The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 92, Issue Supplement 2

Scientific Articles | December 01, 2010

The Evolution of Elbow Arthroplasty: Innovative Solutions to Complex Clinical Problems

Michael B. Cross, MD¹; Seth L. Sherman, MD¹; Christopher K. Kepler, MD, MBA¹; Andrew S. Neviaser, MD¹; Andrew J. Weiland, MD¹

¹ Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M.B. Cross: crossm@hss.edu

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am, 2010 Dec 01;92(Supplement 2):98-104. doi: 10.2106/JBJS.J.00777

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Extract

Total elbow design has evolved dramatically over the last century. Prior to 1947, resection and interposition arthroplasty were the primary surgical procedures for the treatment of severe posttraumatic deformity, trauma, and rheumatoid arthritis. In 1947, surgeons began performing partial elbow replacements of the distal part of the humerus and proximal part of the ulna as well as using custom hinged metal devices to treat these problems. The results were unpredictable pain relief and predictable loosening and/or instability¹-⁵. Beginning in the 1970s, the first simple hinged prosthesis was inserted with use of methylmethacrylate fixation. This improved the stability of the construct, but three to five-year loosening rates were as high as 50%⁶. As a result of these and other failures, three design concepts have emerged: linked, unlinked, and convertible prostheses.

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Introduction

Total elbow design has evolved dramatically over the last century. Prior to 1947, resection and interposition arthroplasty were the primary surgical procedures for the treatment of severe posttraumatic deformity, trauma, and rheumatoid arthritis. In 1947, surgeons began performing partial elbow replacements of the distal part of the humerus and proximal part of the ulna as well as using custom hinged metal devices to treat these problems. The results were unpredictable pain relief and predictable loosening and/or instability^1-5. Beginning in the 1970s, the first simple hinged prosthesis was inserted with use of methylmethacrylate fixation. This improved the stability of the construct, but three to five-year loosening rates were as high as 50%⁶. As a result of these and other failures, three design concepts have emerged: linked, unlinked, and convertible prostheses.

Linked, or "semi-constrained," prostheses (e.g., GSB III [Zimmer, Warsaw, Indiana], Coonrad-Morrey [Zimmer], Discovery [Biomet, Warsaw, Indiana]) are the most commonly used implants in North America and allow some out-of-plane motion. Varus, valgus, and rotational motion of around 6° to 8° is permitted by the "sloppy" hinge^7,8. The advantage of this design is that instability and dislocation are rare. However, as a result of the inherent constraint, increased stress is transferred to the bone-cement interface, and higher loosening rates have been reported⁹.

The second major design is an unlinked prosthesis (e.g., Souter-Strathclyde [Stryker Howmedica Osteonics, Limerick, Ireland], Kudo [Biomet], Instrumented Bone Preserving [Biomet]), in which there is no mechanical linkage between the humeral and ulnar components^10,11. Advantages include maintenance of bone stock and decreased polyethylene wear⁹. However, because there is no linkage, the stability of the implant requires exacting surgical technique and an intact soft-tissue envelope. Well-balanced soft-tissue attachments reduce stress at the bone-cement interface, lowering loosening rates with this design. However, unlinked devices are associated with higher rates of instability and dislocation when compared with linked prostheses¹⁰. The need for intact soft tissues prevents the use of an unlinked prosthesis in the setting of an unstable joint, a neuropathic joint, extensive proximal ulnar bone loss, and severe humeral condylar defects^10,11.

As a result of the imperfections of linked and unlinked designs, a third type of total elbow design concept has emerged: the "convertible" prosthesis (e.g., Latitude [Tornier, Saint-Ismier, France], Acclaim [Depuy, Warsaw, Indiana]). This design allows for conversion of an unlinked prosthesis to a linked prosthesis if the prosthetic elbow is unstable intraoperatively or if instability develops in the postoperative period^9,12. The Latitude prosthesis offers the additional option of replacing the radial head and allows sutures to be placed through the axis of the implant in order to improve the stability and to aid in the repair of the collateral ligaments⁹.

