Bryan J. Loeffler and Patrick M. Connor
DEFINITION
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory condition of unknown etiology affecting 1% to 2% of the population.
It affects females two to three times as frequently as males, and the incidence increases with age, typically peaking between 35 and 50 years of age.
Peripheral joints are often affected in a symmetric pattern.
The elbow is affected in about 20% to 70% of patients with RA, with a wide spectrum of severity.
Ninety percent of these patients also have hand and wrist involvement, and 80% also have shoulder involvement.
Juvenile rheumatoid arthritis (JRA) is diagnosed based on the presence of arthritis, synovitis, or both in at least one joint lasting for more than 6 weeks in an individual less than 16 years old.
Compared with adult-onset RA, JRA is complicated by severe osseous destruction, deformity, and soft tissue contractures.
PATHOGENESIS
The cause of RA is unknown.
Infectious etiologies have been proposed, but no microorganism has been proven to be causative.
Genetic and twin studies have demonstrated that a genetic predisposition clearly exists, and the disease is also associated with autoimmune phenomena.
In patients with RA, numerous cell types, including B lymphocytes, CD4 T cells, mononuclear phagocytes, neutrophils, fibroblasts, and osteoclasts, have been shown to produce abnormally high levels of various cytokines, chemokines, and other inflammatory mediators.
The result is inflammatory-mediated proliferation of synovial tissue, leading to soft tissue and finally bony destruction.
NATURAL HISTORY
Overall, the disease progresses from predominantly soft tissue (synovial) inflammation to articular cartilage damage and ultimately subchondral and periarticular bone destruction.
Manifestations of RA are initiated by synovitis and synovial hyperplasia resulting in pannus formation. This correlates with a boggy, inflamed elbow that is painful and with limited range of motion.
Synovial proliferation coupled with joint capsule distention may produce a compressive neuropathy with pain, paresthesias, or weakness in the ulnar or radial nerve distributions, or both.
Degeneration may progress to ligamentous erosion or disruption, or both. Clinically, the patient experiences progressive instability as ligamentous integrity is compromised.
It may affect the annular ligament and produce radial head instability with anterior displacement.
Eventually the medial and lateral collateral ligament complexes may be disrupted, thus causing further instability.
Prolonged synovitis leads to erosion of the cartilage followed by subchondral cyst and marginal osteophyte formation; the result is end-stage arthritis.
End-stage disease is marked by severe damage to subchondral bone and gross joint instability. At this stage, patients typically have a painful, weak, and functionally unstable elbow.
PATIENT HISTORY AND PHYSICAL FINDINGS
Patients typically describe a history of a swollen, tender, and warm elbow with diminished and painful range of motion.
This may be accompanied by a report of progressively declining function, constitutional complaints, and often polyarticular involvement.
In early stages of the disease, the elbow may appear more boggy, with impressive soft tissue swelling and erythema about the elbow.
As the disease progresses to later stages, soft tissue swelling may become less prominent, and the elbow becomes more stiff and painful.
Differences in Examination Findings Between Rheumatoid Arthritis and Juvenile Rheumatoid Arthritis
Elbows affected by JRA obviously occur in younger patients as compared with elbows affected by RA.
Patients with JRA also have stiffer elbows and therefore typically do not have instability.
Often JRA patients have more joints affected by the rheumatoid process, but they also demonstrate a greater tolerance for pain.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Anteroposterior (AP) and lateral radiographs of the elbow are obtained to assess the degree of rheumatoid involvement and for preoperative planning (FIG 1). No further studies are typically required.
Classification
Although several classification systems have been proposed, the most commonly used is the Mayo Radiographic Classification System (Table 1).6
It allows monitoring of disease progression and often correlates well with clinical examination findings and patients’ functional limitations.
The grading system is based on bone quality, joint space, and bony architecture and delineates four grades of progression in order of increasing severity.
