JBJS | Functional Outcome of Semiconstrained Total Elbow Arthroplasty*

The Journal of Bone & Joint Surgery, Volume 82, Issue 10

Articles | October 01, 2000

Functional Outcome of Semiconstrained Total Elbow Arthroplasty*

Kevin A. Hildebrand, M.D., F.R.C.S.(C)†; Stuart D. Patterson, M.B., Ch.B., F.R.C.S.(C)‡; William D. Regan, M.D., F.R.C.S.(C)§; Joy C. MacDermid, B.Sc., P.T., M.Sc., Ph.D.#; Graham J.W. King, M.D., M.Sc., F.R.C.S.(C)#

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Investigation performed at the Hand and Upper Limb Centre, St. Joseph's Health Centre, University of Western Ontario, London, Ontario, Canada
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Surgery, University of Calgary, 3330 Hospital Drive, N.W., Calgary, Alberta T2N 4N1, Canada.
‡Bond Clinic, 500 East Central Avenue, Winter Haven, Florida 33880.
Â§Department of Orthopaedic Surgery, Allan McGavin Sports Medicine Centre, The University of British Columbia, 3055 Westbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada.
#Department of Surgery, University of Western Ontario, St. Joseph's Health Centre, Hand and Upper Limb Centre, 268 Grosvenor Street, London, Ontario N6A 4L6, Canada.

The Journal of Bone & Joint Surgery. 2000; 82:1379-1379

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Abstract

Background: The objective of the present study was to review the results of primary total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. Two hypotheses were tested: (1) the results in patients with inflammatory arthritis would be superior to those in patients with a traumatic or posttraumatic condition, and (2) the isometric extensor torque after total elbow arthroplasty would be significantly less than that of the contralateral elbow.

Methods: Forty-seven consecutive patients (fifty-one elbows) had the operation performed by one of three surgeons between November 1, 1989, and June 30, 1996. Thirty-six surviving patients (thirty-nine elbows) were available for follow-up. The mean duration (and standard deviation) of follow-up was 50 ± 11 months (range, twenty-four to ninety-seven months). The mean age at the time of the operation was 64 ± 11 years (range, twenty-seven to eighty-seven years). Eighteen patients (twenty-one elbows) had inflammatory arthritis. Eighteen patients (eighteen elbows) had an acute fracture or posttraumatic condition (posttraumatic osteoarthritis in eight, an acute fracture of the humerus in seven, nonunion of the distal aspect of the humerus in two, and primary osteoarthritis in one). The patients were evaluated with use of questionnaires (the Mayo elbow performance index, the Short Form-36 [SF-36], and the Disabilities of the Arm, Shoulder and Hand [DASH] Questionnaire); clinical examination by an orthopaedic surgeon who was not involved with the preoperative, operative, postoperative, or follow-up care; radiographs; and elbow strength-testing with an isokinetic dynamometer.

Results: The mean score (and standard deviation) on the Mayo elbow performance index for the group that had inflammatory arthritis (90 ± 11 points) was significantly higher than that for the group with a traumatic or posttraumatic condition (78 ± 18 points) at the time of the latest follow-up (p < 0.05). In both groups, the mean extensor torque of the involved elbow was significantly less than that of the contralateral elbow (p < 0.05). No significant difference between the groups was found with respect to the flexion-extension arc of motion. Ten elbows (26 percent) had ulnar nerve dysfunction (a transient deficit in six and a permanent deficit in four); nine (23 percent), an intraoperative fracture (of the humeral diaphysis in four, of the ulnar diaphysis in four, and of the olecranon in one); three (8 percent), a periprosthetic infection; three, a triceps disruption; and one (3 percent), a revision because of a fracture of the ulnar component. There were no other revisions. Of the thirty-four elbows with complete radiographic follow-up, twenty-three had no change in the bone-cement interface. Progressive radiolucency was noted around the ulnar prosthesis in eight elbows, around the humeral prosthesis in one elbow, and around both components in two elbows.

Conclusions: Patients who had a total elbow arthroplasty with use of a semiconstrained Coonrad-Morrey prosthesis were generally satisfied; the mean level of patient satisfaction was 9.2 of a possible 10 points for those who had inflammatory arthritis and 8.6 points for those who had a fracture or posttraumatic condition. The rates of complications involving the ulnar nerve, intraoperative fracture, triceps disruption, deep infection, and periprosthetic radiolucency are of concern.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Total elbow arthroplasty has become a more common procedure since Dee reported, approximately thirty years ago, on the use of stemmed metal implants fixed to bone with methylmethacrylate¹⁰. The early designs were true hinges allowing only 1 degree of freedom. Failure at the bone-cement interface in the humerus was common, with a prevalence of loosening of up to 33 percent at five years after the arthroplasty¹¹. Refinements in the design of total elbow prostheses have led to two major categories of implants today: linked, or semiconstrained, prostheses and unlinked, or resurfacing, prostheses⁸.

The Coonrad-Morrey prosthesis (Zimmer, Warsaw, Indiana) has been used at our institution since 1989. A number of reports from the Mayo Clinic have addressed the results of the use of the semiconstrained prosthesis in patients who had rheumatoid arthritis, osteoarthritis, acute fractures of the distal aspect of the humerus, nonunions of the distal aspect of the humerus, posttraumatic arthritis, elbow instability, or revision total elbow arthroplasty^{6,7,14,18,19,25,28,31,35}. In general, these reports indicated that the patients had good relief of pain and good motion, with little or no loosening of the components at three to five years. The rates of infection remained relatively high (3 to 8 percent), and the rates of ulnar nerve dysfunction were between 5 and 10 percent. There are few reports from other centers on the results following total elbow arthroplasty with use of this prosthesis³⁰. The objective of the present study was to review the results of consecutive primary total elbow arthroplasties, performed at a single institution, with use of the Coonrad-Morrey prosthesis. The patients completed general health and musculoskeletal questionnaires, isometric elbow muscle strength was measured, and clinical and radiographic examinations were performed. Two hypotheses were examined: (1) the results in patients with inflammatory arthritis would be superior to those in patients with a traumatic or posttraumatic condition, and (2) the isometric extensor torque after total elbow arthroplasty would be significantly less than that of the contralateral elbow.