Source of Funding

There was no external funding source for the present study.

Evolving Indications

Total elbow arthroplasty, like other joint replacements, is indicated for conditions that produce severe pain and functional limitation. There has been a substantial shift in the uses of total elbow arthroplasty in recent years. In the past, the primary indication for a total elbow replacement was end-stage rheumatoid arthritis. However, disease-modifying antirheumatologic drugs have had a profound impact on the prognosis of rheumatoid arthritis, and, as a result, the number of patients who require total elbow arthroplasty for this diagnosis is decreasing. Patients who have inflammatory elbow arthropathy and require total elbow arthroplasty tend to be more active and to have less generalized disease than similar patients did a decade ago. Higher activity levels place greater demand on the implant and may lead to an increase in total elbow arthroplasty failures.

There has been a recent trend toward the treatment of acute, comminuted distal humeral fractures and distal humeral nonunions with total elbow arthroplasty. In 2003, Frankle et al. reported the results of a retrospective review in which they compared twelve patients with an age of more than sixty-five years who underwent open reduction and internal fixation for the treatment of distal humeral fractures with a comparable group of patients who underwent total elbow arthroplasty¹³. The authors found that the total elbow arthroplasty group had better Mayo Elbow Performance Scores and a greater percentage of patients with good to excellent results at two years of follow-up. In 2009, McKee et al. demonstrated, in a level-I trial in which total elbow arthroplasty was compared with distal humeral open reduction and internal fixation for the treatment of acute distal humeral fractures in the elderly, that total elbow arthroplasty produced better Mayo Elbow Performance Scores; shorter operative time; improved Disabilities of the Arm, Shoulder and Hand (DASH) scores; and greater elbow flexion at two years of follow-up¹⁴. Although the short-term outcomes have been favorable, intermediate and long-term results have not yet been reported.

The use of elbow arthroplasty for fracture treatment has expanded to include distal humeral nonunions as well. Cil et al. reported on the use of linked, semi-constrained total elbow arthroplasty for the treatment of distal humeral nonunions in ninety-one patients¹⁵. The rate of prosthetic survival was 96% at two years, 82% at five years, and 65% at both ten and fifteen years. Factors associated with the need for revision were a patient age of less than sixty-five years, two or more prior surgical procedures, and a history of infection. The authors concluded that semi-constrained total elbow arthroplasty was a viable salvage procedure that can provide pain relief and can restore motion, stability, and function in patients with a distal humeral nonunion that is not amenable to internal fixation.

Severe primary osteoarthritis is an uncommon condition typically afflicting younger males and can also be an indication for total elbow arthroplasty. However, total elbow arthroplasty is usually best done as a last-resort option in older patients with low functional demands. For patients under the age of sixty-five years, interpositional arthroplasty is indicated. Kozak, Adams, and Morrey recommended the algorithm presented in Table I for the treatment of primary osteoarthritis of the elbow¹⁶.

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TABLE I Treatment Algorithm for Primary Osteoarthritis of the Elbow*

Clinical Findings	Radiographic Findings	Procedure
1. Loss of extension with mild pain	Small spur on the olecranon	None—activity modification; medications (NSAIDS)
2. In addition to 1, symptoms limit activity	Larger olecranon and/or coronoid spurs	Arthroscopic debridement
3. Symptoms of locking or catching	Loose body	Arthroscopic removal
4. Pain with flexion/extension, motion restricted	Osteophytes	Arthroscopy, ulnohumeral arthroplasty
5. As for 1-4, with ulnar nerve symptoms	As above	Ulnohumeral arthroplasty, nerve decompression
6. Painful arc of motion, high-grade motion loss, capsular contracture	Extensive osteophytic changes, joint narrowing	Age <65: interposition arthroplasty
		Age >65: semiconstrained total elbow arthroplasty
7. Symptoms localized to radiohumeral joint	Radiohumeral arthritis	Radial head replacement, possible capitellar replacement

*Reproduced, with modification, from: Kozak TKW, Adams RA, Morrey BF. Total elbow arthroplasty for primary osteoarthritis. In: Morrey BF, Sanchez-Sotelo J, editors. The elbow and its disorders. 4th ed. Philadelphia: Saunders; 1985. p 844; with permission from Elsevier.

