping on the medial side and lucency at both the implant-cement and the cement-bone interfaces. Additionally, there is an incomplete lucency at the ulnar cement-bone interface.

Bacteriological and histological specimens obtained at the revisions showed evidence of deep infection in two of the three elbows in which the Coonrad-Morrey implant had been used. One of these infections was detected in the first month after the implantation, and the other was a late infection presenting at twenty-three months. One of the seven elbows in which a Souter-Strathclyde implant failed had an infection presenting at twenty-eight months. There was no evidence of infection in any of the elbows in which a Kudo prosthesis was revised.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

We have presented data for three cohorts of consecutive patients who underwent total elbow arthroplasty, performed by or under the supervision of one surgeon, for the treatment of end-stage rheumatoid elbow disease and who were followed for similar mean amounts of time (sixty-one, sixty-seven, and sixty-eight months following the Souter-Strathclyde, Kudo, and Coonrad-Morrey procedures, respectively). In this way, the only obvious factor that differed among the three groups was the type of implant. Although it was not a randomized trial, our investigation was a unique comparative study of the relative performances of the three implants.

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Fig. 6: A retrieved, disassembled ulnar component from a Kudo total elbow implant, showing the wear of the lateral (ulnar) side of the polyethylene and the underlying metal backing.

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Fig. 7: Focal osteolysis adjacent to the stem of a Coonrad-Morrey ulnar component, with no evidence of gross loosening of the implant.

With revision surgery used as the end point, the Coonrad-Morrey prosthesis was found to have a better survival rate, with tighter confidence intervals, than the other implants. However, the confidence intervals for all of the survival curves were wide, particularly for follow-up beyond 5 years, when the number of implants at risk dropped. While the rates of failure were similar among the three implants, the modes of failure differed. Not surprisingly, dislocation was not seen with the linked Coonrad-Morrey implant, whereas one of the thirty-three Souter-Strathclyde implants and two of the thirty-three Kudo implants dislocated and required revision. These rates are comparable with the pooled reported dislocation rate for unlinked elbow implants of 5%¹. No disassemblies of the Coonrad-Morrey implants were seen. Revision because of aseptic loosening was also less frequent in the Coonrad-Morrey cohort, a finding that supports the results of a previous systematic review¹.

When loose implants (defined as implant migration, progressive radiolucency, or a complete [circumferential] radiolucent line of =2 mm in thickness) were included as failures, the five-year survival rates decreased from 93% to 82% for the Kudo implants, from 90% to 86% for the Coonrad-Morrey implants, and from 85% to 81% for the Souter-Strathclyde implants. Although many of the patients with radiographic loosening were asymptomatic, this trend is troubling. The pattern of radiographically observed loosening varied among the implant cohorts. The mode of loosening characteristically seen with the Souter-Strathclyde implant has been described as tilting of the tip of the humeral stem anteriorly and migration of the articular portion posteriorly, possibly due to the moments acting about the elbow^11,12. The pattern of loosening of the Kudo implants was less predictable, with both components loosening in two patients (Fig. 5) and catastrophic wear of the polyethylene seen in the retrieved specimens (Fig. 6). The polyethylene insert on the ulnar component is 3 mm thick on the bearing surface. Studies of knee replacements have suggested that the yield strength of ultra-high molecular weight polyethylene inserts of <8 mm in thickness is exceeded by the joint contact stresses, leaving them prone to catastrophic wear^13,14. As four of the six implants that exhibited tilting of the ulnar component loosened in our series, we hypothesized that point loading of the polyethylene may occur secondary to tilting of the articular surface of the ulnar component, exceeding the yield strength of the polyethylene and leading to catastrophic wear of the thin insert and subsequent generation of metal wear particles, which drives the loosening process. A similar observation was made by Potter et al.¹⁵.

Loosening was not a major feature in the cohort treated with the Coonrad-Morrey implant, a finding in keeping with those of previous reports^16,17. We did, however, detect a troubling radiographic feature in that cohort. Four of the twenty-five elbows demonstrated progressive focal osteolysis around the ulnar component, a phenomenon that was not seen with the other implants. While only one of the patients with such a lesion had revision surgery, a second was awaiting such surgery at the time of writing. Histological analysis of specimens from the regions of these failed implants has not given us insight into why this may have occurred. We remain concerned that these lesions may herald future progressive loosening or periprosthetic fracture, and others have raised similar concerns^18,19. The version of the Coonrad-Morrey implant used throughout the study period had a collar, precoated with methylmethacrylate, around a textured proximal portion of the stem. This replaced a collar of sintered beads, which had been observed to be the site at which stem fracture could occur²⁰. Hildebrand et al. noted moderate progression of radiolucencies around the ulnar components, more commonly around those precoated with methylmethacrylate than those with beads, as well as lytic lesions at the tip of the stem, although all patients with a methylmethacrylate-coated stem in whom this was seen had an underlying diagnosis of trauma or posttraumatic arthritis¹⁹. Kamineni and Morrey reported that the precoat on the ulnar component has subsequently been changed to a titanium plasma-spray because of concerns about an association between the methylmethacrylate precoat and osteolysis¹⁸. There have been reports of loosening of methylmethacrylate-precoated surface-finished hip implants, and in some cases focal osteolysis preceded the loosening^21-23. Dowd et al. speculated that optimizing the implant-cement interface may magnify the deleterious effects of a deficient cement mantle²³. Given the relatively large size of the ulnar component in relation to the medullary diameter in patients with rheumatoid arthritis, it would not be surprising to find cement mantle defects.