FIG 1 • Preoperative AP and lateral radiographs of a 38-year-old woman with juvenile rheumatoid arthritis demonstrating advanced changes of osteopenia, joint space narrowing, and changes in subchondral architecture.
DIFFERENTIAL DIAGNOSIS
Calcium pyrophosphate deposition disease
Osteoarthritis
Polymyalgia rheumatica
Psoriatic arthritis
Systemic lupus erythematosus
Fibromyalgia
NONOPERATIVE MANAGEMENT
Optimal care of the patient with RA requires a team-based approach between the orthopaedic surgeon, rheumatologist, and physical therapists to coordinate the full gamut of nonsurgical and surgical treatment options.
Medical Therapy
The medical management of RA continues to evolve at an impressive rate.
The mainstays of medical therapy are the classes of drugs known as disease modifying antirheumatic drugs (DMARDs).
These include older agents such as gold salts as well as newer agents such as methotrexate, sulfasalazine, anti-tumor necrosis factor (anti-TNF) medications, and other immunomodulators. Such medications may be given alone or as part of combination therapy.
Other medications prescribed to abate symptoms include nonsteroidal anti-inflammatories (NSAIDs) and steroids.
Judicious use of intra-articular steroid injections also plays a role in symptom management.
The importance of early referral to a rheumatologist for medical management cannot be overemphasized. Aggressive management of the synovitis can limit or delay the onset and severity of joint involvement. The most reliable and effective responses to the DMARDs are observed with therapy initiated in the early stages of the disease.
Physical Therapy
The goal of physical therapy is to encourage range of motion, functional strength, and maintenance of activities of daily living. This is accomplished by activity modification, rest, ice, and gentle exercise.
The primary objective of nonoperative management of the rheumatoid elbow is to minimize soft tissue swelling and to optimize range of motion, as preoperative range of motion is often predictive of postoperative total arc of motion after arthroscopic synovectomy as well as total elbow arthroplasty.
SURGICAL MANAGEMENT
Surgical management of the rheumatoid elbow primarily consists of synovectomy and total elbow arthroplasty.
Surgical Management of the Elbow Before Total Elbow Arthroplasty
For early disease states, excellent clinical results may be achieved with synovectomy performed using open or arthroscopic techniques.
The goal of synovectomy is to relieve pain and swelling. Although this procedure has not necessarily been shown to alter the natural history of the disease, it reliably produces symptomatic relief for 5 or more years in the majority of cases performed on elbows in the early stages of the disease process.3
The arthroscopic approach is advantageous over the more traditional open approach in that it is less invasive, is associated with less perioperative morbidity, and also allows predictable access to the sacciform recess. When open synovectomy is performed, the radial head must be excised to access and completely débride the diseased synovial tissue that exists in this region.
Open synovectomy has traditionally been accompanied by radial head excision due to (1) ubiquitous radiocapitellar and proximal radioulnar joint articular destruction and (2) the need to surgically expose the sacciform recess for the requisite complete synovectomy.
It has been shown that routine radial head excision may predispose some patients with RA to increasing valgus elbow instability due to the loss of the stabilizing effect of the radial head (particularly if the medial collateral ligament is adversely affected by the rheumatoid process).7
Now that the entire synovial proliferation around the radial neck can be accessed arthroscopically, a combined arthroscopic radial head excision is performed only in patients with stable elbows and preoperative elbow symptoms with forearm rotation. Otherwise, a complete arthroscopic synovectomy is performed without excising the radial head.
In addition, the minimally invasive nature of an arthroscopic approach yields the potential advantages of less pain, faster recovery with earlier range of motion, and a lower rate of infection compared with an open procedure.
An arthroscopic anterior capsular release may be performed at the time of the arthroscopic synovectomy to improve elbow extension. A posterior olecranon-plasty may also be performed to re-establish normal concavity of the olecranon fossa.