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TABLE I Treatment Algorithm for Primary Osteoarthritis of the Elbow*

Clinical Findings	Radiographic Findings	Procedure
1. Loss of extension with mild pain	Small spur on the olecranon	None—activity modification; medications (NSAIDS)
2. In addition to 1, symptoms limit activity	Larger olecranon and/or coronoid spurs	Arthroscopic debridement
3. Symptoms of locking or catching	Loose body	Arthroscopic removal
4. Pain with flexion/extension, motion restricted	Osteophytes	Arthroscopy, ulnohumeral arthroplasty
5. As for 1-4, with ulnar nerve symptoms	As above	Ulnohumeral arthroplasty, nerve decompression
6. Painful arc of motion, high-grade motion loss, capsular contracture	Extensive osteophytic changes, joint narrowing	Age <65: interposition arthroplasty
		Age >65: semiconstrained total elbow arthroplasty
7. Symptoms localized to radiohumeral joint	Radiohumeral arthritis	Radial head replacement, possible capitellar replacement

Modular Elbow Arthroplasty

Elbow arthroplasty is complicated by the presence of three articulations within the native elbow joint. The radiocapitellar, proximal radioulnar, and trochlear-ulnar articulations have distinct motion profiles and together comprise the elbow range of motion via coupled actions. The complexity of this articulation is not addressed by the simple hinge mechanism employed in a conventional elbow arthroplasty. Although this conventional prosthesis has demonstrated good results in terms of providing pain relief and restoring limited function in elderly and low-demand patients, results in younger patients have been less predictable because of early failure. The development of a modular elbow replacement system allows for the preservation of uninjured or unaffected aspects of the joint and also allows for future conversion to total elbow replacement via "adding-on" prostheses should the remaining native portions of the joint subsequently fail without the need for explantation. Currently, there are only two modular prostheses available in the United States. The UNI-Elbow Radio Capitellum System (Small Bone Innovations, Morrisville, Pennsylvania) allows for replacement of the radial head and the capitellum, whereas the Latitude Total Elbow prosthesis allows replacement of the ulna, humerus, and radial head.

Results

Modular Implants

The available literature on the results associated with modular prostheses is limited, with only a few published reports with short to intermediate-term follow-up^17-19. Heijink et al. reported on three patients who underwent radiocapitellar hemiarthroplasty with use of the UNI-Elbow prosthesis¹⁷. All patients were initially managed for a radial head fracture and developed subsequent proximal migration of the radius. After an average duration of follow-up of eighty-seven months, one patient had undergone revision of the radial head component and two patients had returned to work. The average Mayo Elbow Performance Score was excellent for two patients and good for one patient. Similarly, Weber et al. reported on eleven patients who were managed with elbow arthroplasty after a distal humeral fracture (three of whom received the Latitude humeral prosthesis) and fifteen patients who were managed with open reduction and internal fixation¹⁸. The average duration of follow-up was twelve months in prosthetic group. The average Mayo Elbow Performance Score was 91 in the prosthetic group (compared with 77 in the open reduction and internal fixation group), and the average arc of motion was 89° in the prosthetic group (compared with 57° in the open reduction and internal fixation group). No complications were reported in the prosthetic group; however, the results were not stratified according to prosthesis type. Finally, Kepler et al. reported the case of a fifty-seven-year-old patient who underwent radiocapitellar hemiarthroplasty with use of the UNI-Elbow prosthesis¹⁹. The patient had previously undergone open reduction and internal fixation for a distal humeral fracture and developed a nonunion and erosion of the radial head. At the time of the twelve-month follow-up, the patient had returned to work and had no functional limitations, with a painless elbow range of motion of 20° to 120° with full pronation and supination.

