Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 – 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 - 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Total Elbow Replacements are indicated for pain and disability in patients with rheumatoid and osteoarthritis of the elbow. The quality of the cementation has been specifically studied and shown to be directly related to the clinical outcome and implant survival. Aim. The aim of our study is to radiologically assess and grade the cementation around the components following total elbow replacement (GSB 3 or Coonrad Morrey) in two groups of patients. Materials and methods. Group I underwent total elbow replacement using Heraeus cement gun with medium palacos viscosity cement and group 2 using Zimmer cement gun with simplex medium viscosity cement. Average age in Group 1 was 72.3 (range 67–88 yrs) and group 2 was 69 years (range 52–87 yrs). 3 Coonrad Morrey and 13 GSB 3 total elbow replacement were used in Group 1 and 2 Coonrad Morrey and 14 GSB 3 in group 2. The primary indication for surgery was osteoarthritis, rheumatoid arthritis, post traumatic arthritis and seronegative arthritis in both groups. The cementation was assessed radiologically using three grading system (Morrey, Gerber & Bristol). Results. In Group I (Heraeus) 14 had adequete cementation in both AP and lateral radiographs, 1 humeral and 1 ulna components on AP radiograph revealed marginal cementing. In Group 2 (Zimmer) 11 had adequete cementation in both AP and lateral radiographs, 1 humeral and 1 ulna on AP and 1 humerus and 3 ulna on lateral radiograph were 4 marginal. Conclusion. Precise application of cement during total elbow arthroplasty is an important factor in achieving good implant fixation. To achieve this, a proper ergonomic design of the cement gun is mandatory. From our study we conclude that there was a difference in quality of cementation between the two groups

Aim. Infections after total elbow arthroplasty are more frequent than after other joint arthroplasties. Therapeutic management varies depending of the patient status, the time of diagnosis of the infection, the status of the implant as well as the remaining bone stock around the implants. Method. Between 1997 and 2017, 180 total elbow arthroplasties were performed in our department. Eleven (6%) sustained a deep infection and were revised. Infection occurred after prosthesis of first intention in 4 and after a revision procedure in 7. Etiologies were: rheumatoid arthritis in 6, trauma sequela in 4 and osteosarcoma in 1. There were 7 women and 4 men of 59 years on average (22–87). Delay between the prosthesis and the diagnosis of infection was 66 months (0.5–300). The infection was stated as acute (<3week) in one, subacute (between 3 week and 3 months) in 1, and chronic (>3 months) in 9. Isolated bacteria were: Staphylococcus (10), Streptococcus (1), P. acnes (1), and Proteus mirabilis (1). Infection were poly microbial in 2 cases. A simple lavage with debridement was performed in 3 cases (Group 1), a 2-stage revision in 4 (Group 2), and a definitive removal of the prosthesis in 4 (Group 3). Adapted antibiotics were prescribed for all patients during at least 6 weeks. Results. All patients were reviewed with 59 months average follow-up. Eight patients were cured of their infection thanks to the initial therapeutic strategy. For 2 patients of Group 2, infection reccurrency required a new surgical procedure with one simple lavage/debridement for one, and 3 lavage/debridement for the other making it possible to cure the infection. For one patient of Group 1, a failure of lavage/debridement required removal of the implants. The MEPS reached 72 points: 67 points for patients of Group 1, 76 points for patients of Group 2, and 74 points for patients of Group 3. Complication rate was 36% (4): 2 ulnar nerve impairment with dysesthesia, one radial nerve palsy, and one humeral stem loosening. Conclusions. An adapted therapeutic strategy can allow suppression of the responsible bacteria after infection of total elbow arthroplasty. Sometimes, several procedures are necessary to obtain the cure. Better functional results were obtained when the prosthesis could be retained or replaced, but satisfactory results could also be obtained after resection arthroplasty when the humeral columns have been preserved to stabilize the joint