The range of motion was similarly and significantly improved following use of all three implants, with no real change in the fixed flexion contracture associated with any of them. This finding is different from our conclusion following our systematic literature review, which was that the Coonrad-Morrey implant might both decrease the fixed flexion deformity and improve the total arc of flexion to a greater degree than the other implants²⁴. This discrepancy may reflect the difference in outcome between a series studied by the designer of an implant and that evaluated by independent surgeons. Our results, in terms of revision, radiographic signs of loosening (albeit without a standard definition among the studies), and improvement in the arc of flexion, appear to be inferior to those presented by Kudo et al.²⁵ and in reports from the Mayo clinic^16,17. There are no comparable data reported by Souter, but our results are similar (in terms of function and survival) to those reported by Ikavalko et al.²⁶ and by van der Lugt et al.²⁷ regarding this implant. The above comparisons support the notion that results reported by an implant's designers tend to be better than those presented in independent studies.

Two previous studies have compared the results of contemporarily used linked and unlinked implants^2,3. Connor and Morrey evaluated eighteen patients with juvenile rheumatoid arthritis who had been treated with the linked Coonrad-Morrey replacement and six who had been treated with the unlinked capitellocondylar implant³, and they reported a greater improvement in the range of motion with the Coonrad-Morrey implant. However, the preoperative arc of flexion was worse in the group treated with the Coonrad-Morrey implant, which suggests that there was a difference in the indications for the two implants that may have influenced the results. The difference in the group sizes and the retrospective nature of that study also made comparison of the two implants difficult. Wright et al. compared the functional outcomes associated with the Coonrad-Morrey prosthesis (referred to as the Mayo-Coonrad prosthesis in their paper) and the Ewald (capitellocondylar) implant, and they found no significant difference in the improvement in the range of motion or in the postoperative function rating between the two groups². They noted progressive radiolucencies adjacent to four of the eight unlinked components and three of the thirteen linked components. The follow-up of the group treated with the unlinked implant was, however, substantially longer, which makes comparison of the performances of the two groups difficult.

All of the implants seemed to provide reliable pain relief, as almost all patients with a surviving implant had no more than mild movement-related pain at the time of final follow-up. This finding supports the view that, although pain relief is clearly very important to patients, it is not a discriminative measure of the outcomes following uncomplicated arthroplasties.

The design of the implants changed during and since the period of recruitment. A Souter-Strathclyde implant with a longer humeral stem was introduced to reduce the likelihood of loosening and tilting, and a snap-fit ulnar articulation was introduced to improve stability. Ikavalko et al. reported lower rates of loosening and better results following use of this modified implant²⁸. The Kudo implant was modified to allow insertion without cement, but subsequent series showed an increased rate of fracture of the uncemented components^29,30. The Coonrad-Morrey implant no longer has a methylmethacrylate coating on the ulnar component. How these design changes will affect performance is not clear, but experience with the adverse effects of design changes on the performance of hip implants and the experience with the uncemented Kudo implant^29,30 suggest that surgeons should be wary about applying the results of previous generations of an implant to modified versions.

A potential source of bias in this study was the choice of implant. The implant used in our institution was changed to try to overcome perceived problems with loosening and instability. The decision to offer surgery was always made by the senior surgeon (A.J.C.), and the indication for surgery remained constant. While the periods during which a given implant was used overlapped, there was no overt selection bias that determined the choice of component. This lack of selection bias is supported by the similarity in the preoperative range of motion and self-reported pain among the three cohorts.

In conclusion, we compared the outcomes of total elbow replacements with three different implants, performed in one center at which none of the implants had been designed and under the supervision of one specialist surgeon. We found that the three devices provided similar pain relief and range of motion but that the five-year survival rate (with revision surgery as the end point) of the Souter-Strathclyde implants was a little lower than that of the Coonrad-Morrey and Kudo devices. The survival rates for all three implants were considerably worse when radiographic signs of loosening were added to the end point. Linkage of the components prevents dislocation without increasing symptomatic loosening. We observed focal osteolysis adjacent to 16% of the Coonrad-Morrey ulnar components, and those lesions will need close follow-up to determine their natural history.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

The life tables on which the survival curves were based are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

References

Materials and Methods | Results | Discussion | Appendix | References

Little CP, Carr AJ, Graham AJ. Total elbow arthroplasty. J Bone Joint Surg Br.2005;87: 437-44.87437 2005 [PubMed][CrossRef]