Total Elbow Arthroplasty

A summary of the results of total elbow arthroplasty, subcategorized by primary diagnosis, is presented in Tables II and III. Diagnostic categories include acute distal humeral fractures and distal humeral nonunions in the elderly, posttraumatic and inflammatory arthritis in young patients, primary osteoarthritis, and inflammatory arthritis. As demonstrated in Tables II and III, the results and complications of total elbow arthroplasty vary substantially, depending on the indication for the procedure, the average age of the patient, the level of functional demand, the type of outcome measure used, the duration of follow-up, and surgeon experience^14,16,20-50. With regard to distal humeral fractures in the elderly, total elbow arthroplasty with the Coonrad-Morrey implant has been shown to be a reliable implant choice in multiple series, with good to excellent Mayo Elbow Performance Scores ranging from 84% to 93%, and minimal complications after a three to seven-year follow-up period^23,24,27. In general, the results of total elbow arthroplasty after distal humeral nonunion have been worse than those after acute distal humeral fracture^15,22,26,27. Satisfaction rates following total elbow arthroplasty for nonunion have ranged from 57% to 86%, and rates of complications, including infection, aseptic loosening, and ulnar neuropathy, have ranged from 18% to 48%^15,22,26,27.

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TABLE II Outcomes of Total Elbow Arthroplasty Subclassified According to Diagnosis

Diagnosis	No. of Patients	Age*(yr)	Duration of Follow-up*	Implant	Outcome†	Complications/Comments
Acute distal humeral fracture
Prasad and Dent²⁷ (2008)	15	78	56.1 mo	Coonrad-Morrey	84% excellent or good MEPS	Regional pain syndrome (1), aseptic loosening (1)
Kamineni and Morrey²⁴ (2004)	43	69	7 yr	Coonrad-Morrey	93% excellent or good MEPS	Heterotopic ossification (7), revision arthroplasty (5)
Garcia et al.²³ (2002)	19	73	3 yr	Coonrad-Morrey	93% excellent or good MEPS	Myocardial infarction (1), superficial wound infection (1)
Distal humeral nonunion
Cil et al.¹⁵ (2008)	91	65	6.5 yr	Coonrad-Morrey	22% fair or poor MEPS; 96% survival at 2 yr, 82% survival at 5 yr, 65% survival at 10 and 15 yr	44 complications, 23 revisions. Increased risk of failure: age <65, ≥2 surgeries, history of infection
Prasad and Dent²⁷ (2008)	17	73	56.1 mo	Coonrad-Morrey	79% excellent or good MEPS	Infection (2), ulnar palsy (2), aseptic loosening (1), heterotopic ossification (1)
Morrey and Adams²⁶ (1995)	36	68	50.4 mo	Coonrad-Morrey	86% excellent or good	18% rate of complications (deep infection [2], synovitis [2], ulnar neuropathy [2], polyethylene wear [1])
Figgie et al.²² (1989)	14	65	5 yr	Semiconstrained	57% excellent or good	Dislocation (1), deep infection (1), aseptic loosening (1)
Inflammatory and posttraumatic arthritis (young patients)
Celli and Morrey²⁰ (2009)	55	33	91 mo	Coonrad-Morrey	93% excellent or good MEPS	22% rate of revision (aseptic loosening [4], triceps weakness [3], polyethylene wear [3], deep infection [2]). Increased complication rate in posttraumatic versus inflammatory (p = 0.02)
Primary osteoarthritis
Espag et al.²¹ (2003)	11	66	68 mo	Souter-Strathclyde	90% subjective satisfaction, 7 patients with no pain, improved average flexion arc from 69° to 107°	9% rate of revision (aseptic loosening [1]). Complications included ulnar neurapraxia (2), superficial wound infection (1), myocardial infarction (1), pulmonary embolism (2)
Kozak et al.⁵⁰ (1998)	5	68	3 yr	Coonrad-Morrey; Pritchard ERS	100% excellent or good MEPS	40% revision rate. Complications in 4 patients, including fracture, subluxation, heterotopic ossification, ulnar neuropathy

*The values are given as the mean.
†MEPS = Mayo Elbow Performance Score.