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Fig. 1:: Radiograph showing a lytic lesion that developed at the tip of the ulnar component twenty-four months after the prosthesis had been inserted.

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Fig. 2:: Radiograph, made seventy-eight months after implantation of the prosthesis, showing wide radiolucent lines where the ulnar component enters the ulna.

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TABLE I: Demographic Data

*The values are given as the mean and the standard deviation.

	Group with Inflammatory Arthritis (18 Patients with 21 Elbows)	Group with Traumatic or Posttraumatic Condition (18 Patients with 18 Elbows)
Age at operation* (yrs.)	62.0 ± 12.1	66.8 ± 9.8
Age at follow-up* (yrs.)	66.5 ± 11.7	70.5 ± 9.2
Duration of follow-up* (mos.)	53.7 ± 24.3	46.4 ± 20.2
Gender (M/F)	5/13	3/15
Side (L/R)	11/10	14/4

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TABLE I: Demographic Data

*The values are given as the mean and the standard deviation.

	Group with Inflammatory Arthritis (18 Patients with 21 Elbows)	Group with Traumatic or Posttraumatic Condition (18 Patients with 18 Elbows)
Age at operation* (yrs.)	62.0 ± 12.1	66.8 ± 9.8
Age at follow-up* (yrs.)	66.5 ± 11.7	70.5 ± 9.2
Duration of follow-up* (mos.)	53.7 ± 24.3	46.4 ± 20.2
Gender (M/F)	5/13	3/15
Side (L/R)	11/10	14/4

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TABLE II: Scores on the Musculoskeletal-Specific and General-Health Questionnaires

*The values are given as the mean and the standard deviation.†Based on nineteen elbows in the group with inflammatory arthritis and seventeen elbows in the group with a traumatic or posttraumatic condition.‡Based on seventeen patients in the group with inflammatory arthritis and eighteen patients in the group with a traumatic or posttraumatic condition.Â§P < 0.05, t test.

	Group with Inflammatory Arthritis*	Group with Traumatic or Posttraumatic Condition*
Mayo elbow performance index†	90 ± 11Â§	78 ± 18Â§
SF-36 mental component summary‡	56 ± 10	52 ± 13
SF-36 physical component summary‡	27 ± 12	33 ± 11
Disabilities of the Arm, Shoulder and Hand Questionnaire‡	47 ± 21	38 ± 23

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TABLE II: Scores on the Musculoskeletal-Specific and General-Health Questionnaires

	Group with Inflammatory Arthritis*	Group with Traumatic or Posttraumatic Condition*
Mayo elbow performance index†	90 ± 11Â§	78 ± 18Â§
SF-36 mental component summary‡	56 ± 10	52 ± 13
SF-36 physical component summary‡	27 ± 12	33 ± 11
Disabilities of the Arm, Shoulder and Hand Questionnaire‡	47 ± 21	38 ± 23

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TABLE III: Extensor Torques

*The values are given as the mean and the standard deviation, in newton-meters per kilogram.†P < 0.05, paired t test.‡P < 0.05, paired t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 14)	Elbows with Traumatic or Posttraumatic Condition* (N = 16)
Replaced elbow	6.0 ± 5.5†	6.9 ± 5.0‡
Contralateral elbow	9.8 ± 7.9†Â§	21.4 ± 7.9‡Â§

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TABLE III: Extensor Torques

*The values are given as the mean and the standard deviation, in newton-meters per kilogram.†P < 0.05, paired t test.‡P < 0.05, paired t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 14)	Elbows with Traumatic or Posttraumatic Condition* (N = 16)
Replaced elbow	6.0 ± 5.5†	6.9 ± 5.0‡
Contralateral elbow	9.8 ± 7.9†Â§	21.4 ± 7.9‡Â§

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TABLE IV: Range of Motion of Replaced Elbows

*The values are given as the mean and the standard deviation, in degrees.†P < 0.05, t test.‡P < 0.05, t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 20)	Elbows with Traumatic or Posttraumatic Condition* (N = 17)
Flexion	143 ± 8†	137 ± 7†
Extension	32 ± 21	30 ± 12
Flexion-extension arc	111 ± 25	107 ± 14
Pronation	71 ± 10	77 ± 10
Supination	71 ± 11‡	81 ± 10‡
Pronation-supination arc	142 ± 18Â§	158 ± 15Â§

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TABLE IV: Range of Motion of Replaced Elbows

*The values are given as the mean and the standard deviation, in degrees.†P < 0.05, t test.‡P < 0.05, t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 20)	Elbows with Traumatic or Posttraumatic Condition* (N = 17)
Flexion	143 ± 8†	137 ± 7†
Extension	32 ± 21	30 ± 12
Flexion-extension arc	111 ± 25	107 ± 14
Pronation	71 ± 10	77 ± 10
Supination	71 ± 11‡	81 ± 10‡
Pronation-supination arc	142 ± 18Â§	158 ± 15Â§

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TABLE V: Progression of Radiolucency Around Thirty-four Ulnar Components According to the Type of Component Surface

*Mild progression is defined as an increase of one type and moderate progression, as an increase of two types or more.†The values are given as the number of elbows.‡The values are given as the mean and the standard deviation.

Progression*	Component Surface
Precoated (N = 12)	Beaded (N = 22)
None	7	17
One type change (mild)†	1	4
Two type changes (moderate)†	4	1
Duration of follow-up‡ (mos.)	31 ± 6	59 ± 23

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TABLE V: Progression of Radiolucency Around Thirty-four Ulnar Components According to the Type of Component Surface

Progression*	Component Surface
Precoated (N = 12)	Beaded (N = 22)
None	7	17
One type change (mild)†	1	4
Two type changes (moderate)†	4	1
Duration of follow-up‡ (mos.)	31 ± 6	59 ± 23

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TABLE VI: Progression of Radiolucency Around Thirty-four Ulnar Components According to Diagnosis

*Mild progression is defined as an increase of one type and moderate progression, as an increase of two types or more.The values are given as the number of elbows.The values are given as the mean and the standard deviation.

