A review of the New Zealand National Joint Registry to evaluate the survivorship and revision rates of Nexel and Coonrad-Morrey total elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty (TEA) is an appropriate surgical treatment option for a variety of conditions ranging from inflammatory arthritis to trauma. Because of a high complication profile, implant companies have attempted to improve patient outcomes with evolving design mechanics and philosophy. However, the Nexel TEA prosthesis has been criticized for its unacceptably high revision rate by other research groups in the literature. The purpose of this study was to evaluate the survivorship and revision rates of the Nexel and Coonrad-Morrey TEA implant systems in New Zealand. METHODS: Prospectively collected National Joint Registry data were used to compare the survival rates of these prostheses. Underlying diagnoses, reasons for revision, and patient demographics were all recorded. Statistical analysis included survival analysis using Kaplan-Meier curves and comparison between groups using independent t tests. RESULTS: Over the 23-year study interval, the Nexel and Coonrad-Morrey prostheses showed similar survivorship and revision rates. The revision rates at 5 years were 7.3% for Nexel and 4.5% for the Coonrad-Morrey cohorts. The average time to revision for those who are revised was 3.13 ± 1.74 years in the Nexel group and 4.93 ± 4.13 years in the Coonrad-Morrey population. CONCLUSION: Our study confirms a lower revision rate of the Nexel TEA compared to other studies in the literature. Additionally, the Nexel TEA implant performs comparably to its predecessor, the Coonrad-Morrey prosthesis in New Zealand. Although it is difficult to explain the discrepancy in results with the study by Morrey et al, future studies should focus on investigating postoperative radiographs and a deep analysis of the specific surgical technique used for this implant.

Midterm follow-up of the Nexel total elbow arthroplasty.

BACKGROUND: Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at midterm follow-up. METHODS: Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3-year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via the Wrightington method by 3 independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Patient-Rated Elbow Evaluation (PREE), and EuroQoL-5 Dimensions (EQ-5D). RESULTS: Thirty-eight consecutive patients (22 female, 16 male) with a mean age of 67 years underwent TEA via a triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were as follows: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), and 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with 1 patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across 3 observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QuickDASH, PREE, and EQ-5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs. CONCLUSION: At midterm follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preoperative to final postoperative follow-up. Although promising, these results should be interpreted with some caution as long-term data regarding this prosthesis are still lacking.

Valgus instability and related factors beyond 2 years following unlinked total elbow arthroplasty.

HYPOTHESIS AND BACKGROUND: Total elbow arthroplasty (TEA), categorized into linked and unlinked types, is a commonly reported treatment for rheumatoid arthritis of the elbow. Although unlinked TEA preserves bone, it may result in instability. This study aimed to assess the outcomes of unlinked TEA in rheumatoid arthritis of the elbow beyond 2 years and to identify factors correlating with postoperative valgus instability of unlinked TEA. METHODS: This study included patients who underwent TEA for rheumatoid arthritis of the elbow at our department between August 2009 and January 2017, with a follow-up period exceeding 2 years. Elbow joint range of motion (ROM) and clinical scores were evaluated preoperatively and at the final follow-up. Factors contributing to valgus instability, such as the Larsen grade, sex, age, side, preoperative ROM, postoperative ROM, implant placement, preoperative carrying angle, and the use of biological disease-modifying antirheumatic drugs (bDMARDs), were also assessed. RESULTS: This study encompassed 26 elbows from 23 patients, with a mean patient age at surgery of 64.8 years and a mean follow-up duration of 92.4 months. Significant improvements were observed in the ROM (extension: from -31° preoperatively to -21° postoperatively [P = .02], flexion: from 116° to137° [P < .001]), Japanese Orthopaedic Association-Japan Elbow Society Elbow Function Score (from 45.9 to 86.3 points [P < .001]), and Mayo Elbow Performance Score (from 43.6 to 91.7 points [P < .001]). At the last follow-up, 2 elbows exhibited radiolucent lines around the humeral stem, whereas 7 had valgus instability. Factors correlated with valgus instability included total arc at the final follow-up, preoperative carrying angle, and the use of bDMARDs. DISCUSSION AND CONCLUSION: Unlinked TEA demonstrated favorable midterm outcomes for rheumatoid arthritis of the elbow, albeit with occasional valgus instability. Surgeons should consider preoperative carrying angle and bDMARD use, and exercise caution regarding intraoperative extensions.

Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial.

BACKGROUND: Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients. MATERIAL AND METHODS: This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60 years and independent living. The final follow-up took place after ≥2 years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength. RESULTS: Forty patients were randomized to TEA (n = 20) and EHA (n = 20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P = .30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P = .39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P = .59), EQ-5D index (0.92 vs. 0.86, P = .13), extension (29° vs. 29°, P = .98), flexion (126° vs. 136°, P = .05), arc of flexion-extension (97° vs. 107°, P = .25), supination (81° vs. 75°, P = .13), pronation (78° vs. 74°, P = .16) or grip strength (17.5 kg vs. 17.2 kg, P = .89). There were 6 adverse events in each treatment group. CONCLUSION: In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2 years of follow-up.

Does timing of total elbow arthroplasty after distal humerus fracture affect 2-year complication rates?

BACKGROUND: Open reduction and internal fixation (ORIF) remains the gold standard for adult distal humerus fractures (DHF). However, indications for total elbow arthroplasty (TEA) continue to expand and the incidence of primary and salvage TEA for DHF has increased. The objective of this study was to compare complication and reoperation rate for acute vs. delayed primary and salvage TEA performed for DHF. METHODS: Patients who underwent TEA for DHF were identified in the PearlDiver database. Patients were sorted into 3 cohorts: (1) acute TEA (within 2 weeks of diagnosis), (2) delayed TEA (between 2 weeks and 6 months after diagnosis), and (3) salvage TEA (after failed ORIF, malunion, nonunion, delayed treatment between 6 months and 1 year or post-traumatic arthritis). Multivariate analysis was used to assess for confounding variables and covariates when identifying differences in complications between cohorts. RESULTS: A total of 788 patients underwent acute TEA, 213 patients underwent delayed TEA, and 422 patients underwent salvage TEA after DHF. The incidence of periprosthetic joint infection (PJI) (8.5% vs. 3.4%, odds ratio [OR] 2.60, P = .002) and triceps injury (2.4% vs. 0.4%, OR 6.29, P = .012) were higher in the delayed compared to acute cohort. The incidence of revision (8.5% vs. 2.1%, OR 3.76, P < 0.001), periprosthetic fracture (4.3% vs. 1.1%, OR 3.64, P = .002), PJI (14.7% vs 3.4%, OR 4.36, P < .001), triceps injury (2.6% vs. 0.4%, OR 5.70, P = .008), and wound complications (6.9% vs 2.9%, OR 2.33, P = .002) were higher in the salvage compared to acute cohort. There was an increased rate of revision (8.5% vs. 1.9%, OR 6.08, P = .002) in the salvage compared to delayed cohort. CONCLUSION: Patients undergoing salvage TEA after DHF have increased rates of revision, periprosthetic fracture, PJI, triceps injury, and wound complications at 2 years post-operatively. The salvage cohort also had an increased risk of revision when compared to the delayed cohort. However, other than revision rates, patients in the salvage and delayed cohorts have similar postoperative complication rates.

Do ChatGPT and Google differ in answers to commonly asked patient questions regarding total shoulder and total elbow arthroplasty?