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TABLE II Outcomes of Total Elbow Arthroplasty Subclassified According to Diagnosis

Diagnosis	No. of Patients	Age*(yr)	Duration of Follow-up*	Implant	Outcome†	Complications/Comments
Acute distal humeral fracture
Prasad and Dent²⁷ (2008)	15	78	56.1 mo	Coonrad-Morrey	84% excellent or good MEPS	Regional pain syndrome (1), aseptic loosening (1)
Kamineni and Morrey²⁴ (2004)	43	69	7 yr	Coonrad-Morrey	93% excellent or good MEPS	Heterotopic ossification (7), revision arthroplasty (5)
Garcia et al.²³ (2002)	19	73	3 yr	Coonrad-Morrey	93% excellent or good MEPS	Myocardial infarction (1), superficial wound infection (1)
Distal humeral nonunion
Cil et al.¹⁵ (2008)	91	65	6.5 yr	Coonrad-Morrey	22% fair or poor MEPS; 96% survival at 2 yr, 82% survival at 5 yr, 65% survival at 10 and 15 yr	44 complications, 23 revisions. Increased risk of failure: age <65, ≥2 surgeries, history of infection
Prasad and Dent²⁷ (2008)	17	73	56.1 mo	Coonrad-Morrey	79% excellent or good MEPS	Infection (2), ulnar palsy (2), aseptic loosening (1), heterotopic ossification (1)
Morrey and Adams²⁶ (1995)	36	68	50.4 mo	Coonrad-Morrey	86% excellent or good	18% rate of complications (deep infection [2], synovitis [2], ulnar neuropathy [2], polyethylene wear [1])
Figgie et al.²² (1989)	14	65	5 yr	Semiconstrained	57% excellent or good	Dislocation (1), deep infection (1), aseptic loosening (1)
Inflammatory and posttraumatic arthritis (young patients)
Celli and Morrey²⁰ (2009)	55	33	91 mo	Coonrad-Morrey	93% excellent or good MEPS	22% rate of revision (aseptic loosening [4], triceps weakness [3], polyethylene wear [3], deep infection [2]). Increased complication rate in posttraumatic versus inflammatory (p = 0.02)
Primary osteoarthritis
Espag et al.²¹ (2003)	11	66	68 mo	Souter-Strathclyde	90% subjective satisfaction, 7 patients with no pain, improved average flexion arc from 69° to 107°	9% rate of revision (aseptic loosening [1]). Complications included ulnar neurapraxia (2), superficial wound infection (1), myocardial infarction (1), pulmonary embolism (2)
Kozak et al.⁵⁰ (1998)	5	68	3 yr	Coonrad-Morrey; Pritchard ERS	100% excellent or good MEPS	40% revision rate. Complications in 4 patients, including fracture, subluxation, heterotopic ossification, ulnar neuropathy

*The values are given as the mean.
†MEPS = Mayo Elbow Performance Score.