Posteromedial capsule release should be avoided to prevent the risk of iatrogenic ulnar nerve injury. If an elbow requires a release of the posterior capsule to regain elbow flexion (typically those with 100 degrees or less of preoperative flexion), then the surgeon should consider performing an open ulnar nerve decompression and subcutaneous transposition followed by complete posterior capsule release (including the posteromedial band of the medial collateral ligament).
(Adapted from Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992;74A:479–490; and from Connor PM, Morrey BF. Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis. J Bone Joint Surg Am 1998;80A:678–688.)
Total Elbow Arthroplasty
This procedures is indicated primarily for advanced (grade III or IV) RA of the elbow in patients with significant pain and limitations in activities of daily living.
Absolute contraindications include active infection, upper extremity paralysis, and a patient’s refusal or inability to abide by postoperative activity restrictions.
Relative contraindications include presence of infection at a remote site and a history of infected elbow or elbow prosthesis.
Preoperative Planning
AP and lateral radiographs of the elbow are reviewed to assess humeral bow and medullary canal diameter as well as angulation and diameter of the ulnar medullary canal.
Preoperative radiographic templates may be helpful to assess preoperative radiographic magnification.
In particular for JRA patients, the canal width may be very small, and therefore the surgeon must ensure that appropriately sized implants as well as intramedullary guidewires and reamers are available.
If an ipsilateral total shoulder arthroplasty has been performed or is anticipated, use of a 4-inch humeral implant and a humeral cement restrictor should be considered.
Preoperative limitations in forearm rotation may be due in part to ipsilateral distal radioulnar joint pathology. Thus, radiographs should also be obtained on the ipsilateral shoulder and wrist.
Implant Selection for Total Elbow Arthroplasty
Implant options have traditionally been classified as linked (semiconstrained) or unlinked.
These terms are being used with decreasing frequency, however, as unlinked implant designs have been developed that have precisely contoured components that create a degree of constraint.
Linked, semiconstrained implants have about 7 degrees of varus–valgus “play” and 7 degrees of axial rotation, while unconstrained implants consist of unlinked, resurfacing components.
The stability of unconstrained implants depends on soft tissue and ligamentous integrity, while such tissues may be destroyed by the rheumatoid inflammatory process or surgically released with semiconstrained implants without compromising stability.
Although no prospective comparisons between linked (semiconstrained) and unlinked implants have yet been performed, both appear to have similar survivorship records.
The semiconstrained design is preferred because it is equally effective in pain relief and in improving range of motion and function, while preserving stability without an observed increase in aseptic loosening.5
The Techniques section below focuses on implantation of a linked (semiconstrained) implant.
Sequence and Timing of Total Elbow Arthroplasty in the Patient with Polyarticular Involvement
Because RA typically affects multiple joint articulations, the timing of elbow arthroplasty should be considered with regard to the need for arthroplasties of other joints.
In general, the most disabling articulation should be addressed first. In the case of equivocal involvement in the elbow and a lower extremity joint in which arthroplasty is planned, the surgeon must consider the postoperative effects of surgery and plan accordingly.
If total elbow arthroplasty is performed first, at least 3 to 6 months should pass before lower extremity reconstruction is performed to allow adequate healing in the elbow. If the lower extremity will be addressed first, total elbow arthroplasty should be delayed until assistive ambulatory devices, which may put strain on the elbow, are no longer required.
Patients with total elbow arthroplasty should not weight bear with crutches. A walker may be used, provided it does not increase strain on the elbow. This may be achieved by raising the walker’s arm rests to an appropriate height such that when the forearms are placed on the arm rests, the elbow may not be extended beyond 90 degrees of flexion.
Assessment of the Cervical Spine
Because nearly 90% of patients with RA have cervical spine involvement, about 30% of whom have significant subluxation, the cervical spine must be evaluated before any surgery in which intubation is likely.
Cervical spine radiographs should be routinely obtained.
If patients have neck pain, decreased range of motion, myelopathic symptoms, or radiographic evidence of instability, a magnetic resonance imaging (MRI) study should be ordered with concomitant referral to a spine surgeon to consider addressing the cervical spine pathology before elbow surgery.