BACKGROUND: Artificial intelligence (AI) and large language models (LLMs) offer a new potential resource for patient education. The answers by Chat Generative Pre-Trained Transformer (ChatGPT), a LLM AI text bot, to frequently asked questions (FAQs) were compared to answers provided by a contemporary Google search to determine the reliability of information provided by these sources for patient education in upper extremity arthroplasty. METHODS: "Total shoulder arthroplasty" (TSA) and "total elbow arthroplasty" (TEA) were entered into Google Search and ChatGPT 3.0 to determine the ten most FAQs. On Google, the FAQs were obtained through the "people also ask" section, while ChatGPT was asked to provide the ten most FAQs. Each question, answer, and reference(s) cited were recorded. A modified version of the Rothwell system was used to categorize questions into 10 subtopics: special activities, timeline of recovery, restrictions, technical details, cost, indications/management, risks and complications, pain, longevity, and evaluation of surgery. Each reference was categorized into the following groups: commercial, academic, medical practice, single surgeon personal, or social media. Questions for TSA and TEA were combined for analysis and compared between Google and ChatGPT with a 2 sample Z-test for proportions. RESULTS: Overall, most questions were related to procedural indications or management (17.5%). There were no significant differences between Google and ChatGPT between question categories. The majority of references were from academic websites (65%). ChatGPT produced a greater number of academic references compared to Google (80% vs. 50%; P = .047), while Google more commonly provided medical practice references (25% vs. 0%; P = .017). CONCLUSION: In conjunction with patient-physician discussions, AI LLMs may provide a reliable resource for patients. By providing information based on academic references, these tools have the potential to improve health literacy and improved shared decision making for patients searching for information about TSA and TEA. CLINICAL SIGNIFICANCE: With the rising prevalence of AI programs, it is essential to understand how these applications affect patient education in medicine.

Outcomes of total elbow arthroplasty in the treatment of distal humeral fractures in the elderly: a retrospective cohort comparison between primary arthroplasty and arthroplasty secondary to failed internal fixation.

BACKGROUND: The primary objective of this study was to compare the clinical outcomes of total elbow arthroplasty as the index procedure in the treatment of traumatic distal humerus fractures with those of secondary total elbow arthroplasty after failed internal fixation. The secondary objective was to compare the complication rates and the radiographic results in the 2 groups. Our hypothesis was that the clinical results of total elbow arthroplasty performed after failed internal fixation were comparable to those of primary total elbow arthroplasty in the treatment of distal humerus fractures in the elderly population. METHODS: We conducted a retrospective cohort comparison study, including 60 patients with a median age of 80 years (71-85 years), who either underwent a primary total elbow arthroplasty (group 1; 45 patients) or secondary total elbow arthroplasty after failed internal fixation (group 2; 15 patients) in the treatment of a post-traumatic supra and intercondylar fracture of the distal humerus, between January 2004 and January 2021. The clinical examination, including the Mayo Elbow Performance Score and triceps proficiency test, complication rates, and the need for reoperation were noted. The average clinical and radiographic follow-up was 40.8 months (24-120 months). RESULTS: The clinical results of the 2 groups were comparable when looking at the Mayo Elbow Performance Score (90.00 [85.00, 100.00], P = .486). With regard to complications, there were 2 surgical site infections in group 1 and 3 in group 2 (P = .099), 1 case of mechanical loosening of the humeral component in group 1 and 1 in group 2 (P = .448), and 1 patient with triceps insufficiency in group 1. CONCLUSIONS: Secondary total elbow arthroplasty after failed internal fixation has shown good functional results and a complication rate comparable to that of index total elbow arthroplasty in the treatment of articular fractures of the distal humerus in the elderly.

High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience.

BACKGROUND: Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. METHODS: We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined. RESULTS: Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179). CONCLUSION: Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.