Heterotopic Ossification (HO) is a known complication that can arise after total elbow arthroplasty (TEA). In most cases it is asymptomatic, however, in some patients it can limit range of motion and lead to poor outcomes. The objective of this review was to assess and report incidence, risk factors, prophylaxis, and management of HO after TEA. A systematic search was conducted using MEDLINE, EMBASE, and PubMed to retrieve all relevant studies evaluating occurrence of HO after TEA. The search was performed in duplicate and a quality assessment was performed of all included studies. A total of 1907 studies were retrieved of which 45 studies were included involving 2256 TEA patients. HO was radiographically present in 10% of patients and was symptomatic in 3%. Less than 1% of patients went on to surgical excision of HO, with outcomes following surgery reported as good or excellent as assessed by range of motion and Mayo Elbow Performance Scores (MEPS). TEA due to ankylosis, primary osteoarthritis, and posttraumatic arthritis are more likely to develop symptomatic HO. HO is an uncommon complication following TEA with the majority of patients developing HO being asymptomatic and requiring no surgical management. Routine HO prophylaxis for TEA is not supported by the literature. The effectiveness of prophylaxis in high risk patients is uncertain and future studies are required to clarify its usefulness. The strength of these conclusions are limited by inconsistent reporting in the available literature

The aim of this study was to assess the long-term results of the Kudo type-5 total elbow prosthesis and compare the results of two types of cemented ulnar components. The Kudo type-5 unlinked total elbow prosthesis (Biomet UK Ltd, Bridgend Wales) was developed in 1993. The stem of humeral component is porous-coated with a plasma spray of titanium alloy for cementless use. The ulnar component may be metal-backed with a porous-coated stem or polyethylene alone; the latter designed mainly for cement use. A metal-backed type without a porous-coated stem designed for cement use also came into being after 2003. Between 1993 and 2010, the Kudo type-5 total elbow arthroplasty was performed on 364 elbows in 274 consecutive patients with rheumatoid arthritis. The mean age of the patients at the time of the operation was 60.7 (27–86) years. Twenty elbows had Larsen grade III, 224 had grade IV, and 120 had grade V changes pre-operatively. Before the operation, 346 elbows had severe or moderate pain, 95 had gross valgus-varus instability. Clinical symptoms and revision rates were assessed 4 to 20 years (mean, 9 years) postoperatively. The mean Mayo elbow performance scores were all poor except for three initially (mean overall score, 39.5 points). The overall score had improved substantially both at the early follow-up (1 to 3 years after the operation) and the latest follow-up (4 to 20 years after the operation), with 89.5 and 84.7 points, respectively. At the latest follow-up the overall result was excellent for 185 elbows, good for 103, fair for 11 and poor for 30, with almost complete relief from pain for 298. The arc of movement had increased from a mean of 85.7 °pre-operatively to 95.1 ° post-operatively, and to 98.1 °at the latest follow-up. Spot welds around the humeral stem suggesting solid osseous integration were often seen in the elbows with cementless fixation of the porous humeral stem. At the latest follow-up, implants were removed due to infection in 3 elbows. Twenty-five elbows required ulnar component revision due to loosening of the all-polyethylene component. Two elbows required ulnar component revision due to loosening of the metal-backed component. Seven elbows required humeral component revision due to loosening of the humeral components. One elbow required revision due to dislocation. A survival analysis with revision or removal of one or both components as the end point was performed according to the Kaplan and Meier method. The overall survival rate of the prosthesis was 75.2% at 19 years. The survival of 87.0% in the metal-backed group was higher than the 74.3% in the all-polyethylene group. Loosening of the all-polyethylene ulnar component was the main reason for deterioration in the long-term outcome. We conclude that the long-term results of the Kudo type-5 total elbow arthroplasty is acceptable and cemented fixation of metal-backed ulnar component had better long-term survival than the all-polyethylene component