Progression*	Diagnosis
Inflammatory Arthritis (N = 19)	Traumatic or Posttraumatic Condition (N = 15)
None	14	10
One type change (mild)	4	1
Two type changes (moderate)	1	4
Duration of follow-up (mos.)	52 ± 24	45 ± 21

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TABLE VI: Progression of Radiolucency Around Thirty-four Ulnar Components According to Diagnosis

Progression*	Diagnosis
Inflammatory Arthritis (N = 19)	Traumatic or Posttraumatic Condition (N = 15)
None	14	10
One type change (mild)	4	1
Two type changes (moderate)	1	4
Duration of follow-up (mos.)	52 ± 24	45 ± 21

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TABLE VII: Complications in Thirty-nine Elbows

*The values are given as the number of elbows, with the percentage in parentheses.

Complication	Frequency*
Ulnar nerve	10 (26)
Neurapraxia	6 (16)
Permanent dysfunction	4 (10)
Intraoperative fracture	9 (23)
Humeral shaft	4 (10)
Ulnar shaft	4 (10)
Olecranon	1 (3)
Periprosthetic infection	3 (8)
Triceps disruption	3 (8)
Postoperative fracture	2 (6)
Olecranon	1 (3)
Medial condyle	1 (3)
Ulnar component fracture, split-ring dissociation, triceps tendinitis, heterotopic ossification and contracture release, and myocardial infarction	1 (3) each

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TABLE VII: Complications in Thirty-nine Elbows

*The values are given as the number of elbows, with the percentage in parentheses.

Complication	Frequency*
Ulnar nerve	10 (26)
Neurapraxia	6 (16)
Permanent dysfunction	4 (10)
Intraoperative fracture	9 (23)
Humeral shaft	4 (10)
Ulnar shaft	4 (10)
Olecranon	1 (3)
Periprosthetic infection	3 (8)
Triceps disruption	3 (8)
Postoperative fracture	2 (6)
Olecranon	1 (3)
Medial condyle	1 (3)
Ulnar component fracture, split-ring dissociation, triceps tendinitis, heterotopic ossification and contracture release, and myocardial infarction	1 (3) each

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patients who had a primary total elbow arthroplasty with a Coonrad-Morrey prosthesis between November 1, 1989, and June 30, 1996, at St. Joseph's Health Centre in London, Ontario, Canada, were identified from the hospital records. All procedures were performed by three surgeons at the institution (S. D. P., W. D. R., and G. J. W. K.). Forty-seven patients (fifty-one elbows) formed the cohort. Eleven patients (twelve elbows) died prior to this review. Thus, thirty-six patients (thirty-nine elbows) were available for follow-up. The mean age (and standard deviation) at the time of the operation was 64 11 years (range, twenty-seven to eighty-seven years). Eighteen patients (twenty-one elbows) had inflammatory arthritis (rheumatoid arthritis in seventeen and psoriatic arthritis in one), while eighteen patients (eighteen elbows) had a traumatic or posttraumatic condition (posttraumatic osteoarthritis in eight, an acute fracture of the distal part of the humerus in seven, nonunion of the distal part of the humerus in two, and primary osteoarthritis in one). All seven patients with an acute fracture of the distal part of the humerus were women who did not have an inflammatory arthropathy, and their mean age at the time of the injury was seventy-four years (range, sixty-four to eighty-seven years).

Operative Procedure and Postoperative Rehabilitation

The operations were performed with tourniquet control. In all but four of the elbows with inflammatory arthritis, the triceps was elevated off the olecranon from medial to lateral (the Bryan-Morrey approach [fourteen elbows]) or lateral to medial (the extended Kocher approach⁵ [three elbows]). Three elbows were entered medially by removing the medial collateral ligament, and one elbow was entered on both sides of the triceps, leaving its insertion onto the olecranon intact. In the patients with a posttraumatic condition or a fracture, the triceps was elevated off the olecranon (the Bryan-Morrey approach [eleven elbows] or the extended Kocher approach [two elbows]) or the triceps insertion was spared with access on the medial and lateral sides of the triceps (five elbows). The ulnar nerve was transposed or had been transposed during prior operations in all but one elbow. All components were fixed with polymethylmethacrylate. Local autogenous bone graft was placed beneath the anterior flange of the humeral prosthesis in all patients. Where applicable, the triceps was reattached to the olecranon with use of large, nonabsorbable sutures as described by Bryan and Morrey⁵. Drains were placed deep to the extensor mechanism and in the subcutaneous layer. Antibiotics were given preoperatively and for twenty-four hours postoperatively. A splint was applied with the elbow in extension, and it was worn for one to two days. Active-assisted flexion and extension (gravity-assisted extension if the triceps was reflected) was then begun. A nighttime extension splint was worn for twelve weeks and adjusted as extension improved, and a daytime resting splint (with the elbow at 90 degrees of flexion) was worn for six weeks. Therapy was the same for all patients while they were in the hospital and after they had been discharged.

Follow-up Evaluation

Patients completed the Mayo elbow performance index, the Short Form-36 (SF-36), and the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire^2,3,16,26,38. Clinical examination included measurement of the range of motion, assessment of varus-valgus rotational and longitudinal stability, and determination of flexor and extensor strength of the elbow, pronation and supination strength of the forearm, intrinsic muscle strength, and distal interphalangeal joint flexor strength. In addition, static two-point discrimination was tested on the volar autonomous zones of the small finger (ulnar nerve) and index finger (median nerve). Muscle strength was given a grade of 0 to 5, according to the Medical Research Council scale²². Clinical triceps disruption was defined as elbow extensor strength of grade 2 or less. Permanent dysfunction of the ulnar nerve was defined as weakness (grade 4 or less) of the intrinsic muscles of the hand and of flexion of the distal interphalangeal joint of the small finger and/or two-point discrimination of greater than ten millimeters on the volar surface of the small finger. If concomitant dysfunction of the peripheral nerve was evident, then we could not diagnose permanent dysfunction of the ulnar nerve clinically.