Non-cefazolin antibiotic prophylaxis is associated with higher rates of elbow periprosthetic joint infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a common source of failure following elbow arthroplasty. Perioperative prophylactic antibiotics are considered standard of care. However, there are no data regarding the comparative efficacy of various antibiotics in the prevention of PJI for elbow arthroplasty. Previous studies in shoulder, hip, and knee arthroplasty have demonstrated higher rates of PJI with administration of non-cefazolin antibiotics. The elbow has higher rates of PJI than other joints. Therefore, this study evaluated whether perioperative antibiotic choice affects rates of PJI in elbow arthroplasty. MATERIALS AND METHODS: A single-institution, prospectively collected total joint registry database was queried to identify patients who underwent primary elbow arthroplasty between 2003 and 2021. Elbows with known infection prior to arthroplasty (25) and procedures with incomplete perioperative antibiotic data (7) were excluded, for a final sample size of 603 total elbow arthroplasties and 19 distal humerus hemiarthroplasties. Cefazolin was administered in 561 elbows (90%) and non-cefazolin antibiotics including vancomycin (32 elbows, 5%), clindamycin (27 elbows, 4%), and piperacillin/tazobactam (2 elbows, 0.3%) were administered in the remaining 61 elbows (10%). Univariate and multivariate analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Infection-free survivorship was estimated using the Kaplan-Meier method. RESULTS: Deep infection occurred in 47 elbows (7.5%), and 16 elbows (2.5%) were diagnosed with superficial infections. Univariate analysis demonstrated that patients receiving non-cefazolin alternatives were at significantly higher risk for any infection (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.4-5.0; P < .01) and deep infection (HR 2.7, 95% CI 1.3-5.5; P < .01) compared with cefazolin administration. Multivariable analysis, controlling for several independent predictors of PJI (tobacco use, male sex, surgical indication other than osteoarthritis, and American Society of Anesthesiologists score), showed that non-cefazolin administration had a higher risk for any infection (HR 2.8, 95% CI 1.4-5.3; P < .01) and deep infection (HR 2.9, 95% CI 1.3-6.3; P < .01). Survivorship free of infection was significantly higher at all time points for the cefazolin cohort. DISCUSSION: In primary elbow arthroplasty, cefazolin administration was associated with significantly lower rates of PJI compared to non-cefazolin antibiotics, even in patients with a greater number of prior surgeries, which is known to increase the risk of PJI. For patients with penicillin or cephalosporin allergies, preoperative allergy testing or a cefazolin test dose should be considered before administering non-cefazolin alternatives.

Long-term outcomes of Kudo type-5 unlinked surface-replacing total elbow arthroplasty for rheumatoid arthritis: a 15-year average follow-up study.

BACKGROUND: Total elbow arthroplasty (TEA) has been used for various conditions including rheumatoid arthritis (RA). While the Kudo TEA has been associated with favorable short-term outcomes, there is limited information on the longer term outcomes of this device. The aim of this study was to investigate the average 15-year outcome of Kudo type-5 TEA in patients with RA. METHODS: For this retrospective cohort study, we reviewed 29 elbows in 28 patients (Larsen grade III, n = 8; IV, n = 19; V, n = 2) with RA who underwent Kudo type-5 TEA between 1999 and 2010. The patients were followed up for a mean of 15 (range: 10-21) years. We investigated the survival with setting revision/removal as the endpoints. The risk factors for revision/loosening were assessed. RESULTS: There was a significant improvement in elbow flexion after Kudo TEA. Preoperative and postoperative Mayo Elbow Performance Score improved significantly from 60.3 to 94.7. Complications included intraoperative medial humeral epicondyle fracture (n = 2), postoperative dislocations (n = 4), deep infections (n = 1), and persistent ulnar nerve neuropathy (n = 1). Aseptic loosening was observed in 7 elbows (24.1%; humerus, n = 3; ulna, n = 3; both sides, n = 1). The causes of the 5 revisions were postoperative dislocation (n = 1), deep infection (n = 1), aseptic loosening of the humerus (n = 2), and aseptic loosening of the ulna (n = 1). All 5 elbows underwent revision of the ulnar component (n = 2) or the linked TEA (n = 3). The survival rate was 81% at 15 years after surgery with setting revision/removal as the endpoints. A deviation of ulnar component insertion angle of over 5° in any plane was associated with more revision compared to those with accurately placed implants. CONCLUSION: The Kudo type-5 elbow showed good results for up to 15 years of follow-up. However, excessive deviation of insertion angle of the ulnar component (over 5°) was associated with more revision. Due to the small sample size, robust statistical analysis of risk factors for postoperative complications or revision could not be performed, and further research is warranted to resolve this limitation.

Failure of the linkage mechanism in a semi-constrained total elbow arthroplasty is a rare and unpredictable event: a review of seven cases.