Implant designs for hip and knee arthroplasty have undergone a continual improvement process, but development of implants for total elbow arthroplasty (TEA) have lagged behind despite the marked mechanical burden placed on these implants. TEA is not as durable with failure rates approaching thirty percent at five years. The Coonrad-Morrey (Zimmer, Warsaw, IN), a linked design, remains the standard-bearer, employing polyethylene bushings through which a metal axle passes. A common failure mode is bushing wear and deformation, causing decreased joint function as the bushing-axle constraint decreases and osteolysis secondary to release of large volumes of wear debris. Improving upon this poor performance requires determining which factors most influence failure, so that failure can be avoided through design improvements. The approach integrates clinical observations of failed TEAs with implant retrieval analysis, followed by measurements of loads across the elbow for use in stress analyses to assess the performance of previous designs, and, finally, new design approaches to improve performance. Examination of the clinical failures of more than seventy Coonrad-Morrey TEAs revealed patterns of decreased constraint and stem loosening. Implant retrieval analysis from more than thirty of these cases showed excessive bushing deformation and wear and burnishing of the fixation stems consistent with varus moments across the joint. To determine loads across the elbow, motion analysis data were collected from eight TEA patients performing various activities of daily living. The kinematic data were input into a computational model to calculate contact forces on the total elbow replacement. The motion that produced the maximum contact force was a feeding motion with the humerus in 90° of abduction. For this motion, the joint reaction forces and moments at the point of maximum contact were determined from a computational model. We applied these loads to numerical models of the articulating bushings and axle of the Coonrad-Morrey to examine polyethylene strains as measures of damage and wear. Strain patterns in response to the large varus moment applied to the elbow during feeding activities showed extensive plastic deformation in the locations at which deformation and wear damage were observed in our retrieved implants (Fig. 1). Finally, we examined a new semi-constrained design concept intended to meet two goals: transfer contact loads away from the center of the joint, thus allowing contact to provide a larger internal moment to resist the large external varus moment; and reduce polyethylene strains by utilizing curved contacting surfaces on both the axle and the bushings (Fig. 2). After a sensitivity analysis to determine optimal dimensional choices (e.g., bushing and axle radii), we compared the resulting polyethylene strains between the Coonrad-Morrey and new design at locations that experienced the largest strains (Fig. 3). Substantial decreases were achieved, suggesting far less deformation and wear, which should relate to marked improvements in performance. Currently, we are incorporating this new design concept, along with alterations in stem design achieved from examination of load transfer at the fixation interfaces based on the same loading conditions, to achieve an implant system intended to improve the performance of TEA

Aim:. To investigate the incidence of post-operative ulna nerve symptoms in total elbow arthroplasty after full in-situ release. Methods:. A retrospective review was completed of the medical records of eighty-three consecutive primary total elbow arthroplasties (TEA) performed between 2003 and 2012. Data analysed included the presence of pre-operative ulnar nerve (UN) symptoms, history of prior UN transposition, intra-operative management of the UN and presence of post-operative symptoms. Results:. One patient had a prior UN transposition. The nerve was transposed at time of TEA in 4 of the 83 elbows (4.8%). The indication for transposition in all 4 cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. The remaining 78 TEA's all received a full in-situ release of the nerve. The incidence of post-operative UN symptoms in this group was 7.7% (6/78). Four neuropraxias resolved in the early post-operative period, whilst two patients (2.6%) continued to experience significant UN symptoms requiring subsequent transposition, at 6 weeks and 12 months post TEA. Conclusion:. A 2.6% incidence of significant post-operative UN symptoms compares favourably with systematic reviews in the literature (3–11% incidence of UN complications). We do not believe routine transposition, which adds to the handling of the nerve and increases total surgical time, is necessary, and should be reserved for cases where intra-operative assessment by the surgeon deems it necessary

Total elbow arthroplasty (TEA) usage is increasing owing to expanded surgical indications, better implant designs, and improved long-term survival. Correct humeral implant positioning has been shown to diminish stem loading in vitro, and radiographic loosening in in the long-term. Replication of the native elbow centre of rotation is thought to restore normal muscle moment arms and has been suggested to improve elbow strength and function. While much of the focus has been on humeral component positioning, little is known about the effect of positioning of the ulnar stem on post-operative range of motion and clinical outcomes. The purpose of this study is to determine the effect of the sagittal alignment and positioning of the humeral and ulnar components on the functional outcomes after TEA. Between 2003 and 2016, 173 semi-constrained TEAs (Wright-Tornier Latitude/Latitude EV, Memphis, TN, USA) were performed at our institution, and our preliminary analysis includes 46 elbows in 41 patients (39 female, 7 male). Patients were excluded if they had severe elbow deformity precluding reliable measurement, experienced a major complication related to an ipsilateral upper limb procedure, or underwent revision TEA. For each elbow, saggital alignment was compared pre- and post-operatively. A best fit circle of the trochlea and capitellum was drawn, with its centre representing the rotation axis. Ninety degree tangent lines from the intramedullary axes of the ulna and humerus, and from the olecranon tip to the centre of rotation were drawn and measured relative to the rotation axis, representing the ulna posterior offset, humerus offset, and ulna proximal offset, respectively. In addition, we measured the ulna stem angle (angle subtended by the implant and the intramedullary axis of the ulna), as well as radial neck offset (the length of a 90o tangent line from the intramedullary axis of the radial neck and the centre of rotation) in patients with retained or replaced radial heads. Our primary outcome measure was the quickDASH score recorded at the latest follow-up for each patient. Our secondary outcome measures were postoperative flexion, extension, pronation and supination measured at the same timepoints. Each variable was tested for linear correlation with the primary and secondary outcome measures using the Pearson two-tailed test. At an average follow-up of 6.8 years (range 2–14 years), there was a strong positive correlation between anterior radial neck offset and the quickDASH (r=0.60, p=0.001). There was also a weak negative correlation between the posterior offset of the ulnar component and the qDASH (r=0.39, p=0.031), and a moderate positive correlation between the change in humeral offset and elbow supination (r=0.41, p=0.044). The ulna proximal offset and ulna stem angle were not correlated with either the primary, or secondary outcome measures. When performing primary TEA with radial head retention, or replacement, care should be taken to ensure that the ulnar component is correctly positioned such that intramedullary axis of the radial neck lines up with the centre of elbow rotation, as this strongly correlates with better function and less pain after surgery