Immediate postoperative and follow-up anteroposterior and lateral radiographs of the elbow were evaluated for signs of prosthetic loosening. Radiographic findings were graded as type 0, which indicates a radiolucent line less than one millimeter thick and involving less than 50 percent of the interface; type I, a radiolucent line at least one millimeter thick and involving less than 50 percent of the interface; type II, a radiolucent line more than one millimeter thick and involving more than 50 percent of the interface; type III, a radiolucent line more than two millimeters thick and around the entire interface; and type IV, gross loosening³⁵. Round lytic lesions that were more than two millimeters in diameter were considered to be type III. Progression of radiolucencies was evaluated, with mild progression defined as an increase of one type and moderate progression defined as an increase of two types or more. Incorporation of the bone graft beneath the anterior flange of the humeral prosthesis was also noted.

An orthopaedic surgeon (K. A. H.) who was not involved with the preoperative, operative, postoperative, or follow-up care of the patients performed the clinical examination and evaluated the radiographic parameters. Elbow flexor and extensor torques and forearm pronation and supination torques were measured with the use of a dynamometer (Lido Workset II; Loredan Biomedical, West Sacramento, California)⁴.

Thirty-six patients (thirty-nine elbows) were alive at the time of the review and were available for follow-up. Thirty patients (thirty-two elbows) were able to return to the research center, and twenty-eight of them had all aspects of the follow-up evaluation performed; the other two patients (two elbows) had all aspects performed except for Lido strength-testing, which they were unable to complete because of a resection arthroplasty or severe generalized rheumatoid arthritis. Four patients (five elbows) were evaluated at another institution by an orthopaedic surgeon (K. A. H.) who had not been involved in their care; all aspects of the evaluation were completed except for Lido strength-testing, and, in addition, one patient (one elbow) who had advanced dementia could not complete the Mayo elbow performance index, the SF-36, or the DASH Questionnaire. Finally, two patients (two elbows) were unable to return to the research center or to have an examination by the orthopaedic surgeon who was not involved in their care. These two patients completed the SF-36 and the DASH Questionnaire and had radiographs made locally and sent to our research center for evaluation.

Statistical analysis was performed with use of the Student t test for continuous data, except for comparisons of torque values, for which a paired t test was used. All continuous measures were given as the mean and the standard deviation. Discrete variables were compared with use of the Fisher exact test. The level of significance was set at p < 0.05.

Results

Introduction | Materials and Methods | Results | Discussion | References

No significant differences between the treatment groups were found with respect to the age at the time of the operation or the follow-up, the duration of follow-up, gender, or the involved side (Table I). More left than right elbows were replaced, and more women than men had a total elbow arthroplasty.

The only significant difference between the two treatment groups with respect to the results on the questionnaires was the mean value on the Mayo elbow performance index (Table II). That score for the group with inflammatory arthritis (90 ± 11 points) was significantly higher than that for the group with a traumatic or posttraumatic condition (78 ± 18 points) (p < 0.05, t test). The SF-36 results revealed that the mental component summary scores for both groups were not significantly different from the reported scores for age-matched samples of the general population in the United States³⁸ (p > 0.05, t test). However, the physical component summary scores for both groups were significantly less than the reported values for age-matched individuals of the general population in the United States (p < 0.05, t test).

Although general population values for the DASH Questionnaire were not available, both groups in the present study had elevated scores (with 0 indicating a normal score and 100, the worst score), reflecting the functional limitations in these patients.

Muscle-strength testing of the involved elbows with the Lido dynamometer demonstrated no significant differences between the patients who had inflammatory arthritis and those who had a traumatic or posttraumatic condition with respect to flexor, extensor, supination, and pronation torques. However, within each group, the mean extensor torque of the involved elbows was significantly lower than that of the contralateral elbows (Table III) (p < 0.05, t test).

Measurement of the range of motion demonstrated significant differences between the groups with respect to flexion and supination (p < 0.05, t test) (Table IV). The elbows with inflammatory arthritis had greater flexion, but the elbows with a traumatic or posttraumatic condition had greater supination. A significant difference between the groups in the total arcs of motion was found with respect to pronation-supination (p < 0.05, t test) but not flexion-extension (p > 0.05, t test) (Table IV). Thirty-five of the thirty-seven forearms met the criteria for functional motion²³ (more than 50 degrees of supination and 50 degrees of pronation), and twenty-four of the thirty-seven elbows met the criteria for functional extension-flexion²³ (30 to 130 degrees). Of the thirteen elbows that were not able to achieve functional flexion-extension, twelve (six in each group) had a flexion contracture of more than 30 degrees.

Radiographic analysis revealed that twenty-three implants had no change in the bone-cement interface and eleven were associated with progressive radiolucency. The ulnar component was involved in eight elbows; the humeral component, in one elbow; and both the humeral and the ulnar component, in two elbows. Four of the twelve elbows with a precoated ulnar component had moderate progression of radiolucency, whereas only one of the twenty-two beaded ulnar components had moderate progression of radiolucency (Table V). Four of the fifteen elbows with a traumatic or posttraumatic condition and one of the nineteen elbows with inflammatory arthritis had moderate progression of radiolucency around the ulnar component (Table VI). The four elbows with moderate progression of radiolucency around a precoated ulnar component all had a traumatic or posttraumatic condition, whereas the only elbow with moderate progression around a beaded ulnar component had inflammatory arthritis and a deep infection. There were two main patterns of progressive ulnar radiolucency. One pattern involved a lytic lesion around the tip of the prosthesis (Fig. 1). The second pattern involved widening of the linear radiolucency as the prosthesis entered the ulna (Fig. 2). There were no completely loose (type-IV) implants. Five elbows did not have complete radiographic follow-up. Immediate postoperative radiographs for two elbows and radiographs made at the most recent follow-up examination for a third could not be located. A fourth elbow had had a resection arthroplasty at the time of follow-up, and a fifth had had a revision of the ulnar component.