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TABLE III Outcomes of Total Elbow Arthroplasty for Treatment of Inflammatory Arthritis*

Author (Year)	No. of Patients/ Elbows	Duration of Follow-up†(mo)	Implant	Outcome‡	Complications/Comments
Little et al.²⁵ (2005)				All implants associated with improvement in terms of pain and range of motion, without any significant differences between implant types
Implant 1	33	61	Souter-Strathclyde		85% 5-year survival
Implant 2	33	67	Kudo		93% 5-year survival
Implant 3	33	68	Coonrad-Morrey		90% 5-year survival
Ewald et al.²⁹ (1993)	312	69	Capitellocondylar	91/65; increased range of motion 27°	22 complications (loosening [3], infection [6], dislocation [5], reoperation [8])
Weiland et al.³⁰ (1989)	45	86	Capitellocondylar	88/58; increased range of motion 16°	4 complications (infection [2], dislocation [2])
Rosenberg and Turner³¹ (1984)	28	35	Capitellocondylar	89/60; increased range of motion 13°	9 complications (loosening [2], infection [2], dislocation [4], reoperation [1])
Davis et al.³² (1982)	30	40	Capitellocondylar	85/77; increased range of motion 25°	7 complications (infection [2], dislocation [4], release ulnar nerve [1])
Schemitsch et al.³³ (1996)	46	48	Capitellocondylar	90/69; increased range of motion 27°	7 complications (loosening [3], dislocation [3], release ulnar nerve [1])
Geschwend et al.³⁴ (1999)	65	162	GSB III	92% doing well at the time of follow-up; increased range of motion 37°	18 complications (loosening [3], infection [1], dislocation [10], reoperation [4])
Machner et al.³⁵ (1999)	34	44	GSB III	85/43; increased range of motion 39°	4 complications (infection [3], release ulnar nerve [1])
Tanaka et al.³⁶ (2001)	50	156	Kudo	77/34; increased range of motion 24°	4 complications (loosening [4])
Verstreken et al.³⁷ (1998)	16	35	Kudo	89/57; increased range of motion 27°	5 complications (loosening [2], dislocation [2], release ulnar nerve [1])
Kudo and Iwano³⁸ (1990)	43	46	Kudo	80/37; increased range of motion 25°	3 complications (dislocation [1], reoperation [2])
Rahme³⁹ (2002)	30	60	Kudo	91/39; increased range of motion 17°	6 complications (loosening [2], infection [1], dislocation [1], fracture [1], reoperation [1])
Soni and Cavendish⁴⁰ (1984)	80	42	Liverpool	81% doing well at the time of follow-up; increased range of motion 32°	22 complications (loosening [8], infection [4], release ulnar nerve [2], reoperation [8])
Dhar and Beddow⁴¹ (1994)	9 (using original humeral component)	141	Liverpool	76/63; increased range of motion 13°	5 complications (loosening [5])
	11 (using modified humeral component)	69	Liverpool	82/67; increased range of motion 27°
Risung⁴² (1997)	118	51	Norway	89/68; increased range of motion 21°	15 complications (loosening [1], infection [3], dislocation [2], release ulnar nerve [2], fracture [1], reoperation [6])
Yanni et al.⁴³ (2000)	59	78	Roper-Tuke	88/56; increased range of motion 29°	5 complications (infection [2], reoperation [3])
Allieu et al.⁴⁴ (1998)	20	114	Roper-Tuke	80/41; increased range of motion 31°	5 complications (loosening [3], infection [2])
Lyall et al.⁴⁵ (1994)	19	41	Souter-Strathclyde	89.5%; increased range of motion 36°	3 complications (loosening [1], fracture [1], reoperation [1])
Van der Lugt et al.⁴⁶ (2004)	204	77	Souter-Strathclyde	85.4%; increased range of motion 25°	41 complications (loosening [16], infection [10], dislocation [4], release ulnar nerve [3], fracture [7], reoperation [1])
Burnett and Fyfe⁴⁷ (1991)	23	36	Souter-Strathclyde	77.2%; increased range of motion 24°	6 complications (loosening [2], dislocation [2], fracture [1], reoperation [1])
Sjödén et al.⁴⁸ (1995)	19	60	Souter-Strathclyde	89.5%; increased range of motion 12°	6 complications (loosening [5], dislocation [1])
Dainton and Hutchins⁴⁹ (2002)	44	72	Souter-Strathclyde	88%; increased range of motion 18°	12 complications (loosening [8], infection [1], release ulnar nerve [1], fracture [2])