Background. The quest for the perfectly designed elbow prosthesis continues as instability and loosening remain the foremost reasons for the failure of total elbow replacement (TER). The Discovery® Elbow System (Biomet, UK) (Figure 1), which has been used in UK since 2003, is one of the latest generations of linked prosthesis. This system was designed to decrease polyethylene-bushing wear, improve anatomic stem design, restore elbow joint biomechanics, and produce a hinge that could be easily revised. This report describes the short term outcome of TER using the Discovery® Elbow System. Patients and Methods. A total of 60 TERs including 48 primary and 12 revisions were performed between 2003 and 2008. Patients included 21 males (37%) and 36 females (63%) with a mean age of 63 years. The indications for primary TER were advanced rheumatoid arthritis (n=19), osteoarthritis (n=16), post traumatic osteoarthritis (n=9), acute fractures (n=3), and haemophilic arthropathy (n=1). The outcome was assessed using pain score, Liverpool Elbow Score (LES), and range of movement during a mean follow-up of 26 months. Associated complications were documented. Radiological assessment included evaluation for loosening, instability and periprosthetic fractures. Results. The mean LES was significantly (p<0.001) improved from 3.8 (±1) pre-operatively to 6.9 (±2) at the final follow- up. Significant improvements were noted in elbow flexion from 100° (±22) to 120° (±15), supination from 41° (±28) to 65° (±20) and pronation from 52° (±22) to 72° (±18). There was no significant change in elbow extension. Mean improvement in flexion-extension and pronation-supination arc was 22° and 44°, respectively. 46 cases (77%) were completely pain-free at the final follow-up. The main complications included deep infection (4 cases – treated with staged revision TER), postoperative ulnar neuropathy (3 cases–treated with decompression), intra-operative fractures of medial condyle (3 cases – treated non-operatively with brace), and elbow haemarthrosis (1 case). Discussion. TER with Discovery® Elbow System resulted in either no pain or mild pain in 87% of cases. Patients undergoing Acclaim, Souter-Strathclyde, GSB III, and Coonrad-Morrey TER have been reported to have no/mild pain in 64%, 67%, 50–92% and 60–100% of cases, respectively. A 22° improvement in flexion-extension arc is comparable to that of Acclaim (23°), Souter-Strathclyde (15°), GSB III (19–33°), and Coonrad-Morrey (17–26°) TER. An improvement of 44° in pronation-supination arc in our series is also comparable to that of 31–67° reported for GSB III and higher than the Coonrad-Morrey prosthesis (21–28°). In terms of complications, an infection rate of 6.7% is consistent with those reported for GSB III TER (7–11%) and Coonrad-Morrey (6–8%). The incidence of persistent ulnar neuropathy was lower compared to GSB III TER (11–14%), Coonrad-Morrey (12–26%), and Acclaim (8%). While the survival of Discovery TER was 93%, the survival of GSB III (5–6 years) and Coonrad-Morrey (5 years) has been reported as 71–85% and 72–90%. The results indicate that Discovery® Elbow System is an effective device for total elbow arthroplasty in terms of functional improvement, pain relief and range of motion at short-term follow-up