Temporary Cessation of Medications Before Total Elbow Arthroplasty
Tumor necrosis factor (TNF) inhibitors affect the immune system and have been found to increase the risk of developing a prosthetic joint infection.
In general, anti-TNF agents are typically stopped for a short period before surgery and for about 2 weeks after surgery to reduce the risk of perioperative morbidity.
Patients on chronic NSAIDs should stop taking those medications about 2 weeks before surgery to reduce the risk of increased bleeding.
For patients on chronic steroids, stress-dose steroids may be required perioperatively.
Communications with the patient’s rheumatologist and the anesthesiologist are imperative to coordinate these efforts.
Positioning
Intravenous antibiotics are administered 30 to 60 minutes before the incision.
The patient is placed in a supine position on the operating table with a rolled towel under the ipsilateral scapula.
The entire operative extremity and shoulder girdle is prepared and draped; a sterile tourniquet is placed.
The arm is exsanguinated and the tourniquet inflated.
Approach
Although multiple approaches may be used, the BryanMorrey approach (triceps–anconeus “slide”) is preferred.
TECHNIQUE
INCISION AND EXPOSURE
A straight incision, measuring about 15 cm, is made centered between the lateral epicondyle and the tip of the olecranon.
The ulnar nerve is carefully identified and isolated along the medial aspect of the triceps.
Proximal neurolysis of the nerve is achieved by incising the fascia from the medial head of the triceps to the medial intermuscular septum and then mobilized to beyond its first motor branch distally by splitting the cubital tunnel retinaculum, which includes the band of Osborne (the fascia between the two heads of the flexor carpi ulnaris [FCU]) and the FCU fascia (TECH FIG 1A,B).
The intermuscular septum is excised and a deep pocket of subcutaneous tissue over the flexor pronator group distally and anterior to the triceps proximally is created.
The nerve is then anteriorly transposed into this subcutaneous tissue pocket; it must be protected throughout the operation.
An incision is then made over the medial aspect of the ulna between the anconeus and FCU. The anconeus is subperiosteally elevated off the ulna.
The medial aspect of the triceps is then retracted along with the fibers of the posterior capsule to tension the Sharpey fibers at their ulnar insertion (TECH FIG 1C,D).
These fibers are then sharply dissected, and the triceps in continuity with the anconeus is reflected from medial to lateral (TECH FIG 1E).
The lateral ulnar collateral ligament complex is released from its humeral attachment, thus allowing the extensor mechanism to be completely reflected to the lateral aspect of the humerus (TECH FIG 1F).
If ulnohumeral ankylosis is present, as is sometimes the case in JRA patients, a saw or osteotome may be necessary to re-establish the joint line and to create the osteotomy at the appropriate center of rotation of the ulnohumeral joint.
The elbow is then progressively flexed, exposing the medial collateral ligament, which is then released subperiosteally from its humeral attachment (TECH FIG 1G).
The tip of the olecranon is removed with a rongeur or oscillating saw, depending on the quality of the bone, and the humerus is then externally rotated and the elbow fully flexed to adequately expose the articulating surfaces of the humerus, ulna, and radial head.
TECH FIG 1 • A,B. The ulnar nerve is identified along the medial border of the triceps, and a vessel loop is placed. C,D. Under tension, the medial and ulnar border of the triceps (C) and the anconeus (D) are incised from their insertions into the olecranon. E. The fibers of the extensor mechanism are further reflected laterally. F. The extensor mechanism is slid lateral to the lateral condyle. G. The medial collateral ligament is released to give the elbow maximal motion and to facilitate complete exposure of the ulnohumeral joint.
HUMERAL PREPARATION
The midportion of the trochlea is then removed, with an oscillating saw if the bone is dense or with a rongeur if the bone is soft, up to the roof of the olecranon fossa.
The removed bone should be preserved for the anterior, distal humeral bone graft needed later in the procedure (TECH FIG 2A).