*Data in this table obtained from the study by van der Lugt and Rozing²⁸.
†The values are given as the mean.
‡Outcomes scoring systems varied according to study. Unless otherwise specified, the outcomes for all implants (except the Souter-Strathclyde implant) are expressed as the score at time of the latest follow-up/the number of points of improvement, followed by the mean increase in the range of motion. For the Souter-Strathclyde implant, the results are listed as the percentage of patients who were well functioning and pain-free.

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TABLE III Outcomes of Total Elbow Arthroplasty for Treatment of Inflammatory Arthritis*

Author (Year)	No. of Patients/ Elbows	Duration of Follow-up†(mo)	Implant	Outcome‡	Complications/Comments
Little et al.²⁵ (2005)				All implants associated with improvement in terms of pain and range of motion, without any significant differences between implant types
Implant 1	33	61	Souter-Strathclyde		85% 5-year survival
Implant 2	33	67	Kudo		93% 5-year survival
Implant 3	33	68	Coonrad-Morrey		90% 5-year survival
Ewald et al.²⁹ (1993)	312	69	Capitellocondylar	91/65; increased range of motion 27°	22 complications (loosening [3], infection [6], dislocation [5], reoperation [8])
Weiland et al.³⁰ (1989)	45	86	Capitellocondylar	88/58; increased range of motion 16°	4 complications (infection [2], dislocation [2])
Rosenberg and Turner³¹ (1984)	28	35	Capitellocondylar	89/60; increased range of motion 13°	9 complications (loosening [2], infection [2], dislocation [4], reoperation [1])
Davis et al.³² (1982)	30	40	Capitellocondylar	85/77; increased range of motion 25°	7 complications (infection [2], dislocation [4], release ulnar nerve [1])
Schemitsch et al.³³ (1996)	46	48	Capitellocondylar	90/69; increased range of motion 27°	7 complications (loosening [3], dislocation [3], release ulnar nerve [1])
Geschwend et al.³⁴ (1999)	65	162	GSB III	92% doing well at the time of follow-up; increased range of motion 37°	18 complications (loosening [3], infection [1], dislocation [10], reoperation [4])
Machner et al.³⁵ (1999)	34	44	GSB III	85/43; increased range of motion 39°	4 complications (infection [3], release ulnar nerve [1])
Tanaka et al.³⁶ (2001)	50	156	Kudo	77/34; increased range of motion 24°	4 complications (loosening [4])
Verstreken et al.³⁷ (1998)	16	35	Kudo	89/57; increased range of motion 27°	5 complications (loosening [2], dislocation [2], release ulnar nerve [1])
Kudo and Iwano³⁸ (1990)	43	46	Kudo	80/37; increased range of motion 25°	3 complications (dislocation [1], reoperation [2])
Rahme³⁹ (2002)	30	60	Kudo	91/39; increased range of motion 17°	6 complications (loosening [2], infection [1], dislocation [1], fracture [1], reoperation [1])
Soni and Cavendish⁴⁰ (1984)	80	42	Liverpool	81% doing well at the time of follow-up; increased range of motion 32°	22 complications (loosening [8], infection [4], release ulnar nerve [2], reoperation [8])
Dhar and Beddow⁴¹ (1994)	9 (using original humeral component)	141	Liverpool	76/63; increased range of motion 13°	5 complications (loosening [5])
	11 (using modified humeral component)	69	Liverpool	82/67; increased range of motion 27°
Risung⁴² (1997)	118	51	Norway	89/68; increased range of motion 21°	15 complications (loosening [1], infection [3], dislocation [2], release ulnar nerve [2], fracture [1], reoperation [6])
Yanni et al.⁴³ (2000)	59	78	Roper-Tuke	88/56; increased range of motion 29°	5 complications (infection [2], reoperation [3])
Allieu et al.⁴⁴ (1998)	20	114	Roper-Tuke	80/41; increased range of motion 31°	5 complications (loosening [3], infection [2])
Lyall et al.⁴⁵ (1994)	19	41	Souter-Strathclyde	89.5%; increased range of motion 36°	3 complications (loosening [1], fracture [1], reoperation [1])
Van der Lugt et al.⁴⁶ (2004)	204	77	Souter-Strathclyde	85.4%; increased range of motion 25°	41 complications (loosening [16], infection [10], dislocation [4], release ulnar nerve [3], fracture [7], reoperation [1])
Burnett and Fyfe⁴⁷ (1991)	23	36	Souter-Strathclyde	77.2%; increased range of motion 24°	6 complications (loosening [2], dislocation [2], fracture [1], reoperation [1])
Sjödén et al.⁴⁸ (1995)	19	60	Souter-Strathclyde	89.5%; increased range of motion 12°	6 complications (loosening [5], dislocation [1])
Dainton and Hutchins⁴⁹ (2002)	44	72	Souter-Strathclyde	88%; increased range of motion 18°	12 complications (loosening [8], infection [1], release ulnar nerve [1], fracture [2])