Aim. To compare radiological and clinical outcomes between triceps-detaching and triceps-sparing approaches in total elbow arthroplasty, with specific focus on cementing technique and post-operative range of motion. Methods. A retrospective review was completed of medical records and radiographs of 56 consecutively managed patients who underwent a primary total elbow arthroplasty between 2000 and 2012 at a tertiary hospital. Rheumatoid Arthritis was the predominant pathology (47/56). Data analysed included patient demographics, range of motion pre-operatively and at various stages post-operatively, approach utilized, operative time and complications. Cementing technique was graded as adequate, marginal or inadequate according to Morrey's criteria. Results. 12 patients were lost to follow-up or had incomplete records, leaving 44 patients for analysis. 15 patients had a triceps-sparing approach, and 29 had a variation of a triceps-detaching approach. Average follow-up was 56.1 months. Flexion range of motion in the triceps-sparing group improved from 25°–122° (±19.6°) pre-op to 10°–140° (±22.5°) at final follow-up, and in the triceps-detaching group from 41°–104° (± 22.2°) pre-op to 27°–129° (±35.0°) at final follow-up. Tourniquet time averaged 85.4 (±17.0) minutes for the triceps-sparing group and 96.1 (±22.6) minutes for the triceps-detaching group. The complication rate in the triceps-sparing group was 13.3%, and included one olecranon fracture and one case of superficial wound sepsis. The complication rate for the triceps-detaching group was 24.1%, and included one patient with persistent ulnar nerve symptoms requiring transposition, one medial condyle fracture and five triceps ruptures. Three patients who had attempted repairs of the rupture developed deep infections requiring multiple further surgeries. Cementing technique was adequate in 91.7% in the triceps-sparing group and in 70.6% in the triceps-detaching group and marginal in the remainder of the cohort. Conclusion. A triceps-sparing approach results in a predictable improvement in range of motion with no compromise of the cement mantle. NO DISCLOSURES

Total Elbow Arthroplasty (TEA) is a procedure to treat a number of conditions including rheumatoid arthritis (RA), post-traumatic arthritis, and osteoarthritis. To date, there has been minimal literature published on the Latitude since its release in 2001. There is one study reporting outcomes from the Latitude, a German study published in 2010. The purpose of this study was to analyse outcomes from primary Latitude TEAs. We performed a retrospective case series of 23 TEAs performed on 20 patients. 6 patients required revision surgery and were not included in the analysis. One patient was lost to follow up, resulting in 17 patients included for ROM analysis. All patients received Latitude TEA through a posterior approach and underwent a standard rehab protocol. 11 Patients were recalled at least two years post-op and were administered DASH and MAYO questionnaires. Complications such as triceps insufficiency, ulnar nerve dysfunction, infection, and aseptic loosening were recorded. Outcomes were compared using the Wilcoxon Signed-Rank test in STATA. Immediate post-op radiographs and patients most recent radiographs were analysed by a blinded upper-extremity surgeon not involved in the initial operation and analysed for loosening and implant malpostioning. Mean follow up was 4.8 years (range 2.6–7.5 years). Analysis of 17 TEAs in 16 patients revealed no difference in pre-operative ROM and post-operative ROM for flexion (121°±20 vs 129°±16, p=0.13) extension (40°±27 vs 27°±15, p=0.19), pronation (73°±13 vs 75°±24, p=0.55) or supination (64°±22 vs 68°±14, p=0.52). Patients who underwent TEA for RA had a significant improvement in flexion (121°±15 vs 135°±10, p<0.02). There was a statistically significant improvement in flexion-extension arc post-operatively (101°±28) compared to pre-operative scores (83±23 degrees, p<0.02). DASH and MAYO scores were calculated from 11elbows in 11 non-revision patients able to return for examination. The average MAYO score was 87.9 with nine patients in the “excellent” category, two patients in the “good” category, one patient in the “fair” category, and one in the “poor” category. The average DASH score was 32.9. Two patients underwent revision for periprosthetic fractures, two patients underwent revision for infection, one underwent revision for aseptic loosening and two for radial head dissociation (rate of 30%). This is one of the first studies examining the outcomes of the Latitude TEA. This retrospective case series demonstrates that the Latitude TEA has promising outcomes with respect to improving patient pain and functioning as assessed by the MAYO. Treatment using the Latitude TEA results in favorable functional outcomes for a majority of patients and offers an improvement in flexion-extension arc. Furthermore, our results are comparable to the MAYO scores reported by other studies analysing different prosthesis designs. The complication rate in our series was comparable to published rates of 20–40%