Thirty-one (84 percent) of thirty-seven bone grafts beneath the anterior flange of the humeral component were incorporated. One patient had dissociation of the split-ring from the axis pin within three weeks after the operation; fortunately, no component dissociation was seen at a follow-up examination six years postoperatively even though the ring had not been replaced.

Twenty-one of the thirty-nine involved elbows had a total of thirty-two complications (Table VII). The most common structure involved was the ulnar nerve, which was affected in ten (26 percent) of the thirty-nine elbows, with permanent dysfunction in four (10 percent) at the time of the latest follow-up. The second most common complication was an intraoperative fracture, which occurred in nine elbows (23 percent). The next most frequent complications were periprosthetic infection and triceps disruption, which occurred in three elbows (8 percent) each.

The nine intraoperative fractures occurred in seven patients, all women. The diagnosis was rheumatoid arthritis in four patients, acute fracture of the distal aspect of the humerus in two, and posttraumatic arthritis in one. All of the fractures occurred between 1993 and 1995, with the exception of one that occurred in 1990. Three of the four humeral fractures were associated with a six-inch (fifteen-centimeter) humeral component; the circumferential fractures occurred near the proximal tip of the humeral component. The fourth humeral fracture was a cortical breach only. All four ulnar fractures were circumferential.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

In the present study of thirty-nine elbows (thirty-six patients) that had had a Coonrad-Morrey total elbow arthroplasty and were evaluated at a mean (and standard deviation) of 50 ± 11 months (range, twenty-four to ninety-seven months) postoperatively, the elbows with inflammatory arthritis scored significantly higher on the Mayo elbow performance index than did the elbows with a traumatic or posttraumatic condition. However, no significant differences were found between the groups with respect to the scores on the SF-36 mental and physical component summaries and the DASH Questionnaire. Objective measures of extensor torque showed that the elbows that had had an arthroplasty had significantly less strength than did the contralateral elbows in both groups. Patient satisfaction with the result of total elbow arthroplasty was very high in this series. The mean self-reported level of satisfaction was 9.2 of a possible 10 points for the patients with inflammatory arthritis and 8.6 points for the patients with a traumatic or posttraumatic condition.

The scores on the Mayo elbow performance index in our study were compared with those reported in several other studies, from the Mayo Clinic, in which this questionnaire had been used to evaluate the results of Coonrad-Morrey total elbow arthroplasty^{6,7,14,26,28,35}. The mean score for the patients in our study who had inflammatory arthritis (90 ± 11 points) was very similar to the results reported by other investigators for patients who had rheumatoid arthritis (range, 87 to 94 points)^7,14,26. The mean score for our patients who had a traumatic or posttraumatic condition (78 ± 18 points) was lower than the scores reported by investigators at the Mayo Clinic for patients who had a nonunion of the distal part of the humerus (ninety-two) and patients who had an acute fracture of the distal part of the humerus (ninety-five), but they were similar to the results for patients who had posttraumatic arthritis (eighty-two) and those who had instability (eighty-six)^6,28,31,35.

Our patients also were evaluated with use of a questionnaire concerning the upper extremity (DASH Questionnaire) and a general-health questionnaire (SF-36). While no significant differences between the two groups were detected with respect to the mean scores on the DASH Questionnaire and the physical component summary of the SF-36, both scores reflected residual functional limitations compared with scores for the general population³⁸. Despite these findings, both groups had scores on the mental component summary of the SF-36 that were similar to those for the general population³⁸.

The mean extensor torque of the elbows that had had an arthroplasty was significantly less than that for the contralateral elbows in both groups. Three elbows with obvious triceps disruption at the time of the review were included in the results. Other investigators also have noted triceps disruption as a complication of total elbow arthroplasty^24,29,35. Pierce and Herndon reported fewer disruptions when they switched from the Bryan-Morrey approach to a triceps-sparing approach in which the tendon was left attached to the olecranon^24,29. In our study, analysis of the mean extensor torque revealed no significant differences between the seven elbows in which the triceps was left on the olecranon (8 ± 4 newton-meters per kilogram) and the twenty-three in which the triceps was dissociated from the olecranon (6 ± 5 newton-meters per kilogram) (p > 0.05, t test). However, measurements of strength for the group that had been treated with a triceps-sparing approach included elderly patients with an acute fracture of the distal aspect of the humerus, which made it difficult to evaluate the potential value of this approach.

The most common complications in the present series were dysfunction of the ulnar nerve and intraoperative fracture. Some investigators have reported that ulnar neurapraxia occurred within a few days after surgery in as many as 21 percent of elbows^{1,13,19,34,39}, but the rate of permanent ulnar nerve dysfunction in those studies ranged from 0 to 5 percent. In several studies, the reported rate of permanent ulnar nerve dysfunction has ranged from 0 to 10 percent^{1,6,7,9,12-15,17-21,24,26-28,30-32,34,36,37,39}. The results in our study showed similar rates, with early ulnar nerve dysfunction in 26 percent and permanent ulnar nerve dysfunction in 10 percent.