PURPOSE: Linked component of total elbow arthroplasty (TEA) consisted of bushing and locking pins. Failure of linked components is a rare complication of TEA. This study aims to investigate the mechanism and consequence of failure of the linkage mechanism in TEA surgeries. METHODS: Between 2010 and 2021, five patients received revision operation due to linked component failure. Besides, two patients underwent primary operation at another institute were also analyzed due to failure of the linkage mechanism. RESULTS: All seven patients underwent primary TEA and mean age for primary TEA was 48 (range, 27-62). Two patients had TEA for post-traumatic arthritis, three patients for rheumatoid arthritis, and two patients for comminuted distal humerus fracture. The average time between primary TEA and revision TEA for linked component failure was 13.6 years. Three bushing wear and four locking pin dissociation were diagnosed according to pre-operative radiography. Elbow pain and swelling are the most common clinical symptoms. Severe osteolysis, periprosthetic fracture, and stem loosening were noted in three bushing wear cases. In four dissociation of locking pin cases, breakage of male locking pin phalanges was demonstrated in two patients. For revision procedures, both the locking pins and bushings were replaced. No patients in the study required additional surgery after the revision operation for linked component failure. CONCLUSION: Osteolysis, component loosening, periprosthetic fracture may be expected after linked component failure. Patients should be regularly followed up from short-term to long-term with radiography. Early diagnosis and intervention with linked component exchange can prevent extensive revision surgery.

The Risk of Early Postoperative Complications Associated With Preoperative Immunosuppression in Patients Undergoing Total Elbow Arthroplasty.

PURPOSE: Patients considering total elbow arthroplasty (TEA) may be receiving immunosuppressive therapy; however, the relationship between immunosuppressive medications and postoperative complications is not well defined. Our purpose was to assess the relationship between preoperative immunosuppression and short-term complications following TEA. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2005 to 2020 to identify patients undergoing TEA. Procedures indicated for malignancy or infection were excluded. Patients were grouped according to preoperative chronic immunosuppressive status. Demographic and operative characteristics were compared between groups. The 30-day incidence of complications and reoperations were compared between groups. Multiple logistic regression models, inverse-weighted by propensity scores, were used to calculate odds ratio (OR) of experiencing any complication or return to the operating room based on immunosuppression status and other demographic characteristics. RESULTS: A total of 769 patients undergoing TEA were included, of whom 142 (18.5%) received chronic immunosuppression. Distribution of age, sex, race, body mass index, diabetes, and American Society of Anesthesiologists classification differed significantly between groups. Most procedures were performed on an inpatient basis, and the median operative duration was 148 minutes. Most procedures were indicated for fracture in the nonimmunosuppressed group and rheumatoid arthritis in the immunosuppressed group. Overall complication rates were 7.0% for immunosuppressed patients and 10.2% for nonimmunosuppressed patients. The incidence of complications and reoperations did not significantly differ between groups. After controlling for confounding and adjusting for patient characteristics, immunosuppressed patients were 0.52 times less likely to experience a complication. Additionally, there was no association between immunosuppression status and odds of return to the operating room. CONCLUSION: Similar rates of complications were observed following TEA, regardless of preoperative immunosuppression status. Chronic immunosuppression does not appear to increase the rates of postoperative complications for patients undergoing TEA. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Complications of Early Versus Delayed Total Elbow Arthroplasty for the Treatment of Distal Humerus Fractures.

PURPOSE: The purpose of this study was to compare the rates of wound complications and heterotopic ossification (HO) between patients who underwent acute total elbow arthroplasty (TEA) and those who underwent delayed TEA performed for the treatment of distal humerus fractures. Our hypothesis was that delayed surgery will have fewer wound complications but a higher rate of HO. METHODS: We retrospectively reviewed 104 patients who had undergone TEA performed at 1 of 3 institutions following a distal humerus fracture. The acute cohort, comprising 69 patients, underwent TEA within 2 weeks; the delayed cohort, comprising 35 patients, received treatment between 2 weeks and 6 months. The rates of wound complications, HO, clinically relevant HO (requiring excision or resulting in loss of functional range of motion), and reoperation were recorded. These patients were followed up for an average of 52 (interquartile range, 18.5-117) weeks. RESULTS: Wound complications occurred in 10 patients (14.5%) in the early group and 7 (20.0%) in the delayed group. The overall rate of HO was 56.7% (59 patients). The rate of clinically relevant HO was 26.0% (27 patients), which was similar between the groups. Reoperation occurred in 20 patients (19.2%), which was similar between the groups. In the early group, 3 reoperations were performed for wound complications and 4 for HO. No patients required reoperation for these indications in the delayed group. The mean flexion-extension and supination-pronation arcs were 20°-130° and 80°-80°, respectively, which were similar between the groups. Rheumatoid arthritis and younger age were associated with increased odds of wound complications and reoperation. CONCLUSIONS: The rates of reoperation, wound complications, and HO were overall higher than those previously reported; however, the study was underpowered to determine a difference between early and delayed treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Controversies in the Management of Bicolumnar Fractures of the Distal Humerus.