Total elbow arthroplasty (TEA) has been shown to be a treatment option for elderly patients with complex distal humeral fractures and osteoporotic bone. The published results have often included rheumatoid patients who traditionally would be expected to do well from elbow arthroplasty. Only short-term results have been published using this technique in non-rheumatoid patients. The current study contains the largest number and longest follow-up of non-rheumatoid patients whose fractures have been treated with a non-custom TEA. In total there were 26 patients, mean age 72 years, 22 female and 4 male, 25% dominant arm. The mean follow-up was of 5 years. There was 1 case of loosening, 1 radial nerve palsy and 2 cases of heterotrophic ossification. At final review the mean range of flexion/extension was 97.5 degrees and the mean range of pronation/supination was 151.75 degrees. The mean Mayo Elbow Performance score was 92. We would suggest that TEA provides a very satisfactory outcome in elderly patients with complex distal humeral fractures, the benefit of which can be observed at a mean of 5 years

Introduction. Recently, computer-aided orthopaedic surgery has enabled three dimensional (3D) preoperative planning, navigation systems and patient matched instrument, and they provide good clinical results in total knee arthroplasty. However, the preoperative planning methods and the criteria in total elbow arthroplasty (TEA) still have not sufficiently established due to the uncertainty of 3D anatomical geometry of the elbow joints. In order to clarify the 3D anatomical geometry, this study measured 3D bone models of the normal elbow joints. Additionally this study attempted to apply the 3D preoperative planning to ordinary surgery. Then the postoperative position of implant has evaluated as compared with the position in 3D preoperative planning. Methods. Three dimensional bone measurements on 4 normal cases were performed. Three dimensional bone models were constructed with CT image using Bone Viewer®(ORTHREE Co., Ltd.). TEA was performed with FINE® Total Elbow System (Nakashima Medical Co., Ltd.) for 3 rheumatoid arthritis (RA) cases (Fig. 1). Three dimensional preoperative planning was based on this bone measurement, and postoperative position of implant were evaluated. The postoperative assessments were evaluated by superimposing preoperative planning image on postoperative CT image using Bone Simulator® (ORTHREE Co., Ltd.). This study only covers humeral part. Results. The results of 3D bone measurements on 4 normal cases shows the average internal rotation angle between the flexion-extension axis and the epicondyles axis in the distal humerus was 2.2 degrees. The average valgus tilt of the distal humerus was 3.7 degrees. Postoperative position of humeral component for 3 RA cases was installed at proximal and valgus position compared to the preoperative planning. Discussion. This study indicates that ordinary two dimensional criteria and 3D anatomical one in the elbow joint may be different in several bony landmarks such as rotation, varus and valgus. Additionally these results show the differences between postoperative position of implant and preoperative position in 3D planning. More studies need to be conducted to validate postoperative evaluation and preoperative planning

Purpose of study:. Total elbow replacement (TER) is one of the surgical options for treatment of severe haemophilic arthropathy of the elbow. There are only a few small series described in the literature. The goal of our study was to evaluate our cases and add these data to the known literature. Methods:. A retrospective analysis of a series of 8 TER's (5 patients) was performed. Patients were seen in clinic and evaluated by physical examination, a VAS score for pain, the Mayo Elbow Performance Score (MEPS, 100 points=excellent) and X-rays of the affected elbow. Mean follow-up was 91 (4–236) months, and 103 months when we excluded a patient with only 4 months follow-up. Primary diagnosis was Hemophilia type A in 4 and von Willebrand disease in 1 patient. 2 patients were positive for Hepatitis C and 3 for HIV. Mean age at primary surgery was 46.7 (31.8–63.1) years. Results:. The mean VAS score for pain improved from 7.9 to 0.5 and the mean Mayo Elbow Performance Score from 36 to 93. The arc for flexion/extension improved from 68° to 91° and from to 75° to 153° for pro- and supination. Revision surgery was performed in 3 out of 8 TER's; 1 because of loosening of the humeral component (18.7 years postop), 1 for loosening of the ulnar component (9.9 years postoperatively) and 1 due to a late deep infection, 4 years postoperatively. The last case was treated with an excision arthroplasty, the others with a revision. No replacement currently shows signs of loosening. Conclusion:. This is a small retrospective study, as are the other studies on TER in haemophilic patients. It demonstrated excellent clinical outcome and an acceptable survival rate of a TER, with a mean follow-up of 7.6 years even in this young patient population