The roof of the olecranon is entered with a rongeur or burr, and a small twist reamer is then used to identify the humeral medullary canal (TECH FIG 2B,C).
For patients with severe stiffness, the effect of humeral shortening should be considered.
Hughes et al4 developed a biomechanical model that demonstrated that resecting 1 cm or less of humeral bone has little effect on triceps strength.
With the elbow in 30 degrees of flexion, resecting 1 to 2 cm reduced triceps strength by 17% to 40%, while shortening of 3 cm reduced extension strength by 63%.
Therefore, the humerus should not be shortened by greater than 2 cm.
An alignment stem is then placed down the canal. The handle of the alignment stem is then replaced by the humeral cutting jig (TECH FIG 2D,E).
An oscillating saw is used to make oblique cuts along the edges of the jig, with the tip of the saw pointing away from the midline of the humerus to avoid cross-hatching at the junction of the column and the olecranon fossa (TECH FIG 2F).
Care must be taken as this area may be very thin in patients with RA, and thus susceptible to fracture.
With the midportion of the trochlea removed, a thin rasp or intramedullary guide is used to again identify the humeral canal.
Progressive 6-inch rasps are typically used unless an ipsilateral shoulder arthroplasty has been performed or is planned (TECH FIG 2G).
In these cases, consider using a 4-inch humeral component.
The anterior capsule is completely subperiosteally released from the anterior aspect of the humerus to accommodate the flange of the humeral component and to allow unencumbered postoperative elbow extension.
TECH FIG 2 • A. For soft bone, a rongeur is used to remove the midportion of the trochlea. B. A burr is used to enter the roof of the olecranon. C. Then a twist reamer is used to identify the medullary canal. D,E. The humeral cutting jig is aligned as a template for removal of the distal humeral articulation. F. An oscillating saw is placed at an oblique angle to the jig to accurately remove the articulating surface of the distal humerus while avoiding cross-hatching of the supracondylar columns. G. An appropriately sized rasp is used for the humeral canal.
ULNAR PREPARATION
It is important to fully expose the greater sigmoid notch.
A high-speed burr is angled 45 degrees relative to the axis of the ulnar shaft at the junction of the sigmoid fossa and coronoid to identify the ulnar medullary canal (TECH FIG 3A,B).
Again, a twist reamer is used to further identify the canal, and an appropriately sized ulnar rasp is then inserted.
The ulnar bow should be acknowledged and palpated while inserting the ulnar rasps to avoid ulnar perforation.
During advancement of the rasp, it is important to maintain proper rotation of the rasp so that the handle is perpendicular to the flat, dorsal aspect of the proximal ulna (TECH FIG 3C,D).
Alternatively, reaming should be considered if the canal is very small, as may be the case in JRA patients.
The ulnar canal is thus prepared, and the ulnar component is inserted to the depth such that the center of the ulnar component is midway between the tips of the olecranon and coronoid to reproduce the elbow’s axis of rotation (TECH FIG 3E).
A rongeur is then used to remove the tip of the coronoid.
Because proximal radioulnar arthritis is ubiquitous in patients with RA and JRA, and the Conrad-Morrey total elbow arthroplasty does not require proximal radioulnar and radiocapitellar reconstruction, a radial head excision is performed.
This may be performed by rotating the forearm and using a rongeur to progressively excise the radial head from an axial orientation, while holding the elbow in full flexion.
TECH FIG 3 • A,B. A high-speed burr is used to identify the ulnar medullary canal. C,D. A small twist reamer is used to identify the ulnar canal (C), which is then rasped to the appropriate size while maintaining proper rotation (D). E. The ulnar component is seated to ensure the proper depth and axis of rotation.
TRIAL REDUCTION
The humeral component is then inserted and a trial reduction is performed.
Range of motion is tested and should be full without limitation in the flexion–extension plane.
If range of motion is limited owing to inadequate soft tissue release, this should be addressed at this time.