Wright TW, Wong AM, Jaffe R. Functional outcome comparison of semiconstrained and unconstrained total elbow arthroplasties. J Shoulder Elbow Surg.2000;9: 524-31.9524 2000 [PubMed][CrossRef]

Connor PM, Morrey BF. Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis. J Bone Joint Surg Am.1998;80: 678-88.80678 1998

Maloney WJ, Schurman DJ. Cast immobilization after total elbow arthroplasty. A safe cost-effective method of initial postoperative care. Clin Orthop Relat Res.1989;245: 117-22.245117 1989 [PubMed]

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Topics

rheumatoid arthritis ; elbow region ; humerus ; pain ; range of motion ; repeat surgery ; infection ; elbow replacement arthroplasty ; flexion deformity ; radiographic signs

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Andrew J. Carr

Posted on December 22, 2005

Mr. Carr responds to Dr. Kudo

University of Oxford, UNITED KINGDOM

We thank Dr Kudo for his letter regarding our paper (1). The implant used in our series was the only one available in the United Kingdom at that time, the Type 4 implant. We appreciate Dr Kudo's views on the potential improvements in the Type 5 prosthesis. It would be useful to see his long-term results published. We feel quite strongly that survival analysis should include not only revision as an end point but also radiographic evidence of loosening.

References:

1.Christopher P. Little, Alastair J. Graham, Georgios Karatzas, David A. Woods, and Andrew J. Carr Outcomes of Total Elbow Arthroplasty for Rheumatoid Arthritis: Comparative Study of Three Implants J Bone Joint Surg Am 2005; 87: 2439-2448

Hiroshi Kudo

Posted on December 13, 2005

Outcomes of total elbow arthroplasty for rheumatoid arthritis

Sagamihara National Hospital, Kanagawa, JAPAN

To The Editor:

In the paper "Outcomes of Total Elbow Arthroplasty for Rheumatoid Arthritis: Comparative Study of Three Implants" (2005;87:2439-2448), Little,et al, compared their clinical results using the Kudo implant (from 1993 to 1997) to those of two other implants. However,the authors did not specifically mention which type of Kudo implant they used.

The type-4 Kudo prosthesis (Biomet UK) was first put on the market in 1988. The humeral component was made of titanium alloy while the ulnar component was made either of polyethylene alone or metal -backed polyethylene. We have since learned that this combination of implant materials was associated with deleterious consequencies-- massive wear of titanium alloy resulting in severe metallosis as well as a high rate of wear of the polyethylene.

In 1992, I asked Biomet UK to modify the humeral component as soon as possible by using cobalt-chromium alloy instead of titanium alloy. At the same time I published interim clinical results of the arthroplasty using the Type-4 prosthesis in 1994, and in that report I described the specific problems (metallosis and subsequent severe osteolysis) caused by the use of titanium alloy (1).

In January 1993, the Type-5 prosthesis became available for clinical use. The humeral component was made of cobalt-chromium alloy while the ulnar component was almost unchanged from that of Type-4. In Japan, since the introduction of the Type 5 design, the Type-4 prosthesis was completely withdrawn from the market. However, the situation in Europe was quite different and the Type-4 prosthesis remained on the market until 1997, along with marketing of Type-5. This complicated situation was clearly shown in the report by Reinhard R., et al (2). They stated in that report that they had used the Type-4 prosthesis alone from 1990 to 1997. Besides this report, most of the authors in the European literature clearly mentioned which type of Kudo prosthesis (Type-4 or Type-5) had been used in their series.

At our institution, 107 elbows with the Type-5 prosthesis have been followed for more than five years, the longest follow-up was 12 years. Of these 107 elbows, six underwent revision because of loosening of the all-polyethylene ulnar component. There was no ulnar component loosening in any of the elbows in which metal- backed ulnar components were used. There were no radiographic signs of loosening of the humeral component in any of the 107 elbows. Even with these good results, we felt it necessary to increase the thickness of the polyethylene of the metal-backed ulnar component, and, in fact, this modification process is now under way.

At the final follow-up of our series of the Type-5 prosthesis, the Kaplan-Meier survival rate is 91% at 11 years with revision arthroplasty as the end-point.

Lastly, I should like to mention that the Type-4 design can be differentiated from the Type-5 design on the lateral radiograph of the elbow; it is not possible to identify the difference between the two designs on the anteroposterior radiograph alone.

References:

1. 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.

2. Reinhart R, van der Hoeven M, de Vos MJ, Eygendaal D. Total elbow arthroplasty with the Kudo prosthesis. Int Orthop.2003;27:370-2.

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Christopher P. Little, Alastair J. Graham, Georgios Karatzas, David A. Woods, Andrew J. Carr; Outcomes of Total Elbow Arthroplasty for Rheumatoid Arthritis: Comparative Study of Three Implants. The Journal of Bone & Joint Surgery. 2005 Nov;87(11):2439-2448.

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