Background. Previously, the Coonrad-Morrey elbow system has typically been performed using linked-type total elbow arthroplasty (TEA) implants. However, this implant have been reported to be associated with some problems, such as wearing down, loosening, the complexity of the necessary surgical techniques and inappropriate implant size for Asian people. The Discovery elbow system (Biomet Inc., Warsaw, US) has recently been developed and it has many advantages when compared to Coonrad-Morrey implant, but the treatment outcome for this system is unclear in patients with rheumatoid arthritis (RA). Objectives. The aim of this study was to clarify the outcome of TEA using the Discovery elbow system. Methods. Eleven RA patients (13 elbows) who underwent TEA using the Discovery elbow system were investigated in this study. Two patients (3 elbows) were males, and 9 patients (10 elbows) were females. Ten were right elbows, and 3 were left elbows. Two elbows has Larsen grade “disease, 7 had grade” disease and 4 elbows underwent revision surgery. The surgical approach used for all cases was Campbell's posterior approach. The Discovery elbow system was installed using cemented fixation. Two weeks after the operation, ROM exercise was started. The elbow ROM, Mayo elbow performance score (MEPS), and any complications observed at baseline, 6 months and 24 months after surgery were assessed. Results. The preoperative elbow ROM (mean±SD) was −33.4±4.4° in extension, 133.5±3.4° in flexion, 48.5±8.4° pronation and 67.7±5.7° in supination. The postoperative elbow ROM (mean±SD) was −18.5±6.2° in extension, 112.7±6.1° in flexion, 70.0±3.4° in pronation and 73.7±1.6° in supination. As a result, a significant improvement was observed in extension, flexion and pronation. The MEPS improved significantly at 6 months and 24 months after surgery. In addition, no implant loosening was found or revision surgery was required at 24 months after surgery. Conclusions. In this study, the elbow function was observed to significantly improve by TEA using the Discovery elbow system based on the short-time outcome. However, further study is still needed to clarify the long-term outcome of this implant in RA patients

INTRODUCTION. Aseptic loosening is the most common failure mode for Total Elbow Arthroplasty (TEA) and is considered to be associated with accelerated polyethylene bearing wear [1, 2]. This study aimed to evaluate three commercially available implant designs under loads associated with daily living. The hypothesis was that more recent designs (Discovery and Nexel) provide greater articular contact areas resulting in lower polyethylene stresses compared to the Coonrad/Morrey (CM). METHODS. Motion tracking was performed on a healthy volunteer during elbow flexion at 0, 45, and 90° shoulder abduction because most daily activities occur with some shoulder abduction [3] resulting in varus stress about the elbow. This kinematic data was used in an OpenSim upper extremity musculoskeletal model [4] to estimate muscle and joint reaction loads with 5lb in hand, consistent with the common clinical restrictions following TEA. Computer aided assemblies of the smallest size implants for each system were imported to ANSYS for finite element analysis. Metallic components were treated as rigid and polyethylene components were modeled using a nonlinear elastoplastic constitutive model calibrated to material data. Articular contacts were frictional. Physiologic joint reaction forces and moments quantified in OpenSim were applied and the resulting peak articular contact area and peak bearing von Mises stresses were assessed. RESULTS. Simulated deformation patterns of CM bearings corresponded well to those reported in retrievals studies [1, 2] supporting the clinical relevance of the modeling approach. Peak stresses for CM and Nexel were consistently found in the central and side bearings respectively. The central bearing stresses remained 2–2.6 times lower in Nexel compared to CM. Peak stress for all three TEA systems increased with shoulder abduction (Fig.1, 2). Highest peak stresses (Fig.2) were obtained in CM and consistently exceeded the polyethylene yield limit; CM showed the lowest contact area (Fig.3). Nexel and Discovery experienced peak polyethylene stresses 26–34% and 17–39% lower than CM respectively (Fig.2). DISCUSSION. Our results support the hypothesis that newer TEA systems provide increased articular contact area and reduced bearing stresses during physiological loading. The cylindrical CM central bearing carries both the joint reaction force and moment leading to edge loading and high stresses (Fig.1). The design of the Nexel central bearing provides limited resistance to varus-valgus moment, thus transferring the moment to the side bearings and reducing central bearing stresses. The hemispherical Discovery bearing design was confirmed to offer a large articular contact area. However, non-concentricity of the contact spheres can lead to edge loading and high polyethylene stresses under off-axis forces. CM and Discovery utilize conventional polyethylene, whereas Nexel utilizes highly cross-linked Vitamin-E polyethylene. This study does not account for the increased wear resistance of Vitamin-E as compared to conventional polyethylene [5]. Long term clinical data are needed to demonstrate how these wear properties, as well as the geometric design which has been shown to impact stresses and contact patterns, translate to in vivo performance. For figures, please contact authors directly