Bicolumnar fractures of the distal humerus pose numerous treatment challenges for upper-extremity surgeons. Although open reduction and internal fixation demonstrates advantages compared with nonsurgical treatment, restoration of osseous anatomy can be difficult, particularly for comminuted, intra-articular fractures. Despite well-recognized complications, total elbow arthroplasty remains an option for elderly patients with fractures not amenable to fixation. Although indications remain controversial, distal humerus hemiarthroplasty has emerged as a potential alternative to total elbow arthroplasty in carefully selected patients with nonreconstructable fractures. Numerous controversies remain with respect to the management decisions for these complex injuries, including the optimal surgical approach, management of the ulnar nerve, and ideal fixation constructs for open reduction internal fixation. Our purpose is to review the management of bicolumnar distal humerus fractures in adult patients and discuss current controversies related to treatment.

Elbow Arthritis.

Elbow arthritis is an uncommon condition that can cause debilitating pain, stiffness, or instability. The most common etiologies include rheumatoid arthritis, posttraumatic arthritis, and primary osteoarthritis. Treatment begins with nonsurgical modalities, including activity modification, anti-inflammatories, hand therapy, and corticosteroids. Operative intervention may be considered once nonsurgical management has failed. Surgical treatment depends on the underlying etiology, chief complaint, patient age, and functional demand. Advances in technology, especially arthroscopic techniques, have expanded the treatment options available to surgeons. The goals of treatment include pain relief and restoration of functional range of motion. The purpose of this article is to review the pertinent soft tissue and osseous anatomy, discuss the etiologies, review the principles of diagnosis and evaluation, and finally, study the treatment options for elbow arthritis.

Biomechanical Evaluation of 2 Common Approaches for Total Elbow Arthroplasty: Triceps Tongue Compared With Triceps Reflecting.

PURPOSE: We hypothesize that the triceps tongue approach will be equivalent in strength to the triceps reflecting approach in load to failure following a cyclic preload. METHODS: Seven paired fresh-frozen cadaveric arms were dissected using the triceps reflecting approach or triceps tongue approach to the posterior elbow. The triceps was then repaired in each specimen, and the elbows were placed in a testing jig. Elbows were preloaded in a cyclic fashion at 5 lbs (2.3 kgf) for 200 cycles in flexion/extension, followed by load to failure. The stiffness and ultimate failure strength for each specimen were determined. We defined ultimate failure as gapping in the suture construct of 4 mm or suture breakage. RESULTS: One of the triceps tongue specimens was excluded due to a testing error, resulting in 6 elbows in this group. There were no tendon repair failures during the cyclic preload. The median ultimate failure of the reflecting group occurred at 65 pounds, compared to 115 pounds in the tongue group. This was significantly different. The reflecting approach consistently failed along the entire bone-tendon interface. The tongue approach failed at the proximal repair site in 4 of 6 specimens, while the longitudinal aspect of the tendon repair remained intact. CONCLUSIONS: Following a cyclic preload of 5 lbs for 200 cycles, the triceps tongue repair is stronger than triceps reflecting in ultimate failure. The mode of failure of triceps tongue repair may be superior to that of triceps reflecting. CLINICAL RELEVANCE: This study may help guide surgeons when choosing a "triceps off" approach to total elbow arthroplasty.

Demographic heterogeneity in valgus angulation of the proximal ulnar canal in relation to the flexion-extension axis.