There is a paucity of outcome data on total elbow arthroplasty for young patients. Celli and Morrey reported on fifty-five patients (mean age, thirty-three years) who underwent total elbow arthroplasty with a Coonrad-Morrey prosthesis for the treatment of either posttraumatic or inflammatory arthritis²⁰. After a mean duration of follow-up of ninety-one months, 93% of the patients had a good or excellent Mayo Elbow Performance Score. However, the revision rate during the study period was 22%, with the main reasons for revision being aseptic loosening, polyethylene wear, triceps weakness, and deep infection. In this young population, the rate of complications was significantly higher in the posttraumatic group as compared with the inflammatory arthritis group (p = 0.02). Total elbow arthroplasty for the treatment of primary osteoarthritis of the elbow is a relatively uncommon procedure and is usually reserved for low-demand, elderly patients. While a few small series have demonstrated a 90% rate of patient satisfaction and a 100% rate of good or excellent Mayo Elbow Performance Scores, the revision rate has been high, ranging from 9% to 40%^16,21. In addition, this procedure also carries the risk of major medical complications, including myocardial infarction and pulmonary embolism^16,21. Total elbow arthroplasty for the treatment of inflammatory arthritis, particularly rheumatoid arthritis, has been the most well studied of all of the indications for total elbow arthroplasty. A recent systematic review²⁸ evaluated the use of eight implant types in twenty-two clinical series (Table III). A study by Little et al. demonstrated 85% to 93% five-year survival rates for the Coonrad-Morrey, Kudo, and Souter-Strathclyde implants, with no differences in pain scores or range of motion improvements among the implant types²⁵. In that series, ninety-nine patients were followed for more than five years, demonstrating that in this population of patients with an age of more than sixty years and inflammatory arthritis, prosthesis linkage was able to decrease the rate of dislocation without increasing the rate of symptomatic loosening.

Overview

Elbow arthroplasty has changed substantially since the 1940s with the development of a growing appreciation of the complexity of the elbow joint. The surgical indications for elbow arthroplasty continue to evolve as it becomes more clear which elbow arthroplasty has the best results in a given age group. Despite improvements in elbow designs, complications still plague high-demand patients and drive further innovation in the design of elbow arthroplasty implants.

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Topics

elbow region ; arthroplasty ; elbow replacement arthroplasty ; elbow joint prosthesis

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Michael B. Cross, Seth L. Sherman, Christopher K. Kepler, Andrew S. Neviaser, Andrew J. Weiland; The Evolution of Elbow Arthroplasty: Innovative Solutions to Complex Clinical Problems. The Journal of Bone & Joint Surgery. 2010 Dec;92(Supplement_2):98-104.

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