Objective. Computed tomography based three-dimensional surgical preoperative planning (3D-planning) has been expanded to achieve more precise placement of knee and hip arthroplasties. However, few reports have addressed the utility of 3D-planning for the total elbow arthroplasty (TEA). The purpose of this study was to assess the reliability and precision of 3D planning in unlinked TEA. Methods. Between April 2012 and April 2014, 17 joints in 17 patients (male 4, female 13) were included in this study. Sixteen patients were rheumatoid arthritis and one was osteoarthritis and the average age at the time of the procedure was 61 years (range 28–88). Unlinked K-NOW total elbow system (Teijin-Nakashima Medical. Co. Ltd.) was used in all cases and 3D planning was performed by Zed View (Lexi.Co.). After the appropriate size and position of the prosthesis were decided on the 3D images [Figure 1], the position of the bone tunnel made for the insertion of humeral and ulnar stem was recorded on axial, sagittal, and coronal plane (4 point measurements for humerus, and 6 points for ulna, See Figure 2). After the elbow was exposed via a posterior approach, bone resection and reaming was performed according to the 3D planning. The surgeon took an appropriate adjustment to align the prosthesis properly during the surgery. The final position of the stem insertion was recorded immediately prior to set the prostheses. We analyzed the accuracy of stem size prediction, the correlation between preoperative and final measurements, and postoperative complications. Results. The sizes of humeral stems and ulnar stems were estimated exactly in 70% (12/17) and 94 % (16/17) of all cases, respectively. All of the stem sizes were estimated accurately within one size. There was a strong correlation between the preoperative measurements around stem insertion and final position of the humerus with the correlation coefficient of 0.96–0.99, whereas the correlation was varied widely 0.48–0.97 for the ulna stem. The mean error in 3D orientation of the stem position was 0.56 mm for the humeral stem and 1.03 mm for the ulnar stem. There were no technical difficulties related to use of 3D-planning and the prostheses were properly placed in 16 cases, however posterior penetration of the ulnar stem occurred in 1 case. Conclusion. This study demonstrated the reliability and precision of preoperative 3D planning for unlinked TEA. Proper positioning of the prosthesis is extremely important to prevent maltracking and instability since postoperative instability has been a major complication of the unlinked TEA. This technique will potentially reduce the postoperative complications

Background. Total elbow arthroplasty (TEA) has become an established procedure in the treatment of patients with rheumatoid arthritis (RA). However, there is little information on whether limited extension of the elbow affects clinical outcome scores after TEA and what causes the limited extension. Methods. We retrospectively analyzed fifty-four cases of primary TEA in patients with RA. There were seven men and thirty-nine women with a mean age of 63.6 years (range, thirty to eighty years). Thirty-seven of Coonrad-Morrey and seventeen of Discovery prostheses were used. The mean length of follow-up was 7.1 ± 4.0 years (range 2.0–14.6 years). Mayo Elbow Performing Score (MEPS) and radiological measurements were recorded. Anteroposterior and lateral radiographs were assessed before and after the operation and at the latest follow-up. Widening of the joint space was calculated by subtracting the length measured on the postoperative radiograph from that on the preoperative radiograph. Results. MEPS was significantly improved after surgery (51.2 to 91.1), especially in the domains of pain (18.6 to 43.1), stability (5.9 to 10) and daily function (10.7 to 21.0). Range of motion was significantly improved, in flexion (111.3° to 140.6°), pronation (62.1° to 72.3°), and supination (60.2° to 72.3°), but not in extension (30.0° to 28.8°). Simple and multivariate analyses showed that longer disease duration (p = 0.004), higher Larsen grade (p = 0.013), worse pronation/supination arc (p = 0.004) and worse postoperative extension (p = 0.033), but not postoperative flexion (p = 0.532), were significantly correlated with lower MEPS daily function. Conversely, simple and multivariate analyses showed that worse postoperative extension was correlated with lower MEPS daily function (p = 0.005) and worse preoperative extension (p < 0.001). Radiological analyses showed that, in the limited extension group (≧40°), the degree of extension was correlated with radiological widening of the joint. Conclusions. In linked TEA, perioperative widening of the elbow joint caused limited extension and worse daily function in patients with RA

Introduction

The aim of this study is to analyse the effect of the degree of coverage of the Total Elbow implant with cement and the significance of cementation index as a predictor of failure.