The rates of intraoperative fracture in the literature are difficult to determine because of variations in the methods used to report them. Some authors have not commented on intraoperative fracture, whereas others have reported complete fracture of the humeral shaft, medial condyle, or ulnar shaft in as many as 4 percent of the elbows^{7,13,14,24,27,31,34,35}. When perforations of the ulnar or humeral cortex were included, rates of intraoperative fracture have been reported to be as high as 9 percent³⁷. The rate of intraoperative fracture was much higher in the present series. The fractures all occurred in women, and the underlying diagnosis was rheumatoid arthritis (four patients) or fracture of the distal aspect of the humerus (two) in six of these seven patients. It would appear that underlying osteoporosis may be a factor that contributed to the rate of intraoperative fracture observed in our study. All ulnar fractures included the shaft, and three of the four were treated with cerclage wires and bone graft. The fourth ulnar fracture was treated nonoperatively. Three of the four intraoperative fractures of the humerus involved the shaft and were treated with a Sarmiento brace³³. These three fractures were associated with a six-inch (fifteen-centimeter) humeral component. The natural bow of the humeral shaft, possibly in combination with the bone graft beneath the anterior flange of the humeral prosthesis, may actually force the tip of the larger (straight six-inch and eight-inch [fifteen-centimeter and twenty-centimeter]) components out of the posterior cortex. The components to be implanted should be checked to ensure that they will insert easily. Bending of the tip of the humeral prosthesis may be required to prevent fracture in some instances^26,28. Small-diameter (five to seven-millimeter) medullary reamers can be helpful for placement of the component in small humeral or ulnar canals. The fourth humeral fracture was a breach in the cortex, which was treated with bone-grafting to prevent escape of polymethylmethacrylate. All humeral and ulnar fractures healed. The intraoperative fracture of the olecranon was treated with a tension-band technique with use of nonabsorbable sutures. The fracture had not healed at the time of the latest review (thirty-two months postoperatively), and the patient had triceps insufficiency.

Periprosthetic infection occurred in three (8 percent) of the thirty-nine elbows. In other studies, involving use of many types of implants, rates of deep periprosthetic infection have ranged from 0 to 9 percent^{1,6,7,13,14,20,25,26,28,31,34,37,39,40}. The three patients in our study who had an infection all had rheumatoid arthritis. One patient was treated with a resection arthroplasty and was not interested in reimplantation. The other two patients were treated with multiple dè¡²idements, and one had a radial forearm flap for closure. Both patients remained on chronic antibiotic suppression.

Triceps disruption following total elbow arthroplasty is a well recognized problem, occurring in as many as 31 percent of elbows in some reports^{6,7,14,25,26,28,29}. Three elbows had clinically obvious triceps disruption in our series at the time of the latest follow-up. All three patients had had a procedure in which the triceps tendon and forearm fascia were reflected from the olecranon in continuity; two were performed with an extended Kocher approach and one, with a Bryan-Morrey approach^5,24. Two of the elbows had reconstruction of the triceps mechanism at least two years before the time of this review; however, the triceps still was not able to overcome gravity.

Radiographic analyses revealed progressive radiolucency in eleven (32 percent) of thirty-four elbows with complete radiographic follow-up. Progressive radiolucency occurred mainly around the ulnar component. This finding contrasts with the results in shorter-term reports from the Mayo Clinic in which the radiolucency rates were less than 10 percent and radiolucency was more common on the humeral side^{6,19,25,26,28,31}. However, in a report with longer-term follow-up from the Mayo Clinic, progressive radiolucency and revision of aseptically loose total elbow prostheses were reported in 17 percent of seventy-six elbows, with more involvement on the ulnar side¹⁴. In studies of total elbow arthroplasty with capitellocondylar resurfacing, radiolucency was seen around the humeral implant in up to 12 percent of the elbows and around the ulnar component in up to 27 percent^13,34,37,39. In our series, we noted that progressive radiolucency was related to the surface finish of the ulnar component and to the diagnosis. The prevalence of progressive radiolucency was greater in the elbows with a precoated ulnar component (four of twelve elbows) than in those with a beaded ulnar component (five of twenty-two; 23 percent). Progressive radiolucency occurred in five of the fifteen elbows with a traumatic or posttraumatic condition and in five of the nineteen elbows with inflammatory arthritis. The moderately progressive radiolucency occurred most often in elbows with a traumatic or posttraumatic condition and a precoated ulnar component. The 84 percent rate of bone-graft incorporation in our study was similar to that reported by several other investigators^{6,7,14,25,26,28,31}. One beaded ulnar component fractured when the patient fell approximately thirteen months after the primary operation. The component was revised, and the patient was doing well at the time of the latest follow-up (a score of 95 points on the Mayo elbow performance index).

In summary, the patients were satisfied with the result of the total elbow arthroplasty; the mean self-reported satisfaction rating was 9.2 of a possible 10 points for the patients with inflammatory arthritis and 8.6 points for the patients with a traumatic or posttraumatic condition. The operative technique is demanding, and the rate of complications, specifically nerve injury, intraoperative fracture, triceps disruption, deep infection, and periprosthetic radiolucency, are of concern. Improvements in operative technique are needed.

References

Introduction | Materials and Methods | Results | Discussion | References

Allieu, Y.; Meyer, Z. U.; Reckendorf, G. M.; and Daude, O.: Long-term results of unconstrained Roper-Tuke total elbow arthroplasty in patients with rheumatoid arthritis. J. Shoulder and Elbow Surg., 7: 560-564, 1998.

Amadio, P.; Beaton, D.; Bombardier, C.; Davis, A.; Hawker, G.; Hudak, P.; Katz, J.; Marx, R.; Punnett, L.; Wright, J.; and Shields, S.: Measuring disability and symptoms of the upper limb: a validation study of the DASH questionnaire [abstract]. J Econ. Med., 14: 11, 1996.

Amadio, P.; Beaton, D.; Bombardier, C.; Cole, D.; Davis, A.; Hawker, G.; Hudak, P.; Katz, J.; Marx, R.; Makela, M.; Punnett, L.; and Wright, J.: Development of an upper extremity outcome measure: the "DASH" (Disabilities of the Arm, Shoulders and Hand) [abstract]. J. Econ. Med., 14: 33, 1996.

Brown, L. E.; Whitehurst, M.; and Bryant, J. R.: Reliability of the LIDO active isokinetic dynamometer concentric mode. Isokinet. and Exerc. Sci., 2: 191-194, 1992.

Bryan, R. S., and Morrey, B. F.: Extensive posterior exposure of the elbow: a triceps-sparing approach. Clin. Orthop., 166: 188-192, 1982.