BACKGROUND: The long-term outcome of total elbow arthroplasty remains unsatisfactory because of loosening and polyethylene wear, which could be caused by malpositioning of the ulnar component. When introducing an ulnar component, 2 different angles should be considered in the coronal plane: the valgus angulation of the proximal ulna in relation to the flexion-extension axis (FE-axis) and the intramedullary varus angulation in relation to the FE-axis. Currently, available TEA designs may not always be able to reconstruct the FE-axis because of the morphologic variability of the ulna. HYPOTHESIS: This study aimed to determine the demographic variability of the ulna and the relation between the 2 angulations in the frontal plane based on 3-dimentional computed tomography (CT) reconstructions of the elbow joint of healthy volunteers. METHODS: Computed tomography scans of 36 left elbows of healthy volunteers were obtained (20 men and 16 women). The scans were segmented and analyzed using the Mimics Research 20.0 software. A local coordinate system was created based on the FE-axis of the elbow and the ulna's longitudinal axis. The measurements were conducted using the 3-Matic Research 12.0 software. RESULTS: The valgus angulation of the proximal medullary canal was on average 16° in men but 12° in women and ranged between 5° and 21°. The varus angulation of the medullary cavity could be determined at 57 mm in men and 64 mm in women from the FE-axis. This angulation was on average 10° in men and 7° in women. There was no significant correlation between this angle and the length of the ulna or the point of varus angulation. CONCLUSION: This study found a wide range of valgus angulation of the proximal ulnar canal in relation to the FE-axis. The available elbow implant designs are discordant with the mean valgus angulation of the proximal ulna found in this study, and the valgus laxity of the implants does not cover the variability in the population.

Trends in total elbow arthroplasty in patients with rheumatoid arthritis receiving disease-modifying antirheumatic drug therapy based on payer status.

INTRODUCTION: Total elbow arthroplasty (TEA) is often used to manage advanced arthropathies of the elbow caused by inflammatory conditions such as rheumatoid arthritis (RA). Recent literature has shown that use of TEA is decreasing in patients with RA, part of which can be attributed to early medical management involving disease-modifying antirheumatic drugs (DMARDs). However, there is a significant economic barrier to accessing DMARD therapy. The purpose of this study was to compare the use of TEA between patients with and without DMARD therapy from 2010 to 2020. METHODS: A retrospective cohort analysis was performed using a national insurance claim database to investigate the trends of patients with RA undergoing TEA from 2010-2020. Patients who underwent TEA and had a diagnosis of RA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 and ICD-10 codes between 2010 and 2020. These patients were then stratified into 2 cohorts: those with DMARD prescription claims and those without. A linear regression, compound annual growth rate (CAGR) analysis, and χ2 analysis were conducted to compare trends and demographic variables, including insurance type, between cohorts. Additionally, a multivariable logistic regression was subsequently performed to observe odds ratios (ORs) and 95% confidence intervals. RESULTS: From 2010 to 2020, there has been no significant change in the incidence of TEA in RA patients without DMARD prescriptions, whereas there has been a statistically significantly decreasing rate of TEA observed in RA patients with DMARD prescription claims. The analysis showed that there was a CAGR of -4%. For patients with a diagnosis of RA and DMARD prescription claims, the highest incidence of undergoing TEA was seen in the age group of 60-69 years, whereas patients with a diagnosis of RA and no DMARD prescription claims had the highest incidence of undergoing TEA in the age group of 70-79 years. CONCLUSION: The incidence of patients undergoing TEA with a diagnosis of RA and DMARD prescription claims has shown a statistically significant decrease from 2010 to 2020, whereas no significant difference was observed for patients without DMARD prescription claims. There were no statistically significant differences in the insurance plans between cohorts.

What factors can reduce the need for repeated revision for humeral loosening in revision total elbow arthroplasty?