The components should also be evaluated for bony impingement, which may commonly occur posteriorly (olecranon impingement on the humerus) or anteriorly (coronoid tip on the anterior flange of the humeral component; TECH FIG 4).
Any impinging bone should be removed with a rongeur.
After satisfactory trial reduction, the provisional components are removed.
TECH FIG 4 • A trial reduction of the components is performed and range of motion is assessed to evaluate for bony impingement.
CEMENTING
Both medullary canals are then pulse lavaged and dried.
Based on the trial components used, the length of the cement applicator is measured to equal that of the humeral component.
The tip of the applicator is cut at this level to ensure appropriate depth of the cement down the humeral canal (TECH FIG 5).
It is recommended that cementing of the components be performed simultaneously.
Two packs of cement with antibiotics are mixed and injected with a runny consistency.
The humeral cement is placed first, followed by the ulnar cement and then the ulnar component.
Remove excess cement.
TECH FIG 5 • Simultaneous cementing of the humeral and ulnar medullary canals is recommended.
HUMERAL COMPONENT AND BONE GRAFT
A small (about 2 cm × 2 cm and 2to 4-mm thick) piece of the removed trochlea is used for the anterior bone graft.
This bone graft is wedged between the anterior aspect of the humerus and the flange as the humeral component is placed (TECH FIG 6).
This provides the humeral component with rotational stability as well as additional stability in the AP plane.
Once again, excess cement is removed at this time.
TECH FIG 6 • The humeral component is inserted to the optimal depth that allows proper articulation with the ulnar component.
ASSEMBLY AND IMPACTION
The components are then linked with the use of two interlocking cross-pins, which are placed from opposite directions (TECH FIG 7A).
If humeral bowing or a small canal exists, a slight bow can be placed in the proximal aspect of the humeral component to ensure proper fit (TECH FIG 7B,C).
After coupling the prosthesis, the components must be seated; the elbow is flexed to 90 degrees and the humeral component is then impacted such that the distal aspect of the humeral component is roughly at or slightly proximal to the contour of the distal capitellum (TECH FIG 7D,E).
Range of motion is checked and a full arc of motion is confirmed.
The elbow is taken through several arcs of flexion–extension to “normalize” the rotational version of components to one another.
Hold the elbow in full extension until the cement cures.
TECH FIG 7 • A. The ulnar and humeral components are linked by two interlocking cross-pins, which are placed from opposite sides. B,C. A slight bow may be created in the proximal aspect of the humeral component if humeral bowing or a small canal is present. D,E. The elbow is flexed to 90 degrees and the humeral component is then impacted.
TRICEPS REATTACHMENT
Small cruciate and transverse drill holes are placed through the olecranon at the site of triceps reattachment, and a heavy, nonabsorbable suture is placed on a Keith needle and then brought through the distal medial cruciate drill hole and out the proximal lateral hole (TECH FIG 8A–C).
The elbow is flexed to about 60 degrees and the extensor mechanism is reduced over the tip of the olecranon; consider slightly overreducing the extensor mechanism medially to minimize the potential for postoperative lateral subluxation.
The suture is woven through the triceps tendon in a locking, crisscross pattern such that the suture emerges at the proximal medial hole (TECH FIG 8D).
The suture is then passed through this hole and out the distal medial hole such that it is located directly across from the initial suture end.
These suture ends are then passed again through the forearm extensor fascia and tied together.
Two reinforcing sutures are then passed through the transverse holes and extensor fascia before being tied together.
Avoid knots directly over the subcutaneous border of the proximal ulna.
The tourniquet is then deflated and hemostasis is achieved.
The medial soft tissue extensor mechanism is then reapproximated.
TECH FIG 8 • Cruciate (A,B) and transverse (C) drill holes are placed in the ulna for triceps reattachment. D. Suture is passed through the proximal ulna and then woven through the triceps tendon before being tied together.