Cobb, T. K., and Morrey, B. F.: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J. Bone and Joint Surg., 79-A: 826-832, June 1997.

Connor, P. M., and Morrey, B. F.: Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis. J. Bone and Joint Surg., 80-A: 678-688, May 1998.

Cooney, W. P., III: Elbow arthroplasty: indications and implant selection. In The Elbow and Its Disorders, edited by B. F. Morrey. Ed. 2, pp. 629-637. Philadelphia, W. B. Saunders, 1993.

Davis, R. F.; Weiland, A. J.; Hungerford, D. S.; Moore, J. R.; and Volenec-Dowling, S.: Nonconstrained total elbow arthroplasty. Clin. Orthop., 171: 156-160, 1982.

Dee, R.: Total replacement arthroplasty of the elbow for rheumatoid arthritis. J. Bone and Joint Surg., 54-B(1): 88-95, 1972.

Dee, R.: Reconstructive surgery following total elbow endoprosthesis. Clin. Orthop., 170: 196-203, 1982.

Ewald, F. C.; Scheinberg, R. D.; Poss, R.; Thomas, W. H.; Scott, R. D.; and Sledge, C. B.: Capitellocondylar total elbow arthroplasty. J. Bone and Joint Surg., 62-A: 1259-1263, Dec. 1980.

Ewald, F. C.; Simmons, E. D., Jr.; Sullivan, J. A.; Thomas, W. H.; Scott, R. D.; Poss, R.; Thornhill, T. S.; and Sledge, C. B.: Capitellocondylar total elbow replacement in rheumatoid arthritis. Long-term results. J. Bone and Joint Surg., 75-A: 498-507, April 1993.

Gill, D. R. J., and Morrey, B. F.: The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow-up study. J. Bone and Joint Surg., 80-A: 1327-1335, Sept. 1998.

Gschwend, N.; Loehr, J.; Ivosevic-Radovanovic, D.; Scheier, H.; and Munzinger, U.: Semiconstrained elbow prostheses with special reference to the GSB III prosthesis. Clin. Orthop., 232: 104-110, 1988.

Hudak, P. L.; Amadio, P. C.; and Bombardier, C.: Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group. Am. J. Indust. Med., 29: 602-608, 1996; erratum, 30: 372, 1996.

Kasten, M. D., and Skinner, H. B.: Total elbow arthroplasty. An 18-year experience. Clin. Orthop., 290: 177-188, 1993.

King, G. J. W.; Adams, R. A.; and Morrey, B. F.: Total elbow arthroplasty: revision with use of a non-custom semiconstrained prosthesis. J. Bone and Joint Surg., 79-A: 394-400, March 1997.

Kozac, T. K.; Adams, R. A.; and Morrey, B. F.: Total elbow arthroplasty in primary osteoarthritis of the elbow. J. Arthroplasty, 13: 837-842, 1998.

Kraay, M. J.; Figgie, M. P.; Inglis, A. E.; Wolfe, S. W.; and Ranawat, C. S.: Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases. J. Bone and Joint Surg., 76-B(4): 636-640, 1994.

Lowe, L. W.; Miller, A. J.; Allum, R. L.; and Higginson, D. W.: The development of an unconstrained elbow arthroplasty. A clinical review. J. Bone and Joint Surg., 66-B(2): 243-247, 1984.

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Morrey, B. F.; Askew, L. J.; and Chao, E. Y.: A biomechanical study of normal functional elbow motion. J. Bone and Joint Surg., 63-A: 872-877, July 1981.

Morrey, B. F., and Bryan, R. S.: Complications of total elbow arthroplasty. Clin. Orthop., 170: 204-212, 1982.

Morrey, B. F.; Adams, R. A.; and Bryan, R. S.: Total replacement for post-traumatic arthritis of the elbow. J. Bone and Joint Surg., 73-B(4): 607-612, 1991.

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Ramsey, M. L.; Adams, R. A.; and Morrey, B. F.: Instability of the elbow treated with semiconstrained total elbow arthroplasty. J. Bone and Joint Surg., 81-A: 38-47, Jan. 1999.

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Schneeberger, A. G.; Adams, R.; and Morrey, B. F.: Semiconstrained total elbow replacement for the treatment of post-traumatic osteoarthrosis. J. Bone and Joint Surg., 79-A: 1211-1222, Aug. 1997.

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Fig. 1:: Radiograph showing a lytic lesion that developed at the tip of the ulnar component twenty-four months after the prosthesis had been inserted.

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Fig. 2:: Radiograph, made seventy-eight months after implantation of the prosthesis, showing wide radiolucent lines where the ulnar component enters the ulna.

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TABLE I: Demographic Data

*The values are given as the mean and the standard deviation.

	Group with Inflammatory Arthritis (18 Patients with 21 Elbows)	Group with Traumatic or Posttraumatic Condition (18 Patients with 18 Elbows)
Age at operation* (yrs.)	62.0 ± 12.1	66.8 ± 9.8
Age at follow-up* (yrs.)	66.5 ± 11.7	70.5 ± 9.2
Duration of follow-up* (mos.)	53.7 ± 24.3	46.4 ± 20.2
Gender (M/F)	5/13	3/15
Side (L/R)	11/10	14/4

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TABLE I: Demographic Data

*The values are given as the mean and the standard deviation.