BACKGROUND: This study aimed to determine the re-revision rate in a cohort of patients who underwent revision total elbow arthroplasty (rTEA) for humeral loosening (HL) and identify factors contributing to re-revision. We hypothesized that proportional increases in the stem and flange lengths would stabilize the bone-implant interface significantly more than a disproportional increase in stem or flange length alone. Additionally, we hypothesized that the indication for the index arthroplasty would impact the need for repeated revision for HL. The secondary objective was to describe the functional outcomes, complications, and presence of radiographic loosening after rTEA. METHODS: We retrospectively reviewed 181 rTEAs performed from 2000-2021. We included 40 rTEAs for HL performed on 40 elbows that either required a subsequent revision for HL (10 rTEAs) or had a minimum of 2 years of clinical or radiographic follow-up. One hundred thirty-one cases were excluded. Patients were grouped based on stem and flange length to determine the re-revision rate. Patients were divided based on re-revision status into the single-revision group and the re-revision group. The stem-to-flange length (S/F) ratio was calculated for each surgical procedure. The mean length of clinical and radiographic follow-up was 71 months (range, 18-221 months and 3-221 months, respectively). RESULTS: Rheumatoid arthritis was statistically significant in predicting re-revision total elbow arthroplasty for HL (P = .024). The overall re-revision rate for HL was 25% at an average of 4.2 years (range, 1-19 years) from the revision procedure. There was a significant increase in stem and flange lengths from the index procedure to revision, on average by 70 ± 47 mm (P < .001) and 28 ± 39 mm (P < .001), respectively. In the cases of re-revision (n = 10), 4 patients underwent an excisional procedure; in the remaining 6 cases, the size of the re-revision implant increased on average by 37 ± 40 mm for the stem and 73 ± 70 mm for the flange (P = .075 and P = .046, respectively). Furthermore, the average flange in these 6 cases was 7 times shorter than the average stem (S/F ratio, 6.7 ± 2.2). This ratio was significantly different from that in cases that were not re-revised (P = .03; S/F ratio, 4.2 ± 2). Mean range of moion was 16° (range, 0°-90°; standard deviation, 20°) extension to 119° (range, 0°-160°; standard deviation, 39°) flexion at final follow-up. Complications included ulnar neuropathy (38%), radial neuropathy (10%), infection (14%), ulnar loosening (14%), and fracture (14%). None of the elbows were considered radiographically loose at final follow-up. CONCLUSION: We show that a primary diagnosis of rheumatoid arthritis and a humeral stem with a relatively short flange relative to the stem length significantly contribute to re-revision of total elbow arthroplasty. The use of an implant where the flange can be extended beyond one-fourth of the stem length may increase implant longevity.

Intraoperative modification of total elbow arthroplasty implants.

BACKGROUND: Modification of total elbow arthroplasty (TEA) implants may be necessary in selected patients with substantial anatomic bone deformity or those undergoing revision surgery. The purpose of this study was to investigate the prevalence and consequences of implant modifications during TEA at our institution. We hypothesized that TEA implant modification would be more common in revisions than in primary replacements, and that it would not be associated with worse clinical outcomes or increased rates of radiographic or surgical complications directly related to the implant modification. METHODS: Elbows that had undergone TEA by any of 3 surgeons at our institution with use of intraoperative implant modification between January 1992 and October 2019 were retrospectively reviewed for the type of modification and complications. Complications were classified as definitely related, probably related, possibly related, or nonrelated to the implant's modification according to the consensus review by the 3 senior surgeons. A survey was sent out to surgeons outside of our institution to investigate whether intraoperative modification to TEA implants is a common clinical practice. RESULTS: A total of 106 implant components were modified during 94 of 731 TEA procedures (13%) in 84 of 560 patients. Implant modifications were performed in 60 of 285 revision cases (21%) compared with 34 of 446 (8%) primary cases (P < .0001). These included shortening the stem in 40 (44%), bending the stem in 16 (15%), notching the stem in 16 (15%), tapering the stem in 9 (9%), and a combination of 2 or more of these modifications in 19 implants (17%). Among the 55 index surgeries available for complication analysis, 40 complications occurred in 28 index surgeries (11 primary and 17 revisions; 25 patients), making the overall complication rate 51%. Of these 40 complications, 23 were considered independent of any implant modification. Of the remaining 17 complications, 9 were considered nonrelated to the implant modification, 6 were possibly related, and 2 were probably related to the implant modification. Therefore, the complication rate possibly related or probably related to implant modification was 15% (8 of 55). No complication was classified as definitely related to the implant modification. No implant breakage or malfunction occurred after any modification. A total of 442 survey responses were received representing 29 countries, of which 144 surgeons (39%) performed modification to implants during TEA procedures. DISCUSSION: This study confirmed our hypothesis that modification of TEA implants is not uncommon at our institution, particularly in revision arthroplasty. Surgeons should keep in mind that complications possibly related or probably related to implant modification were at minimum 15% and could have been as high as 30% if the patients lost to follow-up had all had complications. Implant modification may be necessary in some cases but should be exercised with thoughtful consideration and caution.