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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
View Disclosures and Other Information
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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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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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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.


    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.


    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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