	Group with Inflammatory Arthritis (18 Patients with 21 Elbows)	Group with Traumatic or Posttraumatic Condition (18 Patients with 18 Elbows)
Age at operation* (yrs.)	62.0 ± 12.1	66.8 ± 9.8
Age at follow-up* (yrs.)	66.5 ± 11.7	70.5 ± 9.2
Duration of follow-up* (mos.)	53.7 ± 24.3	46.4 ± 20.2
Gender (M/F)	5/13	3/15
Side (L/R)	11/10	14/4

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TABLE II: Scores on the Musculoskeletal-Specific and General-Health Questionnaires

	Group with Inflammatory Arthritis*	Group with Traumatic or Posttraumatic Condition*
Mayo elbow performance index†	90 ± 11Â§	78 ± 18Â§
SF-36 mental component summary‡	56 ± 10	52 ± 13
SF-36 physical component summary‡	27 ± 12	33 ± 11
Disabilities of the Arm, Shoulder and Hand Questionnaire‡	47 ± 21	38 ± 23

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TABLE II: Scores on the Musculoskeletal-Specific and General-Health Questionnaires

	Group with Inflammatory Arthritis*	Group with Traumatic or Posttraumatic Condition*
Mayo elbow performance index†	90 ± 11Â§	78 ± 18Â§
SF-36 mental component summary‡	56 ± 10	52 ± 13
SF-36 physical component summary‡	27 ± 12	33 ± 11
Disabilities of the Arm, Shoulder and Hand Questionnaire‡	47 ± 21	38 ± 23

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TABLE III: Extensor Torques

*The values are given as the mean and the standard deviation, in newton-meters per kilogram.†P < 0.05, paired t test.‡P < 0.05, paired t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 14)	Elbows with Traumatic or Posttraumatic Condition* (N = 16)
Replaced elbow	6.0 ± 5.5†	6.9 ± 5.0‡
Contralateral elbow	9.8 ± 7.9†Â§	21.4 ± 7.9‡Â§

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TABLE III: Extensor Torques

*The values are given as the mean and the standard deviation, in newton-meters per kilogram.†P < 0.05, paired t test.‡P < 0.05, paired t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 14)	Elbows with Traumatic or Posttraumatic Condition* (N = 16)
Replaced elbow	6.0 ± 5.5†	6.9 ± 5.0‡
Contralateral elbow	9.8 ± 7.9†Â§	21.4 ± 7.9‡Â§

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TABLE IV: Range of Motion of Replaced Elbows

*The values are given as the mean and the standard deviation, in degrees.†P < 0.05, t test.‡P < 0.05, t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 20)	Elbows with Traumatic or Posttraumatic Condition* (N = 17)
Flexion	143 ± 8†	137 ± 7†
Extension	32 ± 21	30 ± 12
Flexion-extension arc	111 ± 25	107 ± 14
Pronation	71 ± 10	77 ± 10
Supination	71 ± 11‡	81 ± 10‡
Pronation-supination arc	142 ± 18Â§	158 ± 15Â§

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TABLE IV: Range of Motion of Replaced Elbows

*The values are given as the mean and the standard deviation, in degrees.†P < 0.05, t test.‡P < 0.05, t test.Â§P < 0.05, t test.

	Elbows with Inflammatory Arthritis* (N = 20)	Elbows with Traumatic or Posttraumatic Condition* (N = 17)
Flexion	143 ± 8†	137 ± 7†
Extension	32 ± 21	30 ± 12
Flexion-extension arc	111 ± 25	107 ± 14
Pronation	71 ± 10	77 ± 10
Supination	71 ± 11‡	81 ± 10‡
Pronation-supination arc	142 ± 18Â§	158 ± 15Â§

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TABLE V: Progression of Radiolucency Around Thirty-four Ulnar Components According to the Type of Component Surface

Progression*	Component Surface
Precoated (N = 12)	Beaded (N = 22)
None	7	17
One type change (mild)†	1	4
Two type changes (moderate)†	4	1
Duration of follow-up‡ (mos.)	31 ± 6	59 ± 23

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TABLE V: Progression of Radiolucency Around Thirty-four Ulnar Components According to the Type of Component Surface

Progression*	Component Surface
Precoated (N = 12)	Beaded (N = 22)
None	7	17
One type change (mild)†	1	4
Two type changes (moderate)†	4	1
Duration of follow-up‡ (mos.)	31 ± 6	59 ± 23

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TABLE VI: Progression of Radiolucency Around Thirty-four Ulnar Components According to Diagnosis

Progression*	Diagnosis
Inflammatory Arthritis (N = 19)	Traumatic or Posttraumatic Condition (N = 15)
None	14	10
One type change (mild)	4	1
Two type changes (moderate)	1	4
Duration of follow-up (mos.)	52 ± 24	45 ± 21

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TABLE VI: Progression of Radiolucency Around Thirty-four Ulnar Components According to Diagnosis

Progression*	Diagnosis
Inflammatory Arthritis (N = 19)	Traumatic or Posttraumatic Condition (N = 15)
None	14	10
One type change (mild)	4	1
Two type changes (moderate)	1	4
Duration of follow-up (mos.)	52 ± 24	45 ± 21

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TABLE VII: Complications in Thirty-nine Elbows

*The values are given as the number of elbows, with the percentage in parentheses.

Complication	Frequency*
Ulnar nerve	10 (26)
Neurapraxia	6 (16)
Permanent dysfunction	4 (10)
Intraoperative fracture	9 (23)
Humeral shaft	4 (10)
Ulnar shaft	4 (10)
Olecranon	1 (3)
Periprosthetic infection	3 (8)
Triceps disruption	3 (8)
Postoperative fracture	2 (6)
Olecranon	1 (3)
Medial condyle	1 (3)
Ulnar component fracture, split-ring dissociation, triceps tendinitis, heterotopic ossification and contracture release, and myocardial infarction	1 (3) each

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TABLE VII: Complications in Thirty-nine Elbows

*The values are given as the number of elbows, with the percentage in parentheses.

Complication	Frequency*
Ulnar nerve	10 (26)
Neurapraxia	6 (16)
Permanent dysfunction	4 (10)
Intraoperative fracture	9 (23)
Humeral shaft	4 (10)
Ulnar shaft	4 (10)
Olecranon	1 (3)
Periprosthetic infection	3 (8)
Triceps disruption	3 (8)
Postoperative fracture	2 (6)
Olecranon	1 (3)
Medial condyle	1 (3)
Ulnar component fracture, split-ring dissociation, triceps tendinitis, heterotopic ossification and contracture release, and myocardial infarction	1 (3) each