ULNAR NERVE TRANSPOSITION AND WOUND CLOSURE
The protected nerve is in the subcutaneous tissue pocket previously created, and dermal sutures are placed to protect and secure the nerve (TECH FIG 9).
Wounds are closed in layers, and a drain is placed. Staples are used to close the skin.
A volar splint is placed with the elbow in full extension, making sure to adequately pad the anterior aspect of the splint both proximally and distally to prevent skin breakdown.
TECH FIG 9 • The ulnar nerve is transposed into the subcutaneous tissue of the medial epicondylar region and secured with sutures in the dermal layer.
PEARLS AND PITFALLS
POSTOPERATIVE CARE
Postoperatively, the anteriorly placed splint maintains the elbow in full extension for about 24 to 36 hours.
The elbow is elevated overnight and on postoperative day 1.
The drain is removed on postoperative day 1 or when output is less than 30 mL in an 8-hour period.
After splint removal, open-chain active-assisted range of motion is allowed. A formal physical therapy consultation is not usually required.
The patient is restricted to no pushing and no overhead activities for 3 months to protect the triceps. In addition, no repetitive lifting of objects heavier than 5 pounds and no lifting greater than 10 pounds in a single event is allowed for life.
A collar and cuff are provided for comfort.
OUTCOMES
Successful outcomes for total elbow arthroplasty are judged based on relief of pain and improved range of motion, stability, and function.
The Mayo Elbow Performance Score assigns numeric values to each of these categories to produce scores for each of these criteria as well as an overall score.6 Outcomes are often compared using this system.
Total elbow arthroplasty for R.
In the largest study with the longest follow-up in the literature, Gill and Morrey2 reported 86% good or excellent results with a 13% reoperation rate on 69 patients with RA treated with a semiconstrained total elbow arthroplasty. Forty-four of these patients were followed for more than 10 years.
The prosthetic survival rate was 92.4% at 10 years of follow-up, thus approaching the success of lower extremity arthroplasty.
Total elbow arthroplasty for JR.
Connor and Morrey1 reported 87% good or excellent results on 19 patients (24 elbows) followed for a mean of 7.4 years.
The mean improvement in the Mayo Elbow Performance Score was 59 points, 96% had little or no pain, and there was no evidence of loosening in any prostheses at the latest follow-up.
The mean flexion–extension arc of motion improved by only 27 degrees (from 67 to 90 degrees) in this study, but these outcomes were reported before shortening of the humerus for severely contracted elbows was routinely performed.
COMPLICATIONS
Infection
Aseptic loosening
Mechanical failur.
Short term
Long term
Ulnar nerve injury
Triceps weakness or avulsion
Ulnar component fracture
Ulnar fracture
Wound healing problems
REFERENCES
· Connor PM, Morrey BF. Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis. J Bone Joint Surg Am 1998;80A:678–688.
· Gill DR, Morrey BF. The Coonrad-Morrey total elbow arthroplasty in patients who have rheumatoid arthritis: a tento fifteen-year follow-up study. J Bone Joint Surg Am 1998;80A:1327–1335.
· Horiuchi K, Momohara S, Tomatsu T, et al. Arthroscopic synovectomy of the elbow in rheumatoid arthritis. J Bone Joint Surg Am 2002;84A:342–347.
· Hughes RE, Schneeberger AG, An KN, et al. Reduction of triceps muscle force after shortening of the distal humerus: a computational model. J Shoulder Elbow Surg 1997;6:444–448.
· Little CP, Graham AJ, Karatzas G, et al. Outcomes of total elbow arthroplasty for rheumatoid arthritis: comparative study of three implants. J Bone Joint Surg Am 2005;87A:2439–2448.
· Morrey BF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow. J Bone Joint Surg Am 1992;74A:479–490.
· Rymaszewski LA, Mackay I, Amis AA, et al. Long-term effects of excision of the radial head in rheumatoid arthritis. J Bone Joint Surg Br 1979;66B